presentation at the international neurosurgery congress held at Oran on march 2012

1. Skin closure of large
spina-bifida
A new approach
By Docteur Ahcene Madjoudj

2. Docteur Ahcene Madjoudj
 Plastic Surgeon.
 I practice in the liberal sector in Algiers (Algeria).
 I also collaborate with neuro-surgery departments of CHU
Blida and Bab-El-Oued mainly in spina-bifida and Cranio-
facial surgery.
 I am a member of the Canadian Society for Aesthetic
Plastic Surgery (csaps).

3. Definition
The myelomeningocele is alterations of :
 Meninges.
 Roots of nervous tissues.
 Medulla.
 the posterior vertebral wall.
 Skin structures above the myelomeningocele.
The cause is an absence of closure of the neural tube during
embryonic life.

4. Question importance
The closure of large myelomeningocele is very challenging , it
often requires a plastic surgeon within the surgery team .
The technique that we will describe in this presentation can be
practiced by any neurosurgeon..

5. Surgical techniques

6. Three forms of spina-bifida:
 spina-bifida Occulta: the most frequent and benign .
 spina-bifida meningocele: with few neurologic disorders.
 spina-bifida myelomeningocele : the severest form with
important neurologic disorders often associated with an
hydrocephaly.

7. Hydrocephalia problem
 Before and after the intervention, the hydrocephaly must
me seriously monitored.
 If present before surgery, it must be shunted.
 After the surgery, we have to look out for its apparition and
shunt it consequently.

8. Existing techniques recap

9. Skin expanding technique
The principle is to expand the adjoining healthy skin
around the spina bifida by skin expanders to cover the
skin defect.
Drawbacks
 Two surgeries.
 Duration of inflating: two to three months.
 Important morbidity.
Personally I have abandoned this technique..

11. Veinous congestion

12. Healing difficulties ..

13. Muscular flaps

14. Latisimus dorsi flap
By using the reversed turnover latissimus dorsi muscle flap.
Drawbacks
 Should not be used with paraplegic patients because it
causes some shoulder disabilities.
 This technique also requires a skin graft.

15. Latissimus dorsi flap

16. Gluteal muscular flap
 Taken from whole buttocks muscle or partially pedicled on upper gluteal
artery
Drawbacks
 This method can’t cover up the cutaneous deficit when it is important.
 The gluteal muscle flap rotating axis is limited.

17. Gluteal muscular flap

18. Cutaneous perforators flaps

19. The principle
Take a large pedicled cutaneous flap on perforators vessels
while preserving the muscle.
The perforators vessels are spotted with Doppler flowmeter.

20. Advantages
 The flap might cover up a large skin loss.
 Its rotation is very large.
Drawbacks
 On babies perforators are very small and delicate.
 This technique requires the presence of a plastic surgeon
with skills in microsurgery.
 In large spina-bifida bilateral flaps are required for the
closure thus increasing morbidity.

22. The most used perforator
flaps

23. The upper gluteal perforator flap
advantages
 Near the lower spina-bifida
 The flap can be large.
 The donar area closure is easy.
Drawbacks:
 Cannot cover large upper spina-bifida .
 With large spina-bifida , 2 flaps must be used which is
damaging.

24. The latero-costal perforator flap
It is centered on the 9th or 11th intercostal artery.
Drawbacks
The region from where the flap is taken can be wide which
makes its closure difficult.

25. The lumbar perforator flap
It is taken from lumber artery, mainly for the 2th or the 4th
lumber artery
Drawback
With large spina-bifida , 2 flaps must be used which is
damaging.

26. Lumbar perforator flap

27. lumbar cutanuous perforator flap

28. The Extensive cutaneous undermining
Our approach

29.  Our surgical approach makes use of the remarkable
vascularization and elasticity of child’s skin

30. ANATOMY RECALL
Cutaneous skin vascularization .
Importance of perforator vessels

31. The technique principles
 The incision must be done with preserving as much skin as
possible, even if the skin doesn’t seem healthy.
 Extensive skin undermining by sacrificing the perforator
vessels.
 Preserve the perforators of the gluteal region for possible
use of gluteal perforator flap if necessary.
 Use discharges incisions or z pasties to relieve the tension
on the scar if necessary.

32. Instrumentation

33. Peculiarity of the incision
 After subcutaneous infiltration around the base of the
spina-bifida xylocaine epinephrine diluted in physiological
saline to the quarter to reduce bleeding.
 Tilt the blade N 15 to 60 degrees for cutting and
maintaining the sclerotic tissue around the sac that will be
used if needed for the neural tube closure.

34. Technique description

35. Sac treatment

36. Nervous tissues are detached
from the sac

37. Sac aspect after treatment

38. Neural tube closure

39. Neural tube closure

40. Important skin loss..

41. Evaluation of the skin
undermining
 We apply few sutures on the subcutaneous tissue at the
base of the spina-bifida.
 We pull together both verges so we can evaluate the
dissection required for the closure.

42. laxity skin evaluation

43. Lateral skin undermining with
perforator vessels sacrifice

44. Sens of skin laxity
 After testing skin laxity , we opt for the best closure
solution which can be horizontal or vertical

45. Vertical closures
Must be favoured because often they are less problem prone

46. • (Photos…..)

48. Vertical closure problems
• If desaturation occurs during closure, it may be adjusted by
discharges incisions.

49. 15 days ..
6 months ..

50. Closure difficulties on some
localized area

51. Closure difficulties on third lower

52. Flap raising

53. Cover up of the area

54. Results day 4

55. Horizontal closures
 Horizontal closure are done along the lines of the back
tensions by sacrificing the perforator vessels.
 This type of closure is only possible if the surrounding
skin is elastic .
 If tensions on the scar occurs, we use the discharges
incisions or z plasties.

57. Horizontal closure problems

58. Long term results

59. Long term results
6 months…

60. 6 months..

61. Techniques comparison
Perforator Muscular Extensive cutaneous
skin flap flap undermining
operative time 4-5h 4-5h 2h
Blood loss important important Less important
CSF leaks n/a n/a null
Infections risks yes yes yes
Healing time long long short(15D)
Hospitalization n/a n/a 8D
duration
skills plastic Plastic neurosurgeon
surgeon surgeon

62. Conclusion
Closure technique by perforator flaps is a surgical
achievement, but results are not superior compared to our
approach.
Our approach does not require the presence of a plastic
surgeon and can take place in all surgical facilities.

63. Bibliography
• Journal of Plastic, Reconstructive & Aesthetic Surgery (2010)
63,1513e1518.
• “Reversed turnover latissimus dorsi muscle flap for closure
of large myelomeningocele defects.”
Yehia Zakaria a, Esam A. Hasan b
• Closure of Large meningomyelocele Defects by Lumbar
Artery Perforator Flaps. Ahmed Hassan El-Sabbagh(M.D.)
• http://www.chirurgieesthetiquealgerie.com/la-spina-
bifidaprogresse-en-algerie

64. Thank you ...
Slides on:
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