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Keystone flap: a safe coverage option in the handling of salvage for myelomeningocele
Oswaldo Gómez1, Carlos Barrera2
1Department of Surgery, Division of Plastic Surgery, School of Medicine, Universidad Nacional de Colombia, Edificio Altos del Bosque, Calle 134 # 7-83, Office 265, Bogotá, D.C., Colombia. ojgomezd@unal.edu.co.
Insights
Keystone flaps provide safe and stable soft tissue coverage for myelomeningocele (MMC) defects, even after failed primary closures. This versatile technique ensures meningeal protection and is a reliable option for neonatal MMC management.
Area of Science:
- Neurosurgery
- Pediatric Surgery
- Plastic Surgery
Background:
- Myelomeningocele (MMC) is a severe form of spina bifida requiring urgent surgical closure.
- Key surgical goals include sealing cerebrospinal fluid (CSF) fistulas and achieving durable soft tissue coverage.
- Failed primary closures present significant reconstructive challenges.
Purpose of the Study:
- To evaluate the efficacy of keystone design fasciocutaneous flaps for covering lumbosacral defects in neonatal MMC patients.
- To assess the safety and aesthetic outcomes of this reconstructive technique, particularly in cases of failed primary closure.
Main Methods:
- Case report detailing the application of keystone fasciocutaneous flaps in two neonatal patients with lumbosacral MMC.
- Focus on patients with prior failed primary closure attempts and subsequent wound dehiscence.
Main Results:
- Successful coverage of large lumbosacral defects was achieved using keystone flaps.
- The technique provided stable and safe meningeal coverage, preventing CSF fistulas.
- Donor site closure was also successfully managed.
Conclusions:
- Keystone flaps are a useful, accessible, and versatile option for lumbosacral defect coverage in MMC.
- Their safety in salvage situations suggests potential as a primary surgical approach for MMC.
- This method offers reliable soft tissue coverage and protects the underlying neural structures.
Background:
Myelomeningocele (MMC) is the most common and severe pathology of open spina bifida compatible with life. Its early closure is an urgent therapeutic objective to reduce the morbidity and mortality of neonates, being a surgical challenge with two major objectives: (1) achieve closure of the dural cerebrum-spinal fluid fistula and (2) ensure a stable and durable soft tissue coverage. The use of fasciocutaneous flaps in keystone design is shown as a safe and stable surgical option with excellent aesthetic results in patients with MMC and who presented failed primary closures.
Methods:
Two clinical cases of fasciocutaneous flaps in keystone design were described as a coverage option in patients with lumbosacral MMC, in whom the primary closure was unsuccessful and required a safe coverage as a priority.
Results:
Successful coverage of the lumbosacral defect was performed using keystone flaps in neonatal patients with MMC and previous manipulation of the soft tissues when attempting primary closure, but they have had dehiscence of the wound, with a large area of lumbosacral defect and sizeable defect/back ratio.
Conclusions:
The use of keystone flaps is a useful, accessible, and versatile technique as a management option for lumbosacral coverage defects in MMC, achieving a stable and safe covering of the meninges, without cerebrum-spinal fluid fistulas, which also allows the primary closure of the soft tissues in the donor area. The safety of this type of flap when used as salvage in lumbosacral defects with previously handled and raised tissues could infer that it is reliable enough to be considered as a first surgical option in the initial management of MMC.
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