RECONSTRUCTIVE SURGERY
Dorsal Intercostal Artery Perforator Propeller Flaps A Reliable Option in Reconstruction of Large Meningomyelocele Defects Yavuz Basterzi, MD and Goktekin Tenekeci, MD Abstract: Several options have been reported for the reconstruction of myelomeningocele defects. In this article, we present our experience on soft tissue reconstruction of myelomeningocele defects by using island propeller dorsal intercostal artery perforator (DIAP) flaps. Between January 2008 and February 2014, all newborns with large myelomeningocele defects (13 newborns) were reconstructed with island propeller DIAP flaps. All flaps survived completely. In 8 patients out of 13, venous insufficiency was observed which then resolved spontaneously. Flap donor sites were closed primarily. Myelomeningocele defects with a diameter larger than 5 cm require reconstruction with flaps. To mobilize a well-vascularized tissue over the defect without tension in which the suture lines will not overlap over the midline where the dura is repaired and over the meninges is one of the goals of reconstruction for such defects. Perforator propeller flaps enable us to reach those goals. Use of perforator flaps provides 2 important advantages, namely, more predictability and also more freedom in mobilizing flaps toward the defect. This study proves the reliability of DIAP propeller flaps in the reconstruction of myelomeningocele defects. Key Words: myelomeningocele, propeller, perforator (Ann Plast Surg 2016;76: 434–437)
N
eural tube defects affect approximately 1 to 2 newborns out of 1000 live births in the United States.1 Myelomeningoceles constitute a variety of neural tube defects. Lower extremities may be affected by myelomeningoceles and patients may present with paraplegia, plegia on single side, or not plegia. Early surgical closure of the defect is performed to prevent cerebrospinal fluid leakage and central nervous system infections. This operation is a combined operation of neurosurgery and plastic surgery. Fascial turnover flaps with or without paraspinous muscle flaps,2 latissimus dorsi flaps,3 rotation-transposition fasciocutaneous flaps,4 bilateral V-Yadvancement flaps,5 bilobed flaps,6 lumbar artery perforator flaps,7 and dorsal intercostal artery perforator (DIAP) flaps8 are some of the options reported for soft tissue reconstruction of myelomeningocele defects. In this article, we present our experience on soft tissue reconstruction of myelomeningocele defects using island propeller DIAP flaps. In this article, reconstruction of 13 consecutive patients who consulted in our clinic between January 2008 and February 2014 with large skin and soft tissue defects related to myelomeningocele were attempted using islanded DIAP propeller flaps. Our experience and the results are discussed.
MATERIALS AND METHODS Between January 2008 and February 2014, all newborns with large myelomeningocele defects (13 newborns) were enrolled in this study (Table 1). After the dura repair was performed by neurosurgery team, DIAPs were mapped by using a handheld Doppler and the flap Received July 2, 2014, and accepted for publication, after revision, November 11, 2014. From the Department of Plastic, Reconstructive and Aesthetic Surgery, Mersin University School of Medicine, Mersin University Hospital, Mersin, Turkey. Conflicts of interest and sources of funding: none declared. Reprints: Goktekin Tenekeci, Plastik, Rekonstruktif and Estetik Cerrahi A.B.D, Mersin Universitesi Tip Fakultesi Hastanesi, Ciftlikkoy Kampusu, Mersin, Turkey. E-mail:[email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7604–0434 DOI: 10.1097/SAP.0000000000000417
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was planned accordingly. Flap orientation may be planned vertically over the posterior hemichest wall or horizontally toward the lateral chest wall. We oriented the long axis of our flaps horizontally, toward the lateral chest wall except for 1 patient. Flap dimensions were planned bigger than the defect size because perforators were found at some distance from the defect border. Thus, we add the distance from the perforator to the defect border while planning the flap. Perforators were located just lateral to the vertebral column (Fig. 1). Flap and pedicle dissection was performed under loupe magnification. Flap is circumferentially incised in all patients and was raised in a subfacial plane. Careful dissection was performed around the perforator. The perforator which seems most reliable by its size (sometimes 2 adjacent perforators, especially if flap is to be planned beyond midaxillary line) is selected and all other perforators are clamped with vascular clamps. The most reliable perforator is dissected off from the surrounding fascia and muscle enough to provide safe rotation of the perforator and avoid kinking. The islanded flap was then transposed over the defect and sutured to the defect borders. Donor site was closed primarily in all patients (Figs. 2A, B). Flap dissection was performed under 4.3 loupe magnification and the pedicle dissection was performed by the use of microsurgical instruments (Fig. 3). During our very first operations, we first identified the perforator pedicle safely after a short skin incision over the superior edge of the planed flap. After seeing the perforators, we incised the skin and subcutaneous tissue over the flap borders completely. This was performed as a safety measure to assess the size of pedicle calibers before the flap borders are incised completely. However, as we gained experience, we abandoned this application. Flap base neighboring the vertebral column where the perforators arise are kept wide to include more perforators from several levels (2 or 3 intervertebral spaces) to the flap and compare their sizes during flap elevation.
RESULTS All flaps survived completely. All defects were located in the midline of back over lumbosacral or thoracolumbar region. Defect sizes range between 5 5 and 8 7 cm. Average flap size was 8.4 6.5 cm, whereas average defect size was 6.3 5.6 cm. None of the patients received blood transfusion, neither intraoperatively nor postoperatively. One patient was reoperated by the neurosurgery team because of cerebrospinal fluid leakage and a ventriculoperitoneal shunt was inserted. In this patient, although flap was completely survived, a dehiscence of 1 cm was observed in the distal border of flap, which was secondary to cerebrospinal fluid leakage and was sutured again, which then healed smoothly. In 8 patients out of 13, venous insufficiency was observed which then resolved spontaneously. No leech therapy or any other interventions were applied for venous insufficiency. No hematoma formation was observed. Flap donor sites were closed primarily. In 1 patient whose flap axis was oriented vertically, wound healing at the donor site was delayed but healed spontaneously without need for additional operation. No other donor-site complications were noted. Mean operative time was around 1 hour; however, as we gained experience, operative time became shorter. Drains are used for 3 days and set without vacuuming. Patients were positioned as prone or lateral decubitus for 2 weeks postoperatively.
DISCUSSION Newborns with myelomeningocele defects must be repaired early in the postpartum period to prevent cerebrospinal fluid leakage and Annals of Plastic Surgery • Volume 76, Number 4, April 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 76, Number 4, April 2016
DIAP Propeller Flaps
TABLE 1. Flap and Defect Characteristics of Patients With Myelomeningocele Defects Patient Number
1 2 3 (Fig. 2) 4 5 6 (Fig. 3) 7 8 9 (Fig. 4) 10 11 12 13
Defect Shape
Defect Location
Defect Size, cm
Flap Dimensions, cm
Follow-up Period, mo
Age at Operation, d
Unicircular Unicircular Unicircular Unicircular Unicircular Unicircular Bicircular Unicircular Unicircular Unicircular Unicircular Unicircular Unicircular
Lumbosacral Lumbosacral Thoracolumbar Lumbosacral Thoracolumbar Lumbosacral Thoracolumbar Lumbosacral Lumbosacral Thoracolumbar Thoracolumbar Lumbosacral Thoracolumbar
87 76 55 55 76 65 66 66 86 76 65 55 65
11 7.5 97 8.5 7 65 10 8 76 76 10 7 11 7 8.5 7 76 75 76
3 1.5 4 2.5 2 3.5 1 2 1 3 1.5 1 1
2 3 2 2 4 4 2 3 2 4 2 3 2
central nervous system infections. Surgical repair of such anomalies is performed through a combined operation of neurosurgery and plastic surgery. After the neural tube is repaired by the neurosurgery team, the plastic surgery team got involved in the operation, and skin and soft tissue reconstruction of myelomeningocele defects are performed (Figs. 4A, B). Myelomeningocele defects with a diameter smaller than 5 cm is accounted as small defects and such defects can be closed primarily,4 whereas larger defects require reconstruction of the flaps. Perforator propeller flaps provide the maximum mobility among all the local options. To mobilize a well-vascularized tissue over the defect without tension in which the suture lines will not overlap over the midline where the dura is repaired and over the meninges is one of the goals of reconstruction for such defects. Perforator propeller flaps enable us to reach those goals. Until now, many techniques were applied and reported for soft tissue reconstruction of myelomeningocele defects. One of them is the use of local turnover fascial flaps, together with approximation of adjacent paraspinous musculature whenever possible and midline linear skin closure.2 This technique was used by Patel et al and requires either 2 or 3 layered closure of myelomeningocele defects. However, all layers are closed in midline which is accounted as an important disadvantage. Primary skin closure of such defects may be too tight if defect is large, and thus, primary closure carries the risk of wound dehiscence.
Another option which is described for the reconstruction of myelomeningocele defects is the use of bilobed flaps.9 This technique does not leave the suture lines over the midline; however, because it is not a perforator flap and is bound with a skin bridge to the donor site, more extensive dissection of the first flap to be able to close the defect is required. Dissection of the second flap is also needed. Another disadvantage of this flap is that it is a random pattern flap, which is known as less predictable when compared to perforator propeller flaps. Use of latissimus dorsi flaps is also reported in the literature, for closure of myelomeningocele defects.10 However, as it is well known, patients affected with myelomeningoceles may present with paraplegia, plegia on one site, or may be completely normal. Latissimus dorsi muscles in this group of patients must be spared for ambulation.6 Such patients are candidates for being future wheelchair users. That is why, whenever a reconstruction for myelomeningocele defect is attempted, preservation of surrounding musculature must be provided. The use of back muscles for reconstruction of myelomeningocele defects will be a challenge for future use of wheelchairs in this group of patients.8 Rotation-transposition flaps are used as another option in reconstruction of myelomeningocele defects.4 However, because rotationtransposition flaps are bound by an intact skin bridge as in all random pattern flaps, mobility of those flaps are limited and, thus, may require the use of a second flap for reconstruction from the opposite side and
FIGURE 1. Schematic illustration of DIAP anatomy and DIAP propeller flap planning for meningomyelocele defects. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Basterzi and Tenekeci
FIGURE 2. A, Flap planning is seen in a myelomeningocele defect. Perforators are mapped with handheld Doppler. A DIAP propeller flap is planned for reconstruction which is oriented horizontally, toward the lateral chest wall. Intraoperative appearance of a patient with a 5 5-cm myelomeningocele defect. B, Flap is raised on its perforator after all the perforators are isolated. The largest perforator is selected and all other perforators are sacrificed. View at postoperative 4 months after reconstruction using a DIAP propeller island flap with 8.5 7-cm dimension.
more extensive dissection. Use of a second flap means that suture line of dura repair and suture line of flap repair will be coinciding at some place which is a risk for wound dehiscence. Tamaki et al reported a late deterioration of neurological function in 15 % of patients with myelomeningocele after repair, due to tethered cord syndrome. They mentioned the presence of dense adhesions at the lowest lamina at the site of previous repair as the most common finding in such patients.11 Duffy et al have used superior gluteal artery perforator flap for the reconstruction of myelomeningocele defects. They reported that due to the vascularity and durability of superior gluteal artery perforator flaps, they are hopeful for decreasing occurrence of chronic pain at the closure site and possibly for diminishing the incidence of tethered cord.12 Our impression is similar; we believe that as vascularity of flaps used for reconstruction becomes more reliable, fibrotic adhesions around the healing site decreases, which may have a positive effect on diminishing symptoms such as chronic pain and other symptoms indicating the presence of tethered cord. Dorsal intercostal artery perforator propeller flaps enable us to cover the whole myelomeningocele defect, either thoracolumbar or lumbosacral, by using only 1 flap which decreases extent of dissection and thus decreasing scar formation over the back. Unlike random pattern flaps, DIAP propeller flaps have a predictable outcome. Dorsal intercostal artery perforators are located within 5 cm from the spinous process of vertebra.13 Dorsal intercostal artery perforators can capture the territories of the musculocutaneous perforators on the latissimus dorsi muscle, the circumflex scapular artery, and the direct cutaneous branch of thoracodorsal artery, by means of choke anastomoses.13 Thus, based on a single DIAP, a large flap can be planned safely (Figs. 2A, B). Random pattern flaps such as bipedicled flaps, local transposition flaps, the double Z-plasty, rotation flaps, and Limberg flaps require extensive undermining and thus have a greater risk of wound edge necrosis.14 Also random flaps do not have a described vascular supply, which makes such options unpredictable for complete flap survival. Skin perforators of the seventh, eighth, and ninth intercostal arteries were less dominant than the other DIAPs because they were covered by latissimus dorsi muscle.13 Skin branches of the seventh, eighth, and ninth DIAPs are less dominant than muscle branches of the same perforators.13 That is why for closure of myelomeningocele defects, we generally use the closest most reliable perforators. So, the sixth and/or more superior dorsal intercostal artery skin perforators are generally selected because they are more sizable. However, this may enlarge and elongate the dimensions of the planned flap. Although the distal end of the DIAP flaps is suggested to be set within the lateral margin of latissimus dorsi muscle,13 we had to elongate the flap tip 436
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until the anterior axillary line margin in one of our patients and until the midaxillary line in the other and the flaps survived completely (Figs. 2A, B). However, sometimes the seventh or more inferior DIAPs may also be selected especially if planned flap is small. Primary closure of flap donor sites is performed in all cases. Unlike many other options, DIAP propeller island flaps successfully reconstruct whole defect by using only 1 flap. Muskett et al15 have reported that minor wound complications increased hospitalization from 23 to 35 days, whereas major wound problems causing return to the operating room increased hospitalization from 23 to 45 days in patients with meningomyelocele defects. Most of the patients included in this study were premature, thus hospitalization period of patients were determined by their general health status and by their pediatricians because we do not have minor or major wound complications related to flap failures. However, we did not compare the hospitalization time of meningomyelocele defects reconstructed with perforator propeller flaps and the ones reconstructed with random pattern flaps. This comparison may be an issue of another study. We oriented DIAP flap horizontally except for 1 patient. In this only case where the flap was oriented vertically, wound healing was not as good as the horizontally oriented ones. Scar tissue was wider in this only case. That is why we used vertical orientation of flap in only 1 case.
FIGURE 3. DIAP is seen after dissection is completed supplying DIAP flap. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 76, Number 4, April 2016
DIAP Propeller Flaps
FIGURE 4. A, A myelomeningocele defect with 6 5 cm was planned for reconstruction with a 7 6-cm vertically oriented DIAP propeller island flap. B, Patient is seen at postoperative 2 weeks.
Isik et al8 also used DIAPs for supplying the flap. They protected DIAPs in reconstruction of 27 cases. Eight of 27 flaps were turned to island flaps for better mobilization. In other 19 cases, intact skin islands of 2 cm were protected. In this article, the reason why 19 cases were not turned to island flaps was not explained. It is not clear if the authors think that DIAP propeller island flaps may not be as predictable as peninsular flaps and may cause distal edge necrosis. But as it is mentioned in the article, islanded perforator flaps provide more mobility. Isik et al reported marginal flap necrosis at the distal part of flaps in 2 patients but it was not mentioned if marginal necrosis occurred in islanded flaps or in flaps with intact skin bridges. However, perforator flaps provide predictability and also more freedom in mobilizing flaps. If flaps are bound by a skin bridge to the donor site, this will limit its move toward the defect area. In our series, island DIAP propeller flaps were used in all 13 cases and all flaps survived completely. This result shows that island DIAP propeller flaps constitute a reliable, well-vascularized option and the skin suture lines do not overlap between the dura suture lines over the midline. During our very first operations, we first identified the perforator pedicle safely after a short skin incision over the superior edge of the planed flap. After seeing the perforators, we incised the skin and subcutaneous tissue over the flap borders completely. This was performed as a safety measure to assess the size of pedicle calibers before the flap borders are incised completely. In case if an unreliable perforator was present, the reconstructive plan could be changed in favor of a random pattern flap to be used for defect reconstruction. However, until now reconstructive plan was not changed in any of our patients. As we gained experience, we abandoned this application. Flap base neighboring the vertebral column, where the perforators arise, are kept wide to include more perforators to the flap from several levels (2 or 3 intervertebral spaces) and compare their sizes during flap elevation. As in every reconstructive case, we have to have a “B plan” in case if flap necrosis occurs. Although all DIAP propeller island flaps survived completely in our series, our “B plan” for myelomeningocele defect reconstruction is to use another reliable perforator from the opposite site of the vertebral column or another perforator from more superior level.
CONCLUSIONS We operated on 13 consecutive cases with myelomeningocele and all were successfully reconstructed with DIAP propeller island flaps with complete flap survival in all cases. Having a reliable and satisfactory “B plan” for reconstruction of defect is an advantage of this technique. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Mobilizing a well-vascularized tissue over the defect, no overlapping of suture lines of dura and skin after layered closure, leaving intact back muscles, and primary closure of flap donor sites are the advantages of DIAP propeller island flaps. Use of perforator flaps provides 2 important advantages, namely, more predictability and more freedom in mobilizing flaps toward the defect. This study proves the reliability of DIAP propeller flaps in the reconstruction of myelomeningocele defects. REFERENCES 1. Au KS, Northrup H, Kirkpatrick TJ, et al. Promoter genotype of the plateletderived growth factor receptor-alpha gene shows population stratification but not association with spina bifida meningomyelocele. Am J Med Genet A. 2005;139: 194–198. 2. Patel KB, Taghinia AH, Proctor MR, et al. Extradural myelomeningocele reconstruction using local turnover fascial flaps and midline linear skin closure. J Plast Reconstr Aesthet Surg. 2012;65:1569–1572. 3. VanderKolk CA, Adson MH, Stevenson TR. The reverse latissimus dorsi muscle flap for closure of meningomyelocele. Plast Reconstr Surg. 1988;81:454–456. 4. Selçuk CT, Civelek B, Bozkurt M, et al. Reconstruction of large meningomyelocele defects with rotation-transposition fasciocutaneous flaps. Ann Plast Surg. 2012;69:197–202. 5. Komuro Y, Yanai A, Koga Y, et al. Bilateral modified V-Yadvancement flaps for closing meningomyelocele defects. Ann Plast Surg. 2006;57:195–198. 6. Lapid O, Rosenberg L, Cohen A. Meningomyelocele reconstruction with bilobed flaps. Br J Plast Surg. 2001;54:570–572. 7. El-Sabbagh AH, Zidan AS. Closure of large myelomeningocele defects by lumbar artery perforator flaps. J Reconstr Microsurg. 2011;27:287–294. 8. Isik D, Tekes L, Eseoglu M, et al. Closure of large myelomeningocele defects using dorsal intercostal artery perforator flap. Ann Plast Surg. 2011;67:159–163. 9. Atik B, Tan O, Kiymaz N, et al. Bilobed fasciocutaneous flap closure of large meningomyeloceles. Ann Plast Surg. 2006;56:562–564. 10. Hosseinpour M, Forghani S. Primary closure of large thoracolumbar myelomeningocele with bilateral latissimus dorsi flaps. J Neurosurg Pediatr. 2009;3: 331–333. 11. Tamaki N, Shirataki K, Kojima N, et al. Tethered cord syndrome of delayed onset following repair of myelomeningocele. J Neurosurg. 1988;69:393. 12. Duffy FJ Jr, Weprin BE, Swift DM. A new approach to closure of large lumbosacral myelomeningoceles: the superior gluteal artery perforator flap. Plast Reconstr Surg. 2004;114:1864–1868. 13. Minabe T, Harii K. Dorsal intercostal artery perforator flap: anatomical study and clinical applications. Plast Reconstr Surg. 2007;120:681–689. 14. Sarifakioglu N, Bingul F, Terzioglu A, et al. Bilateral split latissimus dorsi V-Y flaps for closure of large thoracolumbar meningomyelocele defects. Br J Plast Surg. 2003;5:303–306. 15. Muskett A, Barber WH, Parent AD, et al. Contemporary postnatal plastic surgical management of meningomyelocele. J Plast Reconstr Aesthet Surg. 2012;65: 572–577.
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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
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Dorsal Intercostal Artery Perforator Propeller Flaps A Reliable Option in Reconstruction of Large Meningomyelocele Defects Yavuz Basterzi, MD and Goktekin Tenekeci, MD Abstract: Several options have been reported for the reconstruction of myelomeningocele defects. In this article, we present our experience on soft tissue reconstruction of myelomeningocele defects by using island propeller dorsal intercostal artery perforator (DIAP) flaps. Between January 2008 and February 2014, all newborns with large myelomeningocele defects (13 newborns) were reconstructed with island propeller DIAP flaps. All flaps survived completely. In 8 patients out of 13, venous insufficiency was observed which then resolved spontaneously. Flap donor sites were closed primarily. Myelomeningocele defects with a diameter larger than 5 cm require reconstruction with flaps. To mobilize a well-vascularized tissue over the defect without tension in which the suture lines will not overlap over the midline where the dura is repaired and over the meninges is one of the goals of reconstruction for such defects. Perforator propeller flaps enable us to reach those goals. Use of perforator flaps provides 2 important advantages, namely, more predictability and also more freedom in mobilizing flaps toward the defect. This study proves the reliability of DIAP propeller flaps in the reconstruction of myelomeningocele defects. Key Words: myelomeningocele, propeller, perforator (Ann Plast Surg 2016;76: 434–437)
N
eural tube defects affect approximately 1 to 2 newborns out of 1000 live births in the United States.1 Myelomeningoceles constitute a variety of neural tube defects. Lower extremities may be affected by myelomeningoceles and patients may present with paraplegia, plegia on single side, or not plegia. Early surgical closure of the defect is performed to prevent cerebrospinal fluid leakage and central nervous system infections. This operation is a combined operation of neurosurgery and plastic surgery. Fascial turnover flaps with or without paraspinous muscle flaps,2 latissimus dorsi flaps,3 rotation-transposition fasciocutaneous flaps,4 bilateral V-Yadvancement flaps,5 bilobed flaps,6 lumbar artery perforator flaps,7 and dorsal intercostal artery perforator (DIAP) flaps8 are some of the options reported for soft tissue reconstruction of myelomeningocele defects. In this article, we present our experience on soft tissue reconstruction of myelomeningocele defects using island propeller DIAP flaps. In this article, reconstruction of 13 consecutive patients who consulted in our clinic between January 2008 and February 2014 with large skin and soft tissue defects related to myelomeningocele were attempted using islanded DIAP propeller flaps. Our experience and the results are discussed.
MATERIALS AND METHODS Between January 2008 and February 2014, all newborns with large myelomeningocele defects (13 newborns) were enrolled in this study (Table 1). After the dura repair was performed by neurosurgery team, DIAPs were mapped by using a handheld Doppler and the flap Received July 2, 2014, and accepted for publication, after revision, November 11, 2014. From the Department of Plastic, Reconstructive and Aesthetic Surgery, Mersin University School of Medicine, Mersin University Hospital, Mersin, Turkey. Conflicts of interest and sources of funding: none declared. Reprints: Goktekin Tenekeci, Plastik, Rekonstruktif and Estetik Cerrahi A.B.D, Mersin Universitesi Tip Fakultesi Hastanesi, Ciftlikkoy Kampusu, Mersin, Turkey. E-mail:[email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7604–0434 DOI: 10.1097/SAP.0000000000000417
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was planned accordingly. Flap orientation may be planned vertically over the posterior hemichest wall or horizontally toward the lateral chest wall. We oriented the long axis of our flaps horizontally, toward the lateral chest wall except for 1 patient. Flap dimensions were planned bigger than the defect size because perforators were found at some distance from the defect border. Thus, we add the distance from the perforator to the defect border while planning the flap. Perforators were located just lateral to the vertebral column (Fig. 1). Flap and pedicle dissection was performed under loupe magnification. Flap is circumferentially incised in all patients and was raised in a subfacial plane. Careful dissection was performed around the perforator. The perforator which seems most reliable by its size (sometimes 2 adjacent perforators, especially if flap is to be planned beyond midaxillary line) is selected and all other perforators are clamped with vascular clamps. The most reliable perforator is dissected off from the surrounding fascia and muscle enough to provide safe rotation of the perforator and avoid kinking. The islanded flap was then transposed over the defect and sutured to the defect borders. Donor site was closed primarily in all patients (Figs. 2A, B). Flap dissection was performed under 4.3 loupe magnification and the pedicle dissection was performed by the use of microsurgical instruments (Fig. 3). During our very first operations, we first identified the perforator pedicle safely after a short skin incision over the superior edge of the planed flap. After seeing the perforators, we incised the skin and subcutaneous tissue over the flap borders completely. This was performed as a safety measure to assess the size of pedicle calibers before the flap borders are incised completely. However, as we gained experience, we abandoned this application. Flap base neighboring the vertebral column where the perforators arise are kept wide to include more perforators from several levels (2 or 3 intervertebral spaces) to the flap and compare their sizes during flap elevation.
RESULTS All flaps survived completely. All defects were located in the midline of back over lumbosacral or thoracolumbar region. Defect sizes range between 5 5 and 8 7 cm. Average flap size was 8.4 6.5 cm, whereas average defect size was 6.3 5.6 cm. None of the patients received blood transfusion, neither intraoperatively nor postoperatively. One patient was reoperated by the neurosurgery team because of cerebrospinal fluid leakage and a ventriculoperitoneal shunt was inserted. In this patient, although flap was completely survived, a dehiscence of 1 cm was observed in the distal border of flap, which was secondary to cerebrospinal fluid leakage and was sutured again, which then healed smoothly. In 8 patients out of 13, venous insufficiency was observed which then resolved spontaneously. No leech therapy or any other interventions were applied for venous insufficiency. No hematoma formation was observed. Flap donor sites were closed primarily. In 1 patient whose flap axis was oriented vertically, wound healing at the donor site was delayed but healed spontaneously without need for additional operation. No other donor-site complications were noted. Mean operative time was around 1 hour; however, as we gained experience, operative time became shorter. Drains are used for 3 days and set without vacuuming. Patients were positioned as prone or lateral decubitus for 2 weeks postoperatively.
DISCUSSION Newborns with myelomeningocele defects must be repaired early in the postpartum period to prevent cerebrospinal fluid leakage and Annals of Plastic Surgery • Volume 76, Number 4, April 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 76, Number 4, April 2016
DIAP Propeller Flaps
TABLE 1. Flap and Defect Characteristics of Patients With Myelomeningocele Defects Patient Number
1 2 3 (Fig. 2) 4 5 6 (Fig. 3) 7 8 9 (Fig. 4) 10 11 12 13
Defect Shape
Defect Location
Defect Size, cm
Flap Dimensions, cm
Follow-up Period, mo
Age at Operation, d
Unicircular Unicircular Unicircular Unicircular Unicircular Unicircular Bicircular Unicircular Unicircular Unicircular Unicircular Unicircular Unicircular
Lumbosacral Lumbosacral Thoracolumbar Lumbosacral Thoracolumbar Lumbosacral Thoracolumbar Lumbosacral Lumbosacral Thoracolumbar Thoracolumbar Lumbosacral Thoracolumbar
87 76 55 55 76 65 66 66 86 76 65 55 65
11 7.5 97 8.5 7 65 10 8 76 76 10 7 11 7 8.5 7 76 75 76
3 1.5 4 2.5 2 3.5 1 2 1 3 1.5 1 1
2 3 2 2 4 4 2 3 2 4 2 3 2
central nervous system infections. Surgical repair of such anomalies is performed through a combined operation of neurosurgery and plastic surgery. After the neural tube is repaired by the neurosurgery team, the plastic surgery team got involved in the operation, and skin and soft tissue reconstruction of myelomeningocele defects are performed (Figs. 4A, B). Myelomeningocele defects with a diameter smaller than 5 cm is accounted as small defects and such defects can be closed primarily,4 whereas larger defects require reconstruction of the flaps. Perforator propeller flaps provide the maximum mobility among all the local options. To mobilize a well-vascularized tissue over the defect without tension in which the suture lines will not overlap over the midline where the dura is repaired and over the meninges is one of the goals of reconstruction for such defects. Perforator propeller flaps enable us to reach those goals. Until now, many techniques were applied and reported for soft tissue reconstruction of myelomeningocele defects. One of them is the use of local turnover fascial flaps, together with approximation of adjacent paraspinous musculature whenever possible and midline linear skin closure.2 This technique was used by Patel et al and requires either 2 or 3 layered closure of myelomeningocele defects. However, all layers are closed in midline which is accounted as an important disadvantage. Primary skin closure of such defects may be too tight if defect is large, and thus, primary closure carries the risk of wound dehiscence.
Another option which is described for the reconstruction of myelomeningocele defects is the use of bilobed flaps.9 This technique does not leave the suture lines over the midline; however, because it is not a perforator flap and is bound with a skin bridge to the donor site, more extensive dissection of the first flap to be able to close the defect is required. Dissection of the second flap is also needed. Another disadvantage of this flap is that it is a random pattern flap, which is known as less predictable when compared to perforator propeller flaps. Use of latissimus dorsi flaps is also reported in the literature, for closure of myelomeningocele defects.10 However, as it is well known, patients affected with myelomeningoceles may present with paraplegia, plegia on one site, or may be completely normal. Latissimus dorsi muscles in this group of patients must be spared for ambulation.6 Such patients are candidates for being future wheelchair users. That is why, whenever a reconstruction for myelomeningocele defect is attempted, preservation of surrounding musculature must be provided. The use of back muscles for reconstruction of myelomeningocele defects will be a challenge for future use of wheelchairs in this group of patients.8 Rotation-transposition flaps are used as another option in reconstruction of myelomeningocele defects.4 However, because rotationtransposition flaps are bound by an intact skin bridge as in all random pattern flaps, mobility of those flaps are limited and, thus, may require the use of a second flap for reconstruction from the opposite side and
FIGURE 1. Schematic illustration of DIAP anatomy and DIAP propeller flap planning for meningomyelocele defects. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
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Annals of Plastic Surgery • Volume 76, Number 4, April 2016
Basterzi and Tenekeci
FIGURE 2. A, Flap planning is seen in a myelomeningocele defect. Perforators are mapped with handheld Doppler. A DIAP propeller flap is planned for reconstruction which is oriented horizontally, toward the lateral chest wall. Intraoperative appearance of a patient with a 5 5-cm myelomeningocele defect. B, Flap is raised on its perforator after all the perforators are isolated. The largest perforator is selected and all other perforators are sacrificed. View at postoperative 4 months after reconstruction using a DIAP propeller island flap with 8.5 7-cm dimension.
more extensive dissection. Use of a second flap means that suture line of dura repair and suture line of flap repair will be coinciding at some place which is a risk for wound dehiscence. Tamaki et al reported a late deterioration of neurological function in 15 % of patients with myelomeningocele after repair, due to tethered cord syndrome. They mentioned the presence of dense adhesions at the lowest lamina at the site of previous repair as the most common finding in such patients.11 Duffy et al have used superior gluteal artery perforator flap for the reconstruction of myelomeningocele defects. They reported that due to the vascularity and durability of superior gluteal artery perforator flaps, they are hopeful for decreasing occurrence of chronic pain at the closure site and possibly for diminishing the incidence of tethered cord.12 Our impression is similar; we believe that as vascularity of flaps used for reconstruction becomes more reliable, fibrotic adhesions around the healing site decreases, which may have a positive effect on diminishing symptoms such as chronic pain and other symptoms indicating the presence of tethered cord. Dorsal intercostal artery perforator propeller flaps enable us to cover the whole myelomeningocele defect, either thoracolumbar or lumbosacral, by using only 1 flap which decreases extent of dissection and thus decreasing scar formation over the back. Unlike random pattern flaps, DIAP propeller flaps have a predictable outcome. Dorsal intercostal artery perforators are located within 5 cm from the spinous process of vertebra.13 Dorsal intercostal artery perforators can capture the territories of the musculocutaneous perforators on the latissimus dorsi muscle, the circumflex scapular artery, and the direct cutaneous branch of thoracodorsal artery, by means of choke anastomoses.13 Thus, based on a single DIAP, a large flap can be planned safely (Figs. 2A, B). Random pattern flaps such as bipedicled flaps, local transposition flaps, the double Z-plasty, rotation flaps, and Limberg flaps require extensive undermining and thus have a greater risk of wound edge necrosis.14 Also random flaps do not have a described vascular supply, which makes such options unpredictable for complete flap survival. Skin perforators of the seventh, eighth, and ninth intercostal arteries were less dominant than the other DIAPs because they were covered by latissimus dorsi muscle.13 Skin branches of the seventh, eighth, and ninth DIAPs are less dominant than muscle branches of the same perforators.13 That is why for closure of myelomeningocele defects, we generally use the closest most reliable perforators. So, the sixth and/or more superior dorsal intercostal artery skin perforators are generally selected because they are more sizable. However, this may enlarge and elongate the dimensions of the planned flap. Although the distal end of the DIAP flaps is suggested to be set within the lateral margin of latissimus dorsi muscle,13 we had to elongate the flap tip 436
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until the anterior axillary line margin in one of our patients and until the midaxillary line in the other and the flaps survived completely (Figs. 2A, B). However, sometimes the seventh or more inferior DIAPs may also be selected especially if planned flap is small. Primary closure of flap donor sites is performed in all cases. Unlike many other options, DIAP propeller island flaps successfully reconstruct whole defect by using only 1 flap. Muskett et al15 have reported that minor wound complications increased hospitalization from 23 to 35 days, whereas major wound problems causing return to the operating room increased hospitalization from 23 to 45 days in patients with meningomyelocele defects. Most of the patients included in this study were premature, thus hospitalization period of patients were determined by their general health status and by their pediatricians because we do not have minor or major wound complications related to flap failures. However, we did not compare the hospitalization time of meningomyelocele defects reconstructed with perforator propeller flaps and the ones reconstructed with random pattern flaps. This comparison may be an issue of another study. We oriented DIAP flap horizontally except for 1 patient. In this only case where the flap was oriented vertically, wound healing was not as good as the horizontally oriented ones. Scar tissue was wider in this only case. That is why we used vertical orientation of flap in only 1 case.
FIGURE 3. DIAP is seen after dissection is completed supplying DIAP flap. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 76, Number 4, April 2016
DIAP Propeller Flaps
FIGURE 4. A, A myelomeningocele defect with 6 5 cm was planned for reconstruction with a 7 6-cm vertically oriented DIAP propeller island flap. B, Patient is seen at postoperative 2 weeks.
Isik et al8 also used DIAPs for supplying the flap. They protected DIAPs in reconstruction of 27 cases. Eight of 27 flaps were turned to island flaps for better mobilization. In other 19 cases, intact skin islands of 2 cm were protected. In this article, the reason why 19 cases were not turned to island flaps was not explained. It is not clear if the authors think that DIAP propeller island flaps may not be as predictable as peninsular flaps and may cause distal edge necrosis. But as it is mentioned in the article, islanded perforator flaps provide more mobility. Isik et al reported marginal flap necrosis at the distal part of flaps in 2 patients but it was not mentioned if marginal necrosis occurred in islanded flaps or in flaps with intact skin bridges. However, perforator flaps provide predictability and also more freedom in mobilizing flaps. If flaps are bound by a skin bridge to the donor site, this will limit its move toward the defect area. In our series, island DIAP propeller flaps were used in all 13 cases and all flaps survived completely. This result shows that island DIAP propeller flaps constitute a reliable, well-vascularized option and the skin suture lines do not overlap between the dura suture lines over the midline. During our very first operations, we first identified the perforator pedicle safely after a short skin incision over the superior edge of the planed flap. After seeing the perforators, we incised the skin and subcutaneous tissue over the flap borders completely. This was performed as a safety measure to assess the size of pedicle calibers before the flap borders are incised completely. In case if an unreliable perforator was present, the reconstructive plan could be changed in favor of a random pattern flap to be used for defect reconstruction. However, until now reconstructive plan was not changed in any of our patients. As we gained experience, we abandoned this application. Flap base neighboring the vertebral column, where the perforators arise, are kept wide to include more perforators to the flap from several levels (2 or 3 intervertebral spaces) and compare their sizes during flap elevation. As in every reconstructive case, we have to have a “B plan” in case if flap necrosis occurs. Although all DIAP propeller island flaps survived completely in our series, our “B plan” for myelomeningocele defect reconstruction is to use another reliable perforator from the opposite site of the vertebral column or another perforator from more superior level.
CONCLUSIONS We operated on 13 consecutive cases with myelomeningocele and all were successfully reconstructed with DIAP propeller island flaps with complete flap survival in all cases. Having a reliable and satisfactory “B plan” for reconstruction of defect is an advantage of this technique. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Mobilizing a well-vascularized tissue over the defect, no overlapping of suture lines of dura and skin after layered closure, leaving intact back muscles, and primary closure of flap donor sites are the advantages of DIAP propeller island flaps. Use of perforator flaps provides 2 important advantages, namely, more predictability and more freedom in mobilizing flaps toward the defect. This study proves the reliability of DIAP propeller flaps in the reconstruction of myelomeningocele defects. REFERENCES 1. Au KS, Northrup H, Kirkpatrick TJ, et al. Promoter genotype of the plateletderived growth factor receptor-alpha gene shows population stratification but not association with spina bifida meningomyelocele. Am J Med Genet A. 2005;139: 194–198. 2. Patel KB, Taghinia AH, Proctor MR, et al. Extradural myelomeningocele reconstruction using local turnover fascial flaps and midline linear skin closure. J Plast Reconstr Aesthet Surg. 2012;65:1569–1572. 3. VanderKolk CA, Adson MH, Stevenson TR. The reverse latissimus dorsi muscle flap for closure of meningomyelocele. Plast Reconstr Surg. 1988;81:454–456. 4. Selçuk CT, Civelek B, Bozkurt M, et al. Reconstruction of large meningomyelocele defects with rotation-transposition fasciocutaneous flaps. Ann Plast Surg. 2012;69:197–202. 5. Komuro Y, Yanai A, Koga Y, et al. Bilateral modified V-Yadvancement flaps for closing meningomyelocele defects. Ann Plast Surg. 2006;57:195–198. 6. Lapid O, Rosenberg L, Cohen A. Meningomyelocele reconstruction with bilobed flaps. Br J Plast Surg. 2001;54:570–572. 7. El-Sabbagh AH, Zidan AS. Closure of large myelomeningocele defects by lumbar artery perforator flaps. J Reconstr Microsurg. 2011;27:287–294. 8. Isik D, Tekes L, Eseoglu M, et al. Closure of large myelomeningocele defects using dorsal intercostal artery perforator flap. Ann Plast Surg. 2011;67:159–163. 9. Atik B, Tan O, Kiymaz N, et al. Bilobed fasciocutaneous flap closure of large meningomyeloceles. Ann Plast Surg. 2006;56:562–564. 10. Hosseinpour M, Forghani S. Primary closure of large thoracolumbar myelomeningocele with bilateral latissimus dorsi flaps. J Neurosurg Pediatr. 2009;3: 331–333. 11. Tamaki N, Shirataki K, Kojima N, et al. Tethered cord syndrome of delayed onset following repair of myelomeningocele. J Neurosurg. 1988;69:393. 12. Duffy FJ Jr, Weprin BE, Swift DM. A new approach to closure of large lumbosacral myelomeningoceles: the superior gluteal artery perforator flap. Plast Reconstr Surg. 2004;114:1864–1868. 13. Minabe T, Harii K. Dorsal intercostal artery perforator flap: anatomical study and clinical applications. Plast Reconstr Surg. 2007;120:681–689. 14. Sarifakioglu N, Bingul F, Terzioglu A, et al. Bilateral split latissimus dorsi V-Y flaps for closure of large thoracolumbar meningomyelocele defects. Br J Plast Surg. 2003;5:303–306. 15. Muskett A, Barber WH, Parent AD, et al. Contemporary postnatal plastic surgical management of meningomyelocele. J Plast Reconstr Aesthet Surg. 2012;65: 572–577.
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