Using the keystone design perforator island flap in large myelomeningocele closure

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Many repair techniques have been proposed to treat large myelomeningocele (MMC), and although effective in many cases, some of these techniques can be complex and time consuming, with complications such as cerebrospinal fluid (CSF) leakage, flap loss, tip necrosis, and wound dehiscence. The purpose of this study was to analyze cases of large skin defects and the methods applied and to report the outcomes of the keystone design perforator island flap (KDPIF) technique for large MMC closure.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors performed a retrospective review of all neonatal patients who had undergone KDPIF for MMC closure in the period from 2013 to 2018. All patients had a diagnosis of lumbosacral MMC based on obstetric ultrasound. The neurosurgeons and plastic surgeons had selected the cases after concluding that primary closure would be unlikely. The design of the flap is based on the randomly located vascular perforators, creating two identical opposing flaps to fashion a double keystone flap. During wound closure, V-Y advancement of each end of the double flap in the longitudinal axis creates redundancy in the central portion of the flap and reduces the horizontal tension. After discharge, both the neurosurgery and plastic surgery teams followed up all patients, tracking the results with photography.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>No skin flap dehiscence or necrosis, infection, or CSF leakage was detected, proving the reliability of the flap. One of the patients required further surgery for the large skin defects after insufficient intrauterine closure of the MMC and successfully underwent KDPIF treatment. Another patient (14.3%) had severe neonatal sepsis, which ultimately led to death. A ventriculoperitoneal shunt was required after the skin defect repair in 5 (83.3%) of the 6 surviving patients. Exceptional aesthetic results were achieved for all patients during the follow-up.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>The KDPIF technique is based on well-known vascular perforators of the intercostal, lumbar, and gluteal regions. Wound tension is widely distributed by the flap and, as a consequence, relevant tissue bulk, reliable vascularity, and important geometrical versatility are provided. In addition, most of the muscles and fascia are preserved, which is another advantage in terms of minimizing secondary morbidity to local tissue rearrangement. The use of KDPIF closure was successfully shown to be a viable alternative for more complex MMCs that present with large skin defects.</jats:p></jats:sec>

Myelomeningocele defect reconstruction with keystone flaps: vascular rationale for the design and operative technique

“…We believe that these considerations regarding the blood supply of the flap from an anatomical standpoint and the clinical manifestations of vascular changes are an original perspective that has not been discussed extensively in other reports. A similar study to ours was published by Formentin et al [22]. In their report, some patients underwent intrauterine repair with insufficient closure of the soft-tissue defect, thus requiring a keystone flap as a secondary procedure after birth.…”

Closure of meningomyelocele defects using various types of keystone-design perforator island flaps

“…Eight previous studies have discussed the use of KDPIFs for meningomyelocele defect closure [15,[18][19][20][21][22][23][24]. All of those studies also demonstrated satisfactory experiences in using KDPIFs for meningomyelocele closure.…”

“…Donaldson et al [18] reported that two out of six patients had wound complications after surgery. Both Formentin et al [23] and Hifny and Hamdan [24] reported that one patient out of seven had complications. To our knowledge, our study is the largest clinical case series of keystone flaps for meningomyelocele defect closure with 14 patients with no major complication such as CSF leaks.…”

Keystone Flap Reconstruction after Resection of a Large Paraspinal Venous Malformation in an Infant

“…Keystone flaps in infants have been previously reported in the context of myelomeningocele defects. 8 To our knowledge, this is the first report describing utilization of a keystone flap for reconstruction of a posterior trunk defect after resection of a large venous malformation in an infant. Several other approaches to posterior trunk reconstruction have been described, including various rotation, advancement or transposition flaps, bilobed flaps, Z-plasties, dorsal intercostal artery perforator propeller flaps, and reverse turnover latissimus dorsi muscle flaps.…”