Alternative method for the reconstruction of meningomyelocele defects: V-Y rotation and advancement flap

Abstract

Object: Skin grafts, skin flaps, fasciocutaneous flaps, muscle flaps, and musculocutaneous flaps have been used for closure of large meningomyelocele (MMC) defects that cannot be closed primarily. The V-Y rotation advancement flap technique has been used successfully for the reconstruction of defects in different areas of the body. In the present study, the authors report on their novel use of this technique in both a binary and a quadruple (butterfly) flap manner for closure of large MMC defects. They also present an algorithm that they developed for the evaluation of MMC defects. Methods: Between January 2011 and November 2013, 17 patients (13 girls and 4 boys) with extremely large MMC defects that could not be repaired by direct primary closure underwent reconstruction of the defects with binary and quadruple V-Y rotation and advancement flaps. With the patient prone, the axillary apices, the most craniad point of the intergluteal sulcus, and the posterior axillary lines were marked, and a rectangular area on the back was designed. Edges of the rectangular area and the transverse and longitudinal diameters of the defect were measured and the presence of kyphosis was noted. These measurements and their proportions were used to develop an algorithm for patient assessment. While binary flaps were planned over the transverse diameter of the defects, quadruple flaps were planned over the bisectors of the defects, which were closed by elevating fasciocutaneous flaps. Results: For patients whose defect diameter to back width ratio was between 0.30 and 0.50 and whose mean ratio of defect area to donor area was between 0.09 and 0.15, binary V-Y rotation and advancement flaps were used. When these values were in the range of 0.50-0.66 and 0.16-0.35, respectively, quadruple V-Y rotation and advancement flaps were preferred. The mean duration of postoperative follow-up was 10.4 months. With the exception of minor complications, such as partial necrosis of 0.5 × 0.5 cm in a quadruple flap, all the flaps healed uneventfully. Conclusions: With this study, closure of MMC defects with V-Y rotation and advancement flaps has been defined for the first time in the literature. The use of this technique with multiple flaps is an effective alternative to other flap options for the closure of large MMC defects. The algorithm developed in the course of this study should facilitate evaluation and reconstruction planning for patients with MMC defects.