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Skin closure of large spina-bifida A new approach
By Docteur Ahcene Madjoudj
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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).
Docteur Ahcene Madjoudj
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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.
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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..
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Surgical techniques
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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 anhydrocephaly.
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Hydrocephalia problem
Before and after the intervention, the hydrocephaly mustme 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.
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Existing techniques recap
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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..
Skin expanding technique
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Veinous congestion
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Healing difficulties ..
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Muscular flaps
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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.
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Latissimus dorsi flap
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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.
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Gluteal muscular flap
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Cutaneous perforators flaps
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The principle Take a large pedicled cutaneous flap on perforators vessels while preserving the muscle. The perforators vessels are spotted with Doppler flowmeter.
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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.
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The most used perforator flaps
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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.
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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.
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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.
The lumbar perforator flap
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Lumbar perforator flap
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lumbar cutanuous perforator flap
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Our approach The Extensive cutaneous undermining
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Our surgical approach makes use of the remarkable vascularization and elasticity of child’s skin
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ANATOMY RECALL
Cutaneous skin vascularization . Importance of perforator vessels
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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.
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Instrumentation
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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.
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Technique description
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Sac treatment
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Nervous tissues are detached from the sac
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Sac aspect after treatment
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Neural tube closure
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Neural tube closure
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Important skin loss..
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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.
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laxity skin evaluation
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Lateral skin undermining with perforator vessels sacrifice
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Sens of skin laxity After testing skin laxity , we opt for the best closure
solution which can be horizontal or vertical
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Vertical closures
Must be favoured because often they are less problem prone
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• (Photos…..)
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Vertical closure problems • If desaturation occurs during closure, it may be adjusted by
discharges incisions.
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6 months .. 15 days ..
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Closure difficulties on some localized area
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Closure difficulties on third lower
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Flap raising
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Cover up of the area
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Results day 4
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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.
Horizontal closures
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Horizontal closure problems
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Long term results
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6 months…
Long term results
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6 months..
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Techniques comparison Perforator
skin flap Muscular flap
Extensive cutaneous 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 duration
n/a n/a 8D
skills plastic surgeon
Plastic surgeon
neurosurgeon
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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.
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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
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Thank you ... Slides on: http://www.chirurgieesthetiquealgerie.com