Clinical outcome of V-Y flap with latissimus dorsi and gluteal advancement for treatment of large thoracolumbar myelomeningocele defects: a comparative study

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Surgical repair and closure of myelomeningocele (MMC) defects are important and vital, as the mortality rate is as high as 65%–70% in untreated patients. Closure of large MMC defects is challenging for pediatric neurosurgeons and plastic surgeons. The aim of the current study is to report the operative characteristics and outcome of a series of Iranian patients with large MMC defects utilizing the V-Y flap and with latissimus dorsi or gluteal muscle advancement.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>This comparative study was conducted during a 4-year period from September 2013 to October 2017 in the pediatric neurosurgery department of Shiraz Namazi Hospital, Southern Iran. The authors included 24 patients with large MMC defects who underwent surgery utilizing the bilateral V-Y flap and latissimus dorsi and gluteal muscle advancement. They also retrospectively included 19 patients with similar age, sex, and defect size who underwent surgery using the primary or delayed closure techniques at their center. At least 2 years of follow-up was conducted. The frequency of leakage, necrosis, dehiscence, systemic infection (sepsis, pneumonia), need for ventriculoperitoneal shunt insertion, and mortality was compared between the 2 groups.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>The bilateral V-Y flap with muscle advancement was associated with a significantly longer operative duration (p &lt; 0.001) than the primary closure group. Those undergoing bilateral V-Y flaps with muscle advancement had significantly lower rates of surgical site infection (p = 0.038), wound dehiscence (p = 0.013), and postoperative CSF leakage (p = 0.030) than those undergoing primary repair. The bilateral V-Y flap with muscle advancement was also associated with a lower mortality rate (p = 0.038; OR 5.09 [95% CI 1.12–23.1]) than primary closure. In patients undergoing bilateral V-Y flap and muscle advancement, a longer operative duration was significantly associated with mortality (p = 0.008). In addition, surgical site infection (p = 0.032), wound dehiscence (p = 0.011), and postoperative leakage (p = 0.011) were predictors of mortality. Neonatal sepsis (p = 0.002) and postoperative NEC (p = 0.011) were among other predictors of mortality in this group.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>The bilateral V-Y flap with latissimus dorsi or gluteal advancement is a safe and effective surgical approach for covering large MMC defects and is associated with lower rates of surgical site infection, dehiscence, CSF leakage, and mortality. Further studies are required to elucidate the long-term outcomes.</jats:p></jats:sec>

Closure of Giant Dorsal Lumbosacral Myelomeningocele in Children Using Double Expanded Flaps: A Case Report and Literature Review

“…Mortada et al 10 used the V–Y rotation advancement flap (butterfly flap) and found that the area that could be repaired was larger: one was located in the cervical region with a diameter of 8 cm, the other was located in the thoracolumbar region with a diameter of 16 cm, and the maximum width was more than 0.5 ratio to the back, accompanied with kyphosis. Masoudi et al 11 used V-Y flap with latissimus dorsi-treated large thoracolumbar MMC defects. This method is limited to latissimus flip flaps and muscle-skin grafts.…”

Risk Factors of Neural Tube Defects in a Sample of Iranian Population From Southern Iran: A Hospital-based Investigation

“…Perinatal exposure to anticonvulsants, occupational exposure of the mother to radiation, heavy metals and certain chemical byproducts have been correlated with a higher risk of NTDs [13,14]. A previous population-based study in central Iran revealed that maternal history of abortion and maternal obesity were the only risk factors associated with NTDs in the Iranian population [15]. Although mandatory folic acid supplementation has been proposed in Iran since 2004, the incidence remains still high.…”

Meningomyelocele Reconstruction: Comparison of Repair Methods via Systematic Review

“…[1][2][3][4][5][6][7] Early soft tissue coverage of the defect is imperative to support the repaired dura and neural placode to mitigate the risks of cerebral spinal fluid leak and infection. [8][9][10][11] When there is a paucity of soft tissue for primary coverage or subsequent wound breakdown, plastic surgeons are consulted for more complex wound closure. [12][13][14][15][16][17] More recently in the literature, perforator flaps have become a popular option for soft tissue closure.…”

“…Multiple techniques have been described, including closure with or without paraspinal muscle turnover flaps, local regional flaps, perforator flaps, and regional muscle flaps 1–7 . Early soft tissue coverage of the defect is imperative to support the repaired dura and neural placode to mitigate the risks of cerebral spinal fluid leak and infection 8–11 . When there is a paucity of soft tissue for primary coverage or subsequent wound breakdown, plastic surgeons are consulted for more complex wound closure 12–17 …”