Intraoperative acute tissue expansion for the closure of large myelomeningoceles.

Abstract

Skin closure has always been the main challenge in treating myelomeningoceles (MMCs). Most cutaneous defects can be treated with the simple undermining and primary suture of the wound edges. This is the ideal treatment, but it is not adequate in cases in which the lesions are greater than 5 cm in diameter. Numerous reconstructive procedures have been described and the results have been satisfactory. The need to mobilize large skin areas and the fact of excessive blood loss, however, are major problems in newborns. Moreover, the tissue undermining destroys most of the skin's vascularization and can harm the adaptation of the skin flaps. The authors describe a technique for primary closure of large MMC skin defects in which they use acute skin expansion during the surgical procedure. Skin expansion was achieved by traction of the wound edges with U-shaped sutures and without the need of skin flaps. Sixteen patients with MMCs greater than 5 cm in diameter were evaluated. The MMC areas ranged from 30 to 64 cm2 (mean 45 cm2). Two suture systems were developed based on the quality of the skin edge and the size of the skin defect. Wound edge traction was performed in 10-minute periods. The edges were gradually approximated and this allowed the primary closure of the wound without undermining the tissue in all patients. In one patient skin necrosis developed, which was associated with compression of the malformed underlying vertebrae. Simplicity, low cost, and satisfactory results were the main advantages of the method and an increase in operative time was a disadvantage. The goal of this technique is not to replace the other methods, but the technique constitutes an effective option in the treatment of large MMCs.