Closure of large lumbosacral defect using a combined method of bilateral bipedicle flap with lateral releasing incision and Integra® dermal regeneration template

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Abstract

BACKGROUND: Myelomeningocele is one of the most complex congenital malformations of the central nervous system. It is one of the most common types of spina bifida which involves a failure of neural tube closure. Reconstruction surgery for myelomeningocele had always been challenging for plastic and neurosurgeons.

CLINICAL CASE: We report a case of a new-born with lumbosacral myelomeningocele who received treatment in the Hospital Universiti Sains Malaysia. The myelomeningocele was repaired by the neurosurgery team and subsequently, the child was left with huge lumbosacral skin defect. The large defect was successfully covered by using a combined method of bilateral bipedicle flap with lateral releasing incision and remaining lumbosacral and secondary defect resurfaced using Integra® dermal regeneration template (DRT). We used ACTICOAT interfaced negative pressure wound therapy (NPWT) as our main dressing in preparing the wound bed for autologous epidermal graft. The result of our closure technique provides tension free closure.

DISCUSSION: We incorporated bilateral bipedicle fasciocutaneous flap technique together with DRT for closure of the lumbosacral defect. The bilateral bipedicle flap with lateral releasing incision served to reduce tension on the skin at bilateral lumbar region. The DRT downsized the lumbosacral defect and NPWT dressing provided an optimal sterile environment in giving time for neodermis generation. The remaining secondary defect were also resurfaced utilizing DRT and autologous skin grafting.

CONCLUSIONS: The outcome of surgery demonstrated that the combined use of bilateral bipedicle fasciocutaneous flap with lateral releasing incision and DRT with delayed skin grafting is safe, effective and provide long term stable and supple scar for large, exposed dura defect.

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About the authors

Pauline Yap

Universiti Malaysia Sabah; Universiti Sains Malaysia

Email: paulineyap@live.com
ORCID iD: 0000-0002-2228-3473

MD

Malaysia, Kota Kinabalu, Sabah; 16150 Kubang Kerian, Kelantan

Arman Zaharil Mat Saad

Universiti Sains Malaysia; Management and Science University

Email: armanzaharil@gmail.com
ORCID iD: 0000-0002-4003-6783

M.Sc., Professor

Malaysia, 16150 Kubang Kerian, Kelantan; Shah Alam, Selangor

Wan Azman Wan Sulaiman

Universiti Sains Malaysia

Email: wsazman@yahoo.com
ORCID iD: 0000-0002-0600-9765

M.Sc., Professor

Malaysia, 16150 Kubang Kerian, Kelantan

Siti Fatimah Noor Mat Johar

Universiti Sains Malaysia

Email: fatimahmj@usm.my
ORCID iD: 0000-0003-4120-4918

M.Sc.

Malaysia, 16150 Kubang Kerian, Kelantan

Nurul Syazana Mohamad Shah

Universiti Sains Malaysia

Author for correspondence.
Email: syazanashah@usm.my
ORCID iD: 0000-0001-6731-9962

PhD

Malaysia, 16150 Kubang Kerian, Kelantan

References

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  2. Shim JH, Hwang NH, Yoon ES, et al. Closure of myelomeningocele defects using a limberg flap or direct repair. Arch Plast Surg. 2016;43(1):26–31. doi: 10.5999/aps.2016.43.1.26
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Supplementary files

Supplementary Files
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2. Fig. 1. Initial Wound: Large lumbosacral defect 9 × 4.5 cm revealed after myelomeningocele repair. Central of wound showed repaired exposed dura

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3. Fig. 2. Flap design: Bipedicle bilateral flap with lateral releasing incision made with the ratio of 1:2 at the posterior axillary line. Skin is undermined up to deep fascia

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4. Fig. 3. Immediately After Coverage: Lumbosacral and secondary defect covered with DRT. Bipedicle bilateral flap (shown in black arrow) with lateral releasing incision (shown in red arrow) created with the ratio of 1:2 at the posterior axillary line

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5. Fig. 4. Two weeks after Integra® application. The wound bed showed good sign of neo-dermis integration into the dermal regeneration template. Silicone layer was intact

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6. Fig. 5. Wound Bed After Silicone Layer Removed. Good granulation tissue seen at wound bed and epithelization of wound edges at three weeks post initial surgery. Lumbosacral wound was downsized to 7 × 4 cm

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7. Fig. 6. Autologous skin graft application. Sheet skin graft applied over matured neo-dermis

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8. Fig. 7. 1-year after surgery. The wound appears to have healed and supple skin over the lumbosacral region

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Copyright (c) 2021 Yap P., Mat Saad A., Wan Sulaiman W., Mat Johar S., Mohamad Shah N.

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This work is licensed under a Creative Commons Attribution 4.0 International License.
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