Clinical outcome of V-Y flap with latissimus dorsi and gluteal advancement for treatment of large thoracolumbar myelomeningocele defects: a comparative study

Mohammad Sadegh Masoudi Department of Neurosurgery,

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Mohammad Ali Hoghoughi Department of Plastic and Reconstructive Surgery, and

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Fariborz Ghaffarpasand Research Center for Neuromodulation and Pain, Shiraz University of Medical Sciences, Shiraz, Iran

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Shekoofeh Yaghmaei Department of Neurosurgery,

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Maryam Azadegan Department of Neurosurgery,

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Ghazal Ilami Department of Neurosurgery,

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OBJECTIVE

Surgical repair and closure of myelomeningocele (MMC) defects are important and vital, as the mortality rate is as high as 65%–70% in untreated patients. Closure of large MMC defects is challenging for pediatric neurosurgeons and plastic surgeons. The aim of the current study is to report the operative characteristics and outcome of a series of Iranian patients with large MMC defects utilizing the V-Y flap and with latissimus dorsi or gluteal muscle advancement.

METHODS

This comparative study was conducted during a 4-year period from September 2013 to October 2017 in the pediatric neurosurgery department of Shiraz Namazi Hospital, Southern Iran. The authors included 24 patients with large MMC defects who underwent surgery utilizing the bilateral V-Y flap and latissimus dorsi and gluteal muscle advancement. They also retrospectively included 19 patients with similar age, sex, and defect size who underwent surgery using the primary or delayed closure techniques at their center. At least 2 years of follow-up was conducted. The frequency of leakage, necrosis, dehiscence, systemic infection (sepsis, pneumonia), need for ventriculoperitoneal shunt insertion, and mortality was compared between the 2 groups.

RESULTS

The bilateral V-Y flap with muscle advancement was associated with a significantly longer operative duration (p < 0.001) than the primary closure group. Those undergoing bilateral V-Y flaps with muscle advancement had significantly lower rates of surgical site infection (p = 0.038), wound dehiscence (p = 0.013), and postoperative CSF leakage (p = 0.030) than those undergoing primary repair. The bilateral V-Y flap with muscle advancement was also associated with a lower mortality rate (p = 0.038; OR 5.09 [95% CI 1.12–23.1]) than primary closure. In patients undergoing bilateral V-Y flap and muscle advancement, a longer operative duration was significantly associated with mortality (p = 0.008). In addition, surgical site infection (p = 0.032), wound dehiscence (p = 0.011), and postoperative leakage (p = 0.011) were predictors of mortality. Neonatal sepsis (p = 0.002) and postoperative NEC (p = 0.011) were among other predictors of mortality in this group.

CONCLUSIONS

The bilateral V-Y flap with latissimus dorsi or gluteal advancement is a safe and effective surgical approach for covering large MMC defects and is associated with lower rates of surgical site infection, dehiscence, CSF leakage, and mortality. Further studies are required to elucidate the long-term outcomes.

ABBREVIATIONS

MMC = myelomeningocele; NEC = necrotizing enterocolitis; SSI = surgical site infection; VP = ventriculoperitoneal.

OBJECTIVE

Surgical repair and closure of myelomeningocele (MMC) defects are important and vital, as the mortality rate is as high as 65%–70% in untreated patients. Closure of large MMC defects is challenging for pediatric neurosurgeons and plastic surgeons. The aim of the current study is to report the operative characteristics and outcome of a series of Iranian patients with large MMC defects utilizing the V-Y flap and with latissimus dorsi or gluteal muscle advancement.

METHODS

This comparative study was conducted during a 4-year period from September 2013 to October 2017 in the pediatric neurosurgery department of Shiraz Namazi Hospital, Southern Iran. The authors included 24 patients with large MMC defects who underwent surgery utilizing the bilateral V-Y flap and latissimus dorsi and gluteal muscle advancement. They also retrospectively included 19 patients with similar age, sex, and defect size who underwent surgery using the primary or delayed closure techniques at their center. At least 2 years of follow-up was conducted. The frequency of leakage, necrosis, dehiscence, systemic infection (sepsis, pneumonia), need for ventriculoperitoneal shunt insertion, and mortality was compared between the 2 groups.

RESULTS

The bilateral V-Y flap with muscle advancement was associated with a significantly longer operative duration (p < 0.001) than the primary closure group. Those undergoing bilateral V-Y flaps with muscle advancement had significantly lower rates of surgical site infection (p = 0.038), wound dehiscence (p = 0.013), and postoperative CSF leakage (p = 0.030) than those undergoing primary repair. The bilateral V-Y flap with muscle advancement was also associated with a lower mortality rate (p = 0.038; OR 5.09 [95% CI 1.12–23.1]) than primary closure. In patients undergoing bilateral V-Y flap and muscle advancement, a longer operative duration was significantly associated with mortality (p = 0.008). In addition, surgical site infection (p = 0.032), wound dehiscence (p = 0.011), and postoperative leakage (p = 0.011) were predictors of mortality. Neonatal sepsis (p = 0.002) and postoperative NEC (p = 0.011) were among other predictors of mortality in this group.

CONCLUSIONS

The bilateral V-Y flap with latissimus dorsi or gluteal advancement is a safe and effective surgical approach for covering large MMC defects and is associated with lower rates of surgical site infection, dehiscence, CSF leakage, and mortality. Further studies are required to elucidate the long-term outcomes.

In Brief

The work was done to provide a new and better surgical technique for management of patients with large myelomeningocele defects. The subject is important as the surgical management of patients with large myelomeningocele defects remains challenging to pediatric neurosurgeons.

Surgical repair and closure of myelomeningocele (MMC) defects is important and vital, as the mortality rate is as high as 65%–70% in untreated patients.4 The aim of surgical repair is to protect the neural elements by placing them in the thecal sac, stop the CSF leakage, and decrease the rate of meningitis and infection.2,19 Limited and small defects can be closed and repaired primarily, while closure of large defects remains a challenge for neurosurgeons and plastic surgeons. Large thoracolumbar defects are associated with high mortality and morbidity, and their closure and coverage have been the subject of several research investigations. To date, several surgical techniques have been introduced for closure of large MMC defects, including rotation, advancement, Limberg, bipedicled, musculocutaneous, and perforator flaps.6,10,11,13,14,23,26 However, these methods are all associated with some disadvantages, such as flap necrosis, longer operative duration, and mortality.14,23,26 We herein introduce a new technique, a V-Y flap with advancement of gluteus or latissimus dorsi muscles for closure of large MMC defects. This method provides several advantages, including no need for skin grafts and no wasted muscle tissue. Moreover, this method is simple and easy, resulting in less blood loss and minimal operative time; it is safe and produces reliable results while eliminating wound dehiscence and skin necrosis. We applied this method in conjugation with the plastic surgery team in a series of patients with large MMC defects. The aim of the current study was to determine the operative characteristics and outcome of a series of Iranian patients with large MMC defects utilizing our new technique. We also compare our results with the results of the previously used techniques at our center.

Methods

Study Population

This prospective cohort study was conducted in the pediatric neurosurgery department of Namazi Hospital, a tertiary healthcare center and the major pediatric neurosurgery referral center in southern Iran affiliated with Shiraz University of Medical Sciences during a 4-year period from September 2013 to October 2017. We included all patients with extremely large thoracolumbar MMC defects (with a width larger than 4 cm) who were admitted to our center during the study period. Only those whose defects could not be closed with primary repair and those whose parents provided consent for the operation were included in the current study. We excluded patients with very low birth weight (defined as birth weight lower than 1500 g), those with medical conditions contrary to life, those who could not tolerate general anesthesia, and those whose parents did not provide consent for the operation. We also included a group of patients with similar age, sex, and defect size who underwent surgery at our center between 2010 and 2013 using primary closure techniques. These patients were selected retrospectively, and their medical charts were reviewed for the clinical characteristics and outcome. Those with incomplete medical charts were excluded from the study. We selected a range of age, sex, and defect size. Patients in the V-Y flap group who did not fall within this range were excluded. The study protocol was approved by the institutional review board and medical ethics committee of Shiraz University of Medical Sciences. All patients’ guardians provided their informed written consent before inclusion in the study. For those who were included retrospectively, no informed written consent was required.

Surgical Intervention

All surgical procedures were performed in the pediatric neurosurgery department of Namazi Hospital by the same surgical team consisting of pediatric neurosurgeons (M.S.M. and F.G.) and a specialized plastic surgeon (M.A.H.). The patients underwent surgery in the prone position under general anesthesia; their lower extremities were wrapped, and the arms were placed at 90° of abduction. Draping was performed in a manner that provided us with access to the entire back and lateral sides of the abdomen as well as the gluteal or latissimus dorsi muscles. The first stage of the operation was conducted by the neurosurgery team, and the plastic surgeon was involved during the second stage. First, the MMC sac was incised, and the nerve fibers attached to the sac were separated by microdissection under the surgical microscope. The dural edges adherent to the fibrotic tissue around the sac were released, and then the primary or secondary dural repair utilizing an artificial tissue patch (TissuePatchDural, Tissuemed surgical technologies) was performed in a watertight manner with 5-0 Prolene suturing material. During the dural sac repair, undermining and dissecting the surrounding skin was completely avoided. The surgery was continued by the plastic surgeon.

The margins for the bilateral V-Y flap were marked using a dermatograph by connecting the axillary apices to the most cephalad and most caudal ends of the defect (Fig. 1A). We recorded the transverse and longitudinal dimensions of the rectangle and calculated the surface area of the defect. We also recorded the presence of the spinal kyphosis at the site of the MMC defect. The bilateral V-Y flap and advancement of latissimus dorsi or gluteal muscle flaps were based on the thoracodorsal or superior gluteal arteries, respectively.

FIG. 1.
FIG. 1.

Schematic demonstration of the bilateral V-Y flap with latissimus dorsi muscle advancement for closure of large MMC defects. A: Geometric demonstration of the flap design. B: Drawing showing the large thoracolumbar MMC defect. C: The flaps are dissected and elevated to cover the large thoracolumbar MMC defect. D: Drawing depicting the final closure of the defect utilizing bilateral V-Y flap and advancement of the latissimus muscles. Copyright Fariborz Ghaffarpasand. Published with permission. Figure is available in color online only.

As shown in Fig. 1A, the B-B′ and D-D′ lines were measured, and a blueprint of the V-flap was drawn. The length of the B-C line was a little more than 2 times that of the A-B line. In some cases, with severe kyphosis or tight skin, the length of B-C was nearly 3 times that of the A-B line. The flaps were elevated bilaterally from lateral to medial, and the paravertebral muscles in the medial line were dissected in order to provide free medial advancement of the flap from the thoracolumbar fascia (Fig. 1B and C). After complete dissection, defect closure was achieved through bilateral en bloc myocutaneous V-Y flap medial advancement (Fig. 1D). Posterior kyphectomy was performed as previously described elsewhere for those with severe kyphosis.22 Meticulous hemostasis was performed using bipolar cauterization. The wound was closed in the midline in 3 separate layers without any tension using Vicryl 4-0 and Prolene 4-0 suturing materials. After dissection of the upper and lower flaps at the end base of the bilateral V-flaps (thoracic and gluteal regions), the donor sites were closed with superior and inferior flaps using the same suturing materials. No drains were used in these series. The wound was covered with a loose, tension-free dressing and was checked daily during the postoperative period. All patients were placed in a right or left lateral decubitus position to eliminate pressure on the flaps. The surgical procedure and the repair of the defect are shown in Fig. 2.

FIG. 2.
FIG. 2.

Representative case of bilateral V-Y latissimus dorsi advancement flap for closure of a large MMC defect. A: Photograph of a large MMC defect measuring 12 × 6 cm with severe kyphosis in a 2-day-old female neonate. B: The patient is positioned prone under general anesthesia with her arms at 90° abduction and pressure sites fully padded. C and D: The flap incision is made after repairing the dural sac (C) and is extended laterally to provide an appropriate flap length while preserving the latissimus and superior gluteal arteries (D). E: Posterior kyphectomy was performed, and the flaps were dissected and elevated. F: Photograph obtained at the 1-year follow-up, revealing complete healing of the wound without dehiscence, necrosis, or infection. The patient did not require VP shunt insertion. Figure is available in color online only.

Follow-Up and Outcome Measures

All patients were visited daily during the postoperative course, and flap necrosis, infection, dehiscence, and CSF leakage was recorded. Meningitis was diagnosed based on the CSF analysis obtained via the shunt tap or fontanel tap along with the clinical symptoms. As all patients received intravenous antibiotics from the time of admission, CSF cultures were mostly negative. The patients were also evaluated regarding hydrocephalus and systemic infections such as sepsis and pneumonia. Those with refractory hydrocephalus underwent elective ventriculoperitoneal (VP) shunt insertion. The decision for inserting a VP shunt was based on the CT diameters and the clinical signs, symptoms, and examination findings (fontanel status). Complications included pneumothorax, sepsis, pneumonia, and necrotizing enterocolitis (NEC). All patients underwent follow-up for at least 2 years and were evaluated for wound healing and need for VP shunt insertion. We compared the results with a group of patients with similar age, sex, and defect size from our registry who underwent repair primarily or in delayed fashion. The results were also compared between these groups.

Statistical Analysis

All the statistical analyses were performed using IBM SPSS (version 22.0, IBM Corp.). Data are presented as mean ± SD and proportions as appropriate. The proportions were compared using the chi-square or Fisher’s exact test, while the parametric variables with normal distribution were compared using an independent t-test. The parametric variables without normal distribution were compared using the Mann-Whitney U-test. To determine the predictors of outcome, a multivariate logistic regression analysis was performed. Odds ratios are reported with 95% confidence intervals. A 2-sided p < 0.05 was considered statistically significant.

Results

During the entire study period (2010–2017) we surgically treated 73 patients with MMCs; 43 of these patients had large MMC defects and were included in the current study. Twenty-four patients underwent the bilateral V-Y flap and latissimus dorsi or gluteal advancement (2013 to 2017), and 19 underwent primary repair (2010 to 2013). As demonstrated in Table 1, the baseline demographic characteristics such as age and sex were comparable between the 2 groups. Most of the patients (60.4%) had history of maternal folic acid consumption (1 or 5 mg folic acid tablets provided by the healthcare system based on pregnancy risk) before and during the pregnancy, whereas only 6 (13.9%) patients had a family history of neural tube defects in their first-degree relatives. Kyphectomy was performed in 7 (29.2%) of 24 patients with large MMCs. The delayed repair was due to parental consent and other medical conditions such as sepsis and infection or availability of the neurosurgeon in the primary healthcare center. Twenty-six (60.5%) patients had CSF leakage from the sac and underwent surgery in an emergency setting, whereas the remaining patients (39.5%) were treated in an elective setting. Most of the patients (76.7%) were paraplegic; lesions were more commonly located in the thoracolumbar region than the in lumbosacral area. The defect size and area were comparable between the 2 groups. Patients who underwent primary closure had a significantly longer follow-up period (p < 0.001), likely because they were retrospectively included. The demographic and baseline clinical features of the patients are summarized in Table 1.

TABLE 1.

Baseline demographic and clinical characteristics of 43 patients with large MMC defects operated on with 2 different methods during 2 separate time periods

Bilateral V-Y Flap w/ Advancement (n = 24)Simple Closure (n = 19)p Value
Age, days11.54 ± 7.0816.75 ± 6.660.652
Sex
 Male14 (58.3)8 (42.1)0.364
 Female10 (41.7)11 (57.9)
Family history2 (8.3)4 (21.1)0.380
Folic acid14 (58.3)12 (63.2)0.748
Preop leakage15 (62.5)11 (57.9)0.759
Location
 Thoracolumbar13 (54.2)9 (47.4)0.763
 Lumbosacral11 (45.8)10 (52.6)
Neurological status
 Paraplegia19 (79.2)14 (73.7)0.728
 Paraparesis5 (20.8)5 (26.3)
Mean defect size
 Width, cm6.29 ± 1.856.21 ± 1.810.886
 Length, cm7.37 ± 1.717.78 ± 2.140.486
 Area, cm247.3 ± 19.449.9 ± 22.90.688
Mean donor size
 Width, cm8.66 ± 2.14
 Length, cm11.7 ± 2.90
 Area, cm2107.1 ± 47.6
Mean defect/donor area0.47 ± 0.18
Mean follow-up, mos28.25 ± 3.942.73 ± 10.4<0.001

Values are presented as the number of patients (%) unless stated otherwise. Mean values are presented as mean ± SD. Boldface type indicates statistical significance.

The bilateral V-Y flap with muscle advancement method was associated with a significantly longer operative duration (p < 0.001) when compared with primary closure. The incidences of hydrocephalus, VP shunt insertion, meningitis, and flap necrosis were comparable between the 2 groups (Table 2). Those undergoing bilateral V-Y flap with muscle advancement had significantly lower rates of surgical site infection (SSI; p = 0.038), wound dehiscence (p = 0.013), and postoperative CSF leakage (p = 0.030) than those undergoing primary repair. Bilateral V-Y flap with muscle advancement was also associated with a lower mortality rate (p = 0.038; OR 5.09 [95% CI 1.12–23.1]) compared with primary closure. The results of the 2 surgical methods are summarized in Table 2.

TABLE 2.

Intraoperative characteristics and outcomes of 43 patients with large MMC defects operated on with 2 different methods during 2 separate time periods

Bilat V-Y Flap w/ Advancement (n = 24)Simple Closure (n = 19)p ValueOR (95% CI)
Mean op duration ± SD, mins65.45 ± 7.2253.5 ± 11.86<0.001
Hydrocephalus0.238
 None2 (8.3)3 (15.8)
 Mild2 (8.3)2 (10.5)
 Moderate5 (20.8)8 (42.1)
 Severe15 (62.5)6 (31.6)
VP shunt insertion20 (83.3)14 (73.7)0.4771.78 (0.40–7.85)
Meningitis4 (16.7)8 (42.1)0.0913.63 (0.89–14.8)
SSI3 (12.5)8 (42.1)0.0385.09 (1.12–23.1)
Dehiscence2 (8.3)8 (42.1)0.0138.00 (1.44–44.2)
Necrosis1 (4.2)5 (26.3)0.0728.21 (0.86–77.7)
Postop leakage2 (8.3)7 (36.8)0.0306.41 (1.14–35.8)
Pneumothorax1 (4.2)0 (0.00)0.9980.54 (0.41–0.72)
NEC2 (8.3)3 (15.8)0.6402.06 (0.30–13.8)
Sepsis4 (16.7)3 (15.8)0.9980.93 (0.18–4.80)
Pneumonia2 (8.3)3 (15.8)0.6402.06 (0.30–13.8)
Mortality3 (12.5)8 (42.1)0.0385.09 (1.12–23.1)

Values are presented as the number of patients (%) unless stated otherwise. Boldface type indicates statistical significance.

We ran univariable and multivariable regression models to determine the risk factors of mortality for 2 surgical methods separately. In patients undergoing bilateral V-Y flap and muscle advancement, a longer operative duration was significantly associated with mortality (p = 0.008). In addition, SSI (p = 0.032), wound dehiscence (p = 0.011), and postoperative leakage (p = 0.011) were predictors of mortality. Neonatal sepsis (p = 0.002) and postoperative NEC (p = 0.011) were among other predictors of mortality in this group (Table 3). In the primary closure group, SSI (p = 0.001), wound dehiscence (p = 0.024), and postoperative CSF leakage (p = 0.006) were among the predictors of mortality (Table 4). After adjusting for age, sex, and defect size through a multivariate regression analysis, we found that operative duration, SSI, flap necrosis, postoperative leakage, NEC, and sepsis remained significant predictors of outcome in those undergoing a bilateral V-Y flap with latissimus dorsi or gluteal muscle advancement. The predictors of mortality in the primary closure group after adjusting for confounders were wound dehiscence, necrosis, and postoperative CSF leakage.

TABLE 3.

Risk factors of mortality in 24 patients with large MMC defects undergoing bilateral V-Y flap and latissimus dorsi and gluteal muscle advancement

Alive (n = 21)Dead (n = 3)p ValueOR (95% CI)
Mean age, days10.86 ± 6.3516.33 ± 11.50.218
Mean defect size
 Width, cm7.19 ± 1.728.66 ± 1.150.203
 Length, cm6.47 ± 1.195.0 ± 0.000.168
 Area, cm247.9 ± 20.743.3 ± 5.770.715
Mean donor size
 Width, cm8.71 ± 2.108.33 ± 2.880.780
 Length, cm11.76 ± 2.9112.0 ± 3.460.898
 Area, cm2107.14 ± 47.6106.6 ± 57.70.987
Mean defect/donor area0.47 ± 0.150.54 ± 0.390.506
Mean op duration, mins64.04 ± 6.2275.3 ± 6.800.008
Sex
 Male14 (66.7)0 (0.0)0.0591.42 (0.95–2.14)
 Female7 (33.3)3 (100.0)
Family history11 (52.4)3 (100.0)0.2391.27 (0.96–1.67)
Folic acid2 (9.5)0 (0.0)0.5770.86 (0.73–1.02)
Preop leakage14 (66.7)1 (33.3)0.5330.25 (0.19–3.25)
Location
 Thoracolumbar10 (47.6)3 (100.0)0.2231.30 (0.96–1.75)
 Lumbosacral11 (52.4)0 (0.0)
Neurological status
 Paraplegia16 (76.2)3 (100.0)0.3421.18 (0.97–1.44)
 Paraparesis5 (23.8)0 (0.0)
Hydrocephalus
 None2 (9.5)0 (0.0)0.561
 Mild2 (9.5)0 (0.0)
 Moderate5 (23.8)0 (0.0)
 Severe12 (57.1)3 (100.0)
VP shunt insertion17 (81.0)3 (100.0)0.5631.17 (0.97–1.41)
Meningitis4 (19.0)0 (0.0)0.4080.85 (0.70–1.02)
SSI1 (4.8)2 (66.7)0.03240.0 (1.74–914)
Dehiscence0 (0.0)2 (66.7)0.0110.04 (0.01–0.31)
Necrosis0 (0.0)1 (33.3)0.1250.87 (0.23–1.32)
Postop leakage0 (0.0)2 (66.7)0.0110.04 (0.01–0.31)
Pneumothorax1 (4.8)0 (0.0)0.6990.87 (0.74–1.02)
NEC0 (0.0)2 (66.7)0.0110.04 (0.01–0.31)
Sepsis1 (4.8)3 (100.0)0.0024.00 (0.73–21.8)
Pneumonia1 (4.8)1 (33.3)0.23910.0 (0.43–12.8)

Values are presented as the number of patients (%) unless stated otherwise. Mean values are presented as mean ± SD. Boldface type indicates statistical significance.

TABLE 4.

Risk factors of mortality in 19 patients with large MMC defects undergoing primary repair

Alive (n = 11)Dead (n = 8)p ValueOR (95% CI)
Mean age, days10.64 ± 5.6010.50 ± 8.310.966
Mean defect size
 Width, cm6.00 ± 1.146.50 ± 2.320.568
 Length, cm8.00 ± 2.327.50 ± 2.000.630
 Area, cm249.5 ± 22.850.50 ± 24.50.932
Mean op duration, mins56.5 ± 8.9049.3 ± 14.60.202
Sex
 Male3 (27.3)5 (62.5)0.1810.22 (0.03–1.58)
 Female8 (72.7)3 (37.5)
Family history2 (18.2)2 (25.0)0.7191.50 (0.16–13.7)
Folic acid6 (54.5)6 (75.0)0.6332.50 (0.34–18.3)
Preop leakage6 (54.5)5 (62.5)0.7291.38 (0.21–8.91)
Location
 Thoracolumbar6 (54.5)3 (37.5)0.6500.50 (0.78–3.21)
 Lumbosacral5 (45.5)5 (62.5)
Neurological status
 Paraplegia8 (72.7)6 (75.0)0.9121.12 (0.14–8.99)
 Paraparesis3 (27.3)2 (25.0)
Hydrocephalus
 None1 (9.1)2 (25.0)0.089
 Mild0 (0.0)2 (25.0)
 Moderate7 (63.6)1 (12.5)
 Severe3 (27.3)3 (37.5)
VP shunt insertion9 (81.8)5 (62.5)0.6030.37 (0.04–3.01)
Meningitis4 (36.4)4 (50.0)0.6581.75 (0.27–11.1)
SSI1 (9.1)7 (87.5)0.00170 (3.71–131.7)
Dehiscence2 (18.2)6 (75.0)0.02413.5 (1.4–123.7)
Necrosis0 (0.0)5 (62.5)0.0050.21 (0.79–0.58)
Postop leakage1 (9.1)6 (75.0)0.00630.0 (2.21–40.5)
NEC0 (0.0)3 (37.5)0.0580.31 (0.15–0.64)
Sepsis0 (0.0)3 (37.5)0.0580.31 (0.15–0.64)
Pneumonia0 (0.0)3 (37.5)0.0580.31 (0.15–0.64)

Values are presented as the number of patients (%) unless stated otherwise. Mean values are presented as mean ± SD. Boldface type indicates statistical significance.

Discussion

This study aimed to compare the outcome of large thoracolumbar MMC defects utilizing the bilateral V-Y flap with muscle advancement and primary closure. We demonstrated that bilateral V-Y flap with latissimus dorsi or gluteal muscle advancement has been associated with decreased rates of SSI, wound dehiscence, postoperative CSF leakage, and mortality while the operative duration was significantly longer. The predictors of mortality were found to be the longer operative duration, SSI, wound dehiscence, postoperative leakage, neonatal sepsis, and postoperative NEC. The results of our patients who underwent bilateral V-Y flap with latissimus dorsi or gluteal advancement are comparable with previously reported results with different flap designs.2,10,11,13,14,19,23,26

Several indices have been introduced and applied in a clinical setting to decide whether to perform a sophisticated flap repair or to close the defect primarily. Accordingly, Blanco-Dávila and Luce1 reported successful primary closure in patients with a defect diameter less than 5 cm, whereas Luce and Walsh reported successful primary closure of defects with an area of 22.7 cm2.15 Müslüman et al.19 provided evidence based on a large series of patients with large MMC defects (162 patients) that defects with an area smaller than 24 cm2 could be closed using the primary method. Other authors defined some indices to predict the possibility of primary closure.11,20,26 Ozveren et al.20 demonstrated that successful primary closure could be performed in those with a defect area/thoracolumbar area ratio less than 0.08. Probably the most comprehensive scale was that reported by Kankaya et al.,11 who provided an evidence-based approach to the MMC defects. They believed that the ratio of the transverse diameter of the defect to the back width was a more practical and determinative way to evaluate the defects. They also took into consideration the presence of kyphosis, which limits the wound closure ability.11 Accordingly, all patients included in our series had a defect area/donor area ratio of more than 0.3, which necessitated the use of flap repair. In addition, we performed posterior kyphectomy according to the previous reports of its efficacy.5,22 Our results are comparable with those reported by authors who used bilateral V-Y flap designs.2,10,11,13,14,19,23,26 The use of kyphectomy in management of patients with MMC remains controversial; while it has the immediate benefit of making the closure easier and less risky, it is associated with significant delayed morbidity, including spinal instability and impaired respiratory capacity due to upward pressure on the diaphragm.3,5,22 Patients with MMC are prone to spinal deformity and instability because of the absence of the posterior spinal elements and the anteriorly and laterally displaced erector spinae and quadratus lumborum muscles, which lead to flexion; this adds to the flexion effects of the diaphragm and psoas muscles. These anatomical considerations have been reported as leading to progression of kyphosis at a rate of 6°–12° per year in patients with MMC.3 It has been concluded that kyphectomy is associated with improved sitting balance and resolution of skin problems, while associated with intraoperative and long-term complications such as longer operative duration, higher intraoperative bleeding, a higher rate of infection, and progression of spinal deformity.7 Recently, several lines of evidence have suggested that early kyphectomy along with posterior spinal instrumentation is a safe and beneficial procedure in this group of patients.12,21 Further studies are required, and the limited number of patients affects the quality of the evidence on the subject.

The advantage of our method was better muscular coverage by transferring the latissimus dorsi or gluteal muscles based on the thoracodorsal or superior gluteal arteries, resulting in a reduced rate of wound dehiscence and flap necrosis compared with results of previous reports.10,14,23 Overall, the current technique provides muscular coverage that acts as a bed for the skin graft to provide better coverage. The muscle flaps are pedunculated and have a separate arterial supply, which increases their viability and provides an appropriate vascular bed for the skin graft. The muscular flaps in this technique are selected from different groups on each side, which decreases the rate of the muscular complications and further spinal deformity. This surgical approach also resulted in decreased rates of mortality when compared with primary closure without kyphectomy in patients of similar age, sex, and defect size. The disadvantages, however, were the longer operative duration and higher rates of intraoperative complications. In our series, during dissection of the latissimus dorsi muscle flap in 1 patient, we spontaneously opened the pleura, as the patient suffered from malnutrition. The pneumothorax was conservatively managed by insertion of a chest tube for 3 days and subsequent removal. No mechanical ventilation was required, and the patient recovered well and was discharged in good condition. Similarly, a case of intraoperative pneumothorax in MMC defect closure was reported by Gazula et al.,8 which was secondary to Valsalva maneuver and not the surgical procedure itself. Another disadvantage of this procedure is the effect on the rates of further scoliosis and spinal deformities. In this procedure, we mobilize the important paraspinal muscles, including the latissimus dorsi or gluteal muscles, which might increase the rate of spinal deformity in the future. In the current study with a limited follow-up period, we did not observe any spinal deformity; however, longer follow-up is required. Mummareddy et al.18 in a recent meta-analysis demonstrated that the prevalence of scoliosis in MMC patients could be as much as 53% (95% CI 42%–64%). The motor level was found to be a significant predictor of prevalence, but not severity, of scoliosis in MMC patients. Quality of life metrics, including ambulatory status and stability when seated, are influenced by motor level of the lesion as well as the degree of the scoliosis curvature.3,18

We found that there was a high rate of mortality in the primary closure group, which is explained by the high rate of NEC, wound dehiscence, CSF leakage, and SSI. Cultural issues as well as the socioeconomic status of the family and the care it provides to the patient is also an important indicator of mortality, which we did not address in the current study. These complications along with a longer duration of follow-up in the primary closure group might have resulted in a higher mortality rate. We found that longer operative duration, flap necrosis, wound dehiscence, sepsis, and NEC were predictors of mortality in those undergoing flap repair. The literature lacks appropriate studies on the determinants of outcome in MMC defects. Recently, McDowell et al.16 demonstrated that higher anatomical level of defect, low Apgar scores, large MMC defects, early central apnea, and large head circumference at birth were predictors of mortality in those with MMC and Chiari type II malformation. While Tarcan et al.25 demonstrated that the timing of primary neurosurgical repair significantly affects neurogenic bladder prognosis in children with MMC, Shaer et al.24 demonstrated that the number of involved vertebrae or length of the lesion play no role in determining motor function. We also did not find any association between the defect size and level with the mortality rate in either surgical group.

We note some limitations to our study. First, the number of patients included is limited. The improved perinatal diagnosis and extensive folic acid supplementation program has decreased the incidence of MMC worldwide,9,24 including in the Iranian population.17 In addition, not all parents gave consent for surgical repair, and many families withdrew the care. All of these factors result in a limited sample size. However, we believe that this is a rational series of MMC defects and provides an acceptable insight regarding the outcome and risk factors. Second, the duration of follow-up was not comparable between the 2 groups. Those in the primary closure group who were included retrospectively had a longer duration of follow-up because they underwent surgery before our new interdisciplinary method was established, which could have resulted in the higher mortality rate. We are now following the new patients and will omit this confounding factor in the near future. Another limitation of the study is the fact that the patients in the 2 groups were treated during different time periods, which might have resulted in a bias of time and experience. In other words, the time period has increased the experience of our team in the management of patients with large MMCs, which could have affected the results. However, the new technique is totally performed by our plastic surgeon (second author), who was not involved in our earlier series. The other limitation is that although we have included many variables and ran a multivariate logistic regression model to eliminate the effects of confounders, some other confounders might have been included. This could explain why some variables showed a statistically, but not clinically, significant difference between the groups, such as operative duration. These variables should be considered in later clinical trials or prospective cohorts. And lastly, the dissection and advancement of latissimus dorsi and gluteal muscles based on the thoracodorsal and superior gluteal arteries might result in weakened paraspinal muscular support, leading to scoliosis in the long term. Our limited follow-up duration does not allow us to comment on this issue; longer longitudinal studies are needed.

Conclusions

The bilateral V-Y flap with latissimus dorsi and gluteal muscle advancement is a safe and effective surgical approach for covering large MMC defects. This method is associated with lower rates of SSI, wound dehiscence, CSF leakage, and mortality. Longer operative duration, SSI, wound dehiscence, CSF leakage, neonatal sepsis, and NEC are significant predictors of mortality for this method. It should be kept in mind that these approaches are multidisciplinary and should be performed in combination with expert plastic surgeons. Further longitudinal studies are required to elucidate the long-term outcomes.

Acknowledgments

This manuscript was financially supported by a grant from vice chancellor of research, Shiraz University of Medical Sciences (No. IR.SUMS.MED.REC.1395.983).

We thank all the patients and their families who participated in the current study. We want to thank Mr. Arash Ashkar for providing the schematic illustrations. We would also like to acknowledge the editorial assistance of Diba Negar Research Institute for improving the style and English of the manuscript.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Masoudi, Hoghoughi. Acquisition of data: Ghaffarpasand, Masoudi, Hoghoughi, Yaghmaei. Analysis and interpretation of data: Ghaffarpasand, Yaghmaei, Ilami. Drafting the article: Azadegan, Ilami. Critically revising the article: Ghaffarpasand, Masoudi, Hoghoughi, Yaghmaei, Azadegan. Reviewed submitted version of manuscript: Ghaffarpasand, Masoudi, Hoghoughi. Statistical analysis: Azadegan. Administrative/technical/material support: Masoudi, Ilami. Study supervision: Ghaffarpasand, Hoghoughi.

Supplemental Information

Previous Presentations

The primary results of the study were presented at the 25th International Congress of Neurosurgery, Urmia, Iran, November 15–17, 2017.

References

  • 1

    Blanco-Dávila F, Luce EA: Current considerations for myelomeningocele repair. J Craniofac Surg 11:500508, 2000

  • 2

    Butz DR, Seitz IA, Frim DM, Reid RR, Gottlieb LJ: A ten-year review of myelodysplastic defect management and use of a novel closure technique with V-Y crescentic rotation advancement flaps. J Plast Reconstr Aesthet Surg 67:533539, 2014

    • Crossref
    • PubMed
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    • Export Citation
  • 3

    Canaz H, Alatas I, Canaz G, Gumussuyu G, Cacan MA, Saracoglu A, et al.: Surgical treatment of patients with myelomeningocele-related spine deformities: study of 26 cases. Childs Nerv Syst 34:13671374, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Dillon CM, Davis BE, Duguay S, Seidel KD, Shurtleff DB: Longevity of patients born with myelomeningocele. Eur J Pediatr Surg 10 (Suppl 1):3334, 2000

  • 5

    Dunn RN, Bomela LN: Kyphectomy in children with severe myelomeningocele-related kyphosis. Spine Deform 4:230236, 2016

  • 6

    Emsen IM: Closure of large myelomeningocele defects using the O-S flap technique. J Craniofac Surg 26:21672170, 2015

  • 7

    Garg S, Oetgen M, Rathjen K, Richards BS: Kyphectomy improves sitting and skin problems in patients with myelomeningocele. Clin Orthop Relat Res 469:12791285, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Gazula S, Gooty S, Thakur N: Life-threatening complication of intraoperative Valsalva maneuver in an infant. J Neurosurg Anesthesiol 27:179181, 2015

  • 9

    Harris DA, Cherian J, LoPresti M, Jea A, Lam S: Trends in epidemiology and hospitalization utilization for myelomeningocele repair from 2000 to 2009. Childs Nerv Syst 32:12731279, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Hosseinpour M, Forghani S: Primary closure of large thoracolumbar myelomeningocele with bilateral latissimus dorsi flaps. J Neurosurg Pediatr 3:331333, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Kankaya Y, Sungur N, Aslan OC, Ozer K, Ulusoy MG, Karatay M, et al.: Alternative method for the reconstruction of meningomyelocele defects: V-Y rotation and advancement flap. J Neurosurg Pediatr 15:467474, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Kaplan SC, Ekşi MS, Bayri Y, Toktaş ZO, Konya D: Kyphectomy and pedicular screw fixation with posterior-only approach in pediatric patients with myelomeningocele. Pediatr Neurosurg 50:133144, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Kesan K, Kothari P, Gupta R, Gupta A, Karkera P, Ranjan R, et al.: Closure of large meningomyelocele wound defects with subcutaneous based pedicle flap with bilateral V-Y advancement: our experience and review of literature. Eur J Pediatr Surg 25:189194, 2015

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Komuro Y, Yanai A, Koga Y, Seno H, Inoue M: Bilateral modified V-Y advancement flaps for closing meningomyelocele defects. Ann Plast Surg 57:195198, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Luce EA, Walsh J: Wound closure of the myelomeningocoele defect. Plast Reconstr Surg 75:389393, 1985

  • 16

    McDowell MM, Blatt JE, Deibert CP, Zwagerman NT, Tempel ZJ, Greene S: Predictors of mortality in children with myelomeningocele and symptomatic Chiari type II malformation. J Neurosurg Pediatr 21:587596, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Moradi B, Katouli FS, Gity M, Kazemi MA, Shakiba M, Masrour FF: Neural tube defects: distribution and associated anomalies diagnosed by prenatal ultrasonography in Iranian fetuses. J Obstet Gynecol Cancer Res 2:64382, 2017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Mummareddy N, Dewan MC, Mercier MR, Naftel RP, Wellons JC III, Bonfield CM: Scoliosis in myelomeningocele: epidemiology, management, and functional outcome. J Neurosurg Pediatr 20:99108, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Müslüman AM, Karşıdağ S, Sucu DO, Akçal A, Yılmaz A, Sirinoğlu D, et al.: Clinical outcomes of myelomeningocele defect closure over 10 years. J Clin Neurosci 19:984990, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Ozveren MF, Erol FS, Topsakal C, Tiftikci MT, Akdemir I: The significance of the percentage of the defect size in spina bifida cystica in determination of the surgical technique. Childs Nerv Syst 18:614620, 2002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Ryabykh SO, Pavlova OM, Savin DM, Burtsev AV, Gubin AV: Surgical management of myelomeningocele-related spinal deformities. World Neurosurg 112:e431e441, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Samagh SP, Cheng I, Elzik M, Kondrashov DG, Rinsky LA: Kyphectomy in the treatment of patients with myelomeningocele. Spine J 11:e5e11, 2011

  • 23

    Sarifakioglu N, Bingül F, Terzioglu A, Ates L, Aslan G: Bilateral split latissimus dorsi V-Y flaps for closure of large thoracolumbar meningomyelocele defects. Br J Plast Surg 56:303306, 2003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Shaer CM, Chescheir N, Schulkin J: Myelomeningocele: a review of the epidemiology, genetics, risk factors for conception, prenatal diagnosis, and prognosis for affected individuals. Obstet Gynecol Surv 62:471479, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Tarcan T, Onol FF, Ilker Y, Alpay H, Simşek F, Ozek M: The timing of primary neurosurgical repair significantly affects neurogenic bladder prognosis in children with myelomeningocele. J Urol 176:11611165, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Ulusoy MG, Koçer U, Sungur N, Karaaslan O, Kankaya Y, Ozdemir R, et al.: Closure of meningomyelocele defects with bilateral modified V-Y advancement flaps. Ann Plast Surg 54:640644, 2005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand
  • FIG. 1.

    Schematic demonstration of the bilateral V-Y flap with latissimus dorsi muscle advancement for closure of large MMC defects. A: Geometric demonstration of the flap design. B: Drawing showing the large thoracolumbar MMC defect. C: The flaps are dissected and elevated to cover the large thoracolumbar MMC defect. D: Drawing depicting the final closure of the defect utilizing bilateral V-Y flap and advancement of the latissimus muscles. Copyright Fariborz Ghaffarpasand. Published with permission. Figure is available in color online only.

  • FIG. 2.

    Representative case of bilateral V-Y latissimus dorsi advancement flap for closure of a large MMC defect. A: Photograph of a large MMC defect measuring 12 × 6 cm with severe kyphosis in a 2-day-old female neonate. B: The patient is positioned prone under general anesthesia with her arms at 90° abduction and pressure sites fully padded. C and D: The flap incision is made after repairing the dural sac (C) and is extended laterally to provide an appropriate flap length while preserving the latissimus and superior gluteal arteries (D). E: Posterior kyphectomy was performed, and the flaps were dissected and elevated. F: Photograph obtained at the 1-year follow-up, revealing complete healing of the wound without dehiscence, necrosis, or infection. The patient did not require VP shunt insertion. Figure is available in color online only.

  • 1

    Blanco-Dávila F, Luce EA: Current considerations for myelomeningocele repair. J Craniofac Surg 11:500508, 2000

  • 2

    Butz DR, Seitz IA, Frim DM, Reid RR, Gottlieb LJ: A ten-year review of myelodysplastic defect management and use of a novel closure technique with V-Y crescentic rotation advancement flaps. J Plast Reconstr Aesthet Surg 67:533539, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Canaz H, Alatas I, Canaz G, Gumussuyu G, Cacan MA, Saracoglu A, et al.: Surgical treatment of patients with myelomeningocele-related spine deformities: study of 26 cases. Childs Nerv Syst 34:13671374, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Dillon CM, Davis BE, Duguay S, Seidel KD, Shurtleff DB: Longevity of patients born with myelomeningocele. Eur J Pediatr Surg 10 (Suppl 1):3334, 2000

  • 5

    Dunn RN, Bomela LN: Kyphectomy in children with severe myelomeningocele-related kyphosis. Spine Deform 4:230236, 2016

  • 6

    Emsen IM: Closure of large myelomeningocele defects using the O-S flap technique. J Craniofac Surg 26:21672170, 2015

  • 7

    Garg S, Oetgen M, Rathjen K, Richards BS: Kyphectomy improves sitting and skin problems in patients with myelomeningocele. Clin Orthop Relat Res 469:12791285, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Gazula S, Gooty S, Thakur N: Life-threatening complication of intraoperative Valsalva maneuver in an infant. J Neurosurg Anesthesiol 27:179181, 2015

  • 9

    Harris DA, Cherian J, LoPresti M, Jea A, Lam S: Trends in epidemiology and hospitalization utilization for myelomeningocele repair from 2000 to 2009. Childs Nerv Syst 32:12731279, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Hosseinpour M, Forghani S: Primary closure of large thoracolumbar myelomeningocele with bilateral latissimus dorsi flaps. J Neurosurg Pediatr 3:331333, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Kankaya Y, Sungur N, Aslan OC, Ozer K, Ulusoy MG, Karatay M, et al.: Alternative method for the reconstruction of meningomyelocele defects: V-Y rotation and advancement flap. J Neurosurg Pediatr 15:467474, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Kaplan SC, Ekşi MS, Bayri Y, Toktaş ZO, Konya D: Kyphectomy and pedicular screw fixation with posterior-only approach in pediatric patients with myelomeningocele. Pediatr Neurosurg 50:133144, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Kesan K, Kothari P, Gupta R, Gupta A, Karkera P, Ranjan R, et al.: Closure of large meningomyelocele wound defects with subcutaneous based pedicle flap with bilateral V-Y advancement: our experience and review of literature. Eur J Pediatr Surg 25:189194, 2015

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Komuro Y, Yanai A, Koga Y, Seno H, Inoue M: Bilateral modified V-Y advancement flaps for closing meningomyelocele defects. Ann Plast Surg 57:195198, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Luce EA, Walsh J: Wound closure of the myelomeningocoele defect. Plast Reconstr Surg 75:389393, 1985

  • 16

    McDowell MM, Blatt JE, Deibert CP, Zwagerman NT, Tempel ZJ, Greene S: Predictors of mortality in children with myelomeningocele and symptomatic Chiari type II malformation. J Neurosurg Pediatr 21:587596, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Moradi B, Katouli FS, Gity M, Kazemi MA, Shakiba M, Masrour FF: Neural tube defects: distribution and associated anomalies diagnosed by prenatal ultrasonography in Iranian fetuses. J Obstet Gynecol Cancer Res 2:64382, 2017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Mummareddy N, Dewan MC, Mercier MR, Naftel RP, Wellons JC III, Bonfield CM: Scoliosis in myelomeningocele: epidemiology, management, and functional outcome. J Neurosurg Pediatr 20:99108, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Müslüman AM, Karşıdağ S, Sucu DO, Akçal A, Yılmaz A, Sirinoğlu D, et al.: Clinical outcomes of myelomeningocele defect closure over 10 years. J Clin Neurosci 19:984990, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Ozveren MF, Erol FS, Topsakal C, Tiftikci MT, Akdemir I: The significance of the percentage of the defect size in spina bifida cystica in determination of the surgical technique. Childs Nerv Syst 18:614620, 2002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Ryabykh SO, Pavlova OM, Savin DM, Burtsev AV, Gubin AV: Surgical management of myelomeningocele-related spinal deformities. World Neurosurg 112:e431e441, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Samagh SP, Cheng I, Elzik M, Kondrashov DG, Rinsky LA: Kyphectomy in the treatment of patients with myelomeningocele. Spine J 11:e5e11, 2011

  • 23

    Sarifakioglu N, Bingül F, Terzioglu A, Ates L, Aslan G: Bilateral split latissimus dorsi V-Y flaps for closure of large thoracolumbar meningomyelocele defects. Br J Plast Surg 56:303306, 2003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Shaer CM, Chescheir N, Schulkin J: Myelomeningocele: a review of the epidemiology, genetics, risk factors for conception, prenatal diagnosis, and prognosis for affected individuals. Obstet Gynecol Surv 62:471479, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Tarcan T, Onol FF, Ilker Y, Alpay H, Simşek F, Ozek M: The timing of primary neurosurgical repair significantly affects neurogenic bladder prognosis in children with myelomeningocele. J Urol 176:11611165, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Ulusoy MG, Koçer U, Sungur N, Karaaslan O, Kankaya Y, Ozdemir R, et al.: Closure of meningomyelocele defects with bilateral modified V-Y advancement flaps. Ann Plast Surg 54:640644, 2005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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