In utero Plastic Surgery in Zurich: Successful Use of Distally Pedicled Random Pattern Transposition Flaps for Definitive Skin Closure during Open Fetal Spina Bifida Repair

Abstract

Background: One of the intraoperative challenges of fetal spina bifida repair is skin closure when there is an extended skin defect. Thus, we examined whether distally pedicled random pattern transposition flaps (TFs) are a valid option to overcome this problem. Subjects and Methods: All patients undergoing in utero repair of spina bifida with application of a TF for back skin closure were analyzed focusing on intraoperative flap characteristics and postoperative flap performance. Results: In 30 (70%) of the 43 fetuses a primary skin closure was achieved, in 5 (12%) a skin substitute was used, and in 8 (18%) a TF was applied. Flap raising and insertion was uneventful and perfusion was sufficient in all 8 fetuses (100%). In 3 fetuses (37%) the donor sites were closed primarily, and in 5 (63%) a skin substitute was used for coverage. At birth, 7 flaps were viable and provided robust skin coverage over the center of the former lesion. Complications included a small skin defect with CSF leakage in 1 patient (13%). Conclusion: During open fetal spina bifida repair, TFs can be safely and efficaciously used to obtain solid and durable skin coverage over lesions too large to allow conventional primary skin closure.

Bioengineering and in utero transplantation of fetal skin in the sheep model: A crucial step towards clinical application in human fetal spina bifida repair

“…Here, postnatal healing by secondary intention over weeks or a ultrathin skin graft (Meuli et al, ) are needed to complete skin reconstruction. For smaller defects, performing pedicled transposition flaps is a suitable approach, even though it means an additional procedure that prolongs fetal operation time, and that, postnatally, might mandate cumbersome flap donor site management (Meuli et al, ). Taken together, we assume that autologous grafting with a close to natural fetal skin analog might be a more elegant and effective solution.…”

“…Doubtlessly, approaches based on tissue engineering harbor great potential in this respect. For instance, an autologous, tissue engineered skin substitute may be used to easily and readily close large defects where primary skin closure is not possible (in 20–30%), superseding the need of time‐consuming and complicated skin mobilization and flap construction (Mangels, Tulipan, Bruner, & Nickolaus, ; Meuli et al, ), or the implantation of acellular skin substitutes (Lapa Pedreira et al, ; Meuli et al, ; Papanna, Fletcher, Moise, Mann, & Tseng, ). It is also conceivable that such a tissue engineered skin “patch” could be used to cover a spina bifida earlier in gestation with minimal‐invasive techniques, allowing spinal cord protection earlier in gestation and hence achieve better results with less invasiveness.…”

Maternal Complications following Open Fetal Myelomeningocele Repair at the Zurich Center for Fetal Diagnosis and Therapy

“…It consists of a tubularization of the neural placode (whenever possible), covered by an additional 3-layer closure. In order to avoid prosthetic material, we sometimes use transposition flaps for skin closure [20]. These operative steps differ slightly from the surgical technique used in the MOMS trial [5].…”

Inclusion Cysts after Fetal Spina Bifida Repair: A Third Hit?

“…A dura substitute was used if the dural layer was not large enough, to provide secure closure. The skin was closed primarily, occasionally using transposition flaps [11]. When direct skin closure was not feasible, a skin substitute (Integra ® [12] or Alloderm ® ) was implanted.…”