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OPERTAIVE NUANCES
Year : 2009  |  Volume : 4  |  Issue : 1  |  Page : 25-29
 

Tissue expansion technique for closure of myelomeningocele


1 Department of Neurosurgery, BGS Global Neuroscience Institute, India
2 Department of Plastic Surgery, Manipal Hospital, India

Correspondence Address:
N K Venkataramana
Director - BGS Global Neuroscience Institute, Vice Chairman- BGS Global Hospital, BGS Health and Education City, No. 67, Uttarahalli Road, Kengeri, Bangalore - 560060
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1817-1745.49104

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How to cite this article:
Venkataramana N K, Anantheshwar Y N. Tissue expansion technique for closure of myelomeningocele. J Pediatr Neurosci 2009;4:25-9

How to cite this URL:
Venkataramana N K, Anantheshwar Y N. Tissue expansion technique for closure of myelomeningocele. J Pediatr Neurosci [serial online] 2009 [cited 2019 Apr 18];4:25-9. Available from: http://www.pediatricneurosciences.com/text.asp?2009/4/1/25/49104


Skin closure of a wide-based myelomeningoceles is still a surgical challenge. The difficulties are compounded by dysplastic skin, secondary infection, the wide base of the defect, and poor development of facial and muscular structures underneath. Conventionally, surgeons have used mobilization of skin flaps, relaxing incisions, and rotational flaps, which need team work with plastic surgeons. However, these techniques are associated with longer duration of surgery , blood loss, and morbidity in the form of wound dehiscence. [1],[4] We report here a surgical technique on a child with a wide-based, thoraco-lumbar Myelomeningocele with dysplastic skin, wherein tissue expansion was used to achieve primary closure [Figure 1],[Figure 2],[Figure 3],[Figure 4].

The expansion of skin was first reported in 1947 by Nuemann. [2] Expanders are available in variety of shapes and sizes and their selection depends on the size of the tissue required and the age of the child. The size and shape of the expander and the incision to be inserted need to be properly planned preoperatively. The surgery is performed in two stages 1. Insertion of the expander 2. Definitive procedure. [3],[4]

The child was positioned prone under general anesthesia and the part was prepared. A curvilinear incision was made just at the upper margin of the myelomeningocele. The subcutaneous tissue was dissected and a plane was created in the healthy area. A Eurosilicon tissue expander was inserted horizontally and the incision was closed, leaving an access port at one corner [Figure 5]. The child was discharged after being prescribed antibiotics. Usually, the expansion should start one to two weeks after the insertion, ensuring proper wound healing to avoid disruption of the incision during expansion. Biweekly injections of 50 mL of sterile saline through the port were carried out as recommended by the manufacturer until an expansion capacity of 300 mL was reached [Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10].Then, an additional 200 mL was injected to overexpand the device as recommended. These saline injections were done as an outpatient procedure. The required expansion took six weeks in our case [Figure 11], the integrity of the skin being checked (as deemed mandatory) during each visit.

The child was later readmitted for definitive surgery where the incision was planned under general anesthesia by the plastic surgeons. The skin and the subcutaneous tissues were dissected [Figure 16], the dysplastic skin was totally excised [Figure 12], and the neuronal placode was isolated [Figure 13],[Figure 14], dissected around, and repositioned. The dural tube was reconstructed and the fascia was mobilized and covered over the dural tube [Figure 15]. There was a wide skin defect [Figure 18] and the incision was expanded to deliver the tissue expander in toto [Figure 19],[Figure 20],[Figure 21]. The expanded skin was now mobilized onto the defect to cover the skin defect over the myelomeningocele [Figure 17]. Thus, primary closure was achieved easily [Figure 22] and the wound healed well without any complications. We feel this is a well tolerated, sophisticated procedure with minimum morbidity for children with larger skin defects.

 
   References Top

1.Harold L Rekate, Comprehensive Management of Spina Bifida. CRC Press. Inc; 1991.  Back to cited text no. 1    
2.O Conell JE. Craniopagus twins surgical anatomy and embryology and their implication: J Neurol Neurosurg Psychiatry 1976:39:1-22.  Back to cited text no. 2    
3.Rivera R, LoGiudice J, Gosain AK. Tissue expansion in pediatric patients. Clin Plstic Surg 2005;32:35-44.  Back to cited text no. 3    
4.Venkataramana, Surgery for Myelomeningocele, Text book of Operative Neurosurgery 2005;2:1115-9.  Back to cited text no. 4    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22]


This article has been cited by
1 Spinal dysraphism
Venkataramana, N.K.
Journal of Pediatric Neurosciences. 2011; 6(3 sup): 31-40
[Pubmed]



 

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