Back Closure
With a Latissimus
By S. Jaworski,
Z. Dudkiewicz,
Dorsi
K. Lodziliski,
Myocutaneous
Flap
and T. Lenkiewicz
Warsaw, Poland l A method of back closure with the use of latissimus dorsi myocutaneous flap in cases of myelomeningocele is reported. A three-layer cover consisting of the skin, subcutaneous fat, and the muscle with proper innervation and blood supply of the flap permits successful closure of large defects. Well-vascularized coverage prevents common complications such as partial necrosis of the flap or wound breakdown and consequent infection of the central nervous system. This report is based on 30 cases of newborns with large thoracolumbar myelomeningocale. Copyright o 1992 by W. B. Saunders Company INDEX WORDS:
Myelomeningocele,
back closure.
0
NE OF THE main difficulties in the surgery of large myelomeningocele is the problem of reconstruction of the back to cover the denuded spine. Usually the defect has an oval shape and reaches the size of 6 x 10 cm. The base of the wound is formed by maldeveloped spine surrounded by dura matter, often with associated kyphosis. The surrounding skin and subcutaneous fat have diminished vitality due to defective innervation. The necessity of wide mobilization imperils the blood supply of the adjoining skin.‘” We have a special interest in the management of children with myelomeningocele in this department and in past years have obtained relatively good results by closing the large myelomeningocele defects using two pedicled S-shaped flaps of surrounding skin.‘,’ Therefore, in many such cases wound healing was
Fig 1.
Patient with typical thoracolumbar
Rhomboid flap marked out.
prolonged and there was some necrosis of the skin edges and consequent breakdown of the wound. When this occurs there is clearly a danger of wound infection and consequent meningitis. Because of our dissatisfaction with this method of closure, we have in recent years started to use a procedure that is particularly applicable to large myelomeningoceles in the thoracolumbar region (Fig l).’ Following repair of the dura a single pedicle flap is prepared. This rhomboid flap on the lateral side of the back contains three layers: the skin, subcutaneous fat, and part of the latissimus dorsi muscle (Fig 2). The muscular tissue is very well nourished by the thoracodorsal artery. The rhomboid flap must be cut on transverse direction and the deeper muscular layer is about 1 cm wider and longer than the dermal layer. This myocu-
skin defect.
From the Pediatric Surgical Department, Klinika Chirurgii Dzieci i Myoa’ziej, Instytut Matki i Dziecka, Warsaw, Poland. Date accepted: November 1, 1990. Address reprint requests to K. todziriski, MD, Klinika Chinugii Dzieci i Myodziej, Kasprzaka I7A, 01211 Warsaw, Poland. Copyright o 1992 by W.B. Saunders Company 0022.3468/92/2701-0020$03.00/0 74
Fig 2.
Fig 3.
Elevation of flap.
JaurnalofPediatric Surgery,
Vol27,No 1 (January),
1992: pp 74-75
BACK CLOSURE WITH A MYOCUTANEOUS
Fig 4.
FLAP
75
Rotation of flap.
Fig 5.
taneous flap is then dissected off its base (Fig 3) and rotated 90” downward to the defect that has to be covered (Fig 4). If there is difficulty in rotating the flap a transverse section of one third to one half of the muscular pedicle may be carried out. As mentioned, the myocutaneous flap is sutured in place in layers, fastening the muscle carefully to the dorsal fascia making sure to completely cover the spinal defect, and then suturing the subcutaneous tissue and skin to the edges of the adjoining skin defect (Fig 5). This
Final appearance.
method preserves the perforating blood vessels going from the muscle to the skin and results in sufficient blood supply to ensure the viability of the flap.‘.’ In our opinion, the advantages of this method of cover are as follows: (1) it allows effective closure of large defects in myelomeningocele cases; (2) the covering flap is of normal vitality; (3) therefore, it covers the spine and dura very satisfactorily; and (4) there is little, if any, tendency to develop pressure sores at a later date.
REFERENCES 1. Lodzinski K: Surgical treatment of myelomeningocele. Z Kinderchir 1388-90, 1973 2. todzinski K: Morfologia przepukliny rdzeniowej i wad towarzyszacych. Prob Chir Dziec 9:16-24, 1982 3. Munro IR, Neu BR, Humpreys RP, et al: Limberg-latissimus dorsi myocutaneous flap for closure of myelomeningocele. Child Brain lo:38 l-386, I983
4. Russel RC, Pribaz J, Zook EG, et al: Functional evaluation of latissimus dorsi donor site. Plast Reconstr Surg 78336-344. 1986 5. Scheflan M, Mehrhof AI, Ward JD: Meningocele closure with distally based iatissimus dorsi flap. Plast Reconstr Surg 73:9X959, 1984
With a Latissimus
By S. Jaworski,
Z. Dudkiewicz,
Dorsi
K. Lodziliski,
Myocutaneous
Flap
and T. Lenkiewicz
Warsaw, Poland l A method of back closure with the use of latissimus dorsi myocutaneous flap in cases of myelomeningocele is reported. A three-layer cover consisting of the skin, subcutaneous fat, and the muscle with proper innervation and blood supply of the flap permits successful closure of large defects. Well-vascularized coverage prevents common complications such as partial necrosis of the flap or wound breakdown and consequent infection of the central nervous system. This report is based on 30 cases of newborns with large thoracolumbar myelomeningocale. Copyright o 1992 by W. B. Saunders Company INDEX WORDS:
Myelomeningocele,
back closure.
0
NE OF THE main difficulties in the surgery of large myelomeningocele is the problem of reconstruction of the back to cover the denuded spine. Usually the defect has an oval shape and reaches the size of 6 x 10 cm. The base of the wound is formed by maldeveloped spine surrounded by dura matter, often with associated kyphosis. The surrounding skin and subcutaneous fat have diminished vitality due to defective innervation. The necessity of wide mobilization imperils the blood supply of the adjoining skin.‘” We have a special interest in the management of children with myelomeningocele in this department and in past years have obtained relatively good results by closing the large myelomeningocele defects using two pedicled S-shaped flaps of surrounding skin.‘,’ Therefore, in many such cases wound healing was
Fig 1.
Patient with typical thoracolumbar
Rhomboid flap marked out.
prolonged and there was some necrosis of the skin edges and consequent breakdown of the wound. When this occurs there is clearly a danger of wound infection and consequent meningitis. Because of our dissatisfaction with this method of closure, we have in recent years started to use a procedure that is particularly applicable to large myelomeningoceles in the thoracolumbar region (Fig l).’ Following repair of the dura a single pedicle flap is prepared. This rhomboid flap on the lateral side of the back contains three layers: the skin, subcutaneous fat, and part of the latissimus dorsi muscle (Fig 2). The muscular tissue is very well nourished by the thoracodorsal artery. The rhomboid flap must be cut on transverse direction and the deeper muscular layer is about 1 cm wider and longer than the dermal layer. This myocu-
skin defect.
From the Pediatric Surgical Department, Klinika Chirurgii Dzieci i Myoa’ziej, Instytut Matki i Dziecka, Warsaw, Poland. Date accepted: November 1, 1990. Address reprint requests to K. todziriski, MD, Klinika Chinugii Dzieci i Myodziej, Kasprzaka I7A, 01211 Warsaw, Poland. Copyright o 1992 by W.B. Saunders Company 0022.3468/92/2701-0020$03.00/0 74
Fig 2.
Fig 3.
Elevation of flap.
JaurnalofPediatric Surgery,
Vol27,No 1 (January),
1992: pp 74-75
BACK CLOSURE WITH A MYOCUTANEOUS
Fig 4.
FLAP
75
Rotation of flap.
Fig 5.
taneous flap is then dissected off its base (Fig 3) and rotated 90” downward to the defect that has to be covered (Fig 4). If there is difficulty in rotating the flap a transverse section of one third to one half of the muscular pedicle may be carried out. As mentioned, the myocutaneous flap is sutured in place in layers, fastening the muscle carefully to the dorsal fascia making sure to completely cover the spinal defect, and then suturing the subcutaneous tissue and skin to the edges of the adjoining skin defect (Fig 5). This
Final appearance.
method preserves the perforating blood vessels going from the muscle to the skin and results in sufficient blood supply to ensure the viability of the flap.‘.’ In our opinion, the advantages of this method of cover are as follows: (1) it allows effective closure of large defects in myelomeningocele cases; (2) the covering flap is of normal vitality; (3) therefore, it covers the spine and dura very satisfactorily; and (4) there is little, if any, tendency to develop pressure sores at a later date.
REFERENCES 1. Lodzinski K: Surgical treatment of myelomeningocele. Z Kinderchir 1388-90, 1973 2. todzinski K: Morfologia przepukliny rdzeniowej i wad towarzyszacych. Prob Chir Dziec 9:16-24, 1982 3. Munro IR, Neu BR, Humpreys RP, et al: Limberg-latissimus dorsi myocutaneous flap for closure of myelomeningocele. Child Brain lo:38 l-386, I983
4. Russel RC, Pribaz J, Zook EG, et al: Functional evaluation of latissimus dorsi donor site. Plast Reconstr Surg 78336-344. 1986 5. Scheflan M, Mehrhof AI, Ward JD: Meningocele closure with distally based iatissimus dorsi flap. Plast Reconstr Surg 73:9X959, 1984
