PURPOSE: Repair of myelomeningocele defects traditionally involved simple approximation and closure of tissue adjacent to the defect. The result was deep deformational scarring, contraction, and a thin soft tissue covering over the spinal cord, leaving it vulnerable to physical agitation, trauma, CSF leak, and infection. A recent trend has been toward reduction of the myelomeningocele and midline closure of the dura followed by soft tissue closure utilizing muscle and fascial flap techniques to attain multiple anatomic layers. The goal of this composite closure is to provide a generous, durable, protective, and tension-free soft tissue covering over the repaired dura and spinal cord and to restore the muscular organization of the lower back. Although large defects frequently prompt plastic surgical consultation to help manage wound closure, smaller soft tissue defects associated with myelomeningocele repair are thought to be amenable to simple soft tissue approximation and are often handled by neurosurgeons alone. We propose that composite tissue closure yields superior outcomes regardless of defect size and that a collaborative effort between Neurosurgery and Plastic surgery can be rewarded with enhanced structural and functional results. To support this hypothesis, we present our experience with a 15-year retrospective review, the largest study to date, whereby Plastic Surgery performed the soft tissue component closure of every myelomeningocele repair performed in our hospital.
METHODS: Patients born with a myelomeningocele defect received primary repair and closure by Neurosurgery and Plastic Surgery between 1994 and 2008 at the University of Michigan C.S. Mott Children’s Hospital. A retrospective review of these patients’ medical records was performed to document patient demographics, defect characteristics, hospital course, and post-operative complications.
RESULTS: A total of 45 patients were evaluated. The average defect size was 5.9 cm in length by 4.4 cm in width. The technique used for soft tissue closure was dictated by defect characteristics, utilizing varied combinations of muscle and fascial flaps to protect the spinal cord and dura, stagger suture lines to protect from CSF leak, and restore natural lumbosacral contours while minimizing scarring. Skin was closed through simple linear closure or local tissue re-arrangement. Post-operatively, no patients developed CSF leaks and only one patient required re-operation after developing an area of flap necrosis treated with excision and flap re-advancement. Complications were otherwise minor and did not require re-operation, with the most common being superficial skin flap separation (22% of patients) and subcutaneous infection requiring antibiotic administration (4% of patients).
CONCLUSION: This is the largest study to date looking at multiple-layered soft tissue closure following myelomeningocele reduction and the first to suggest beneficial outcomes as a result of universal Plastic Surgery involvement. Although defect size and co-morbidities varied, consistent principles were used to achieve our goals while minimizing complications. Our results are superior to those reported in previous studies, which cite higher rates of CSF leak, re-operation, and minor complications. Objective measures show that the armamentarium of flap techniques brought to the table by Plastic Surgery leads to better outcomes for soft tissue closure after myelomeningocele repair.