Tissue expansion technique for closure of myelomeningocele.

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.[14] 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 [Figures 1–4].

Figure 1

Myelomeningocele

Figure 4

Axial section of MRI showing the spinal defect and the placode

Saggital section of MRI

Axial Section of MRI

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.[34]

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 [Figures 6–10]. 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.

Figure 5

Insertion of Euro silicon tissue expander

Figure 6

Expansion in stages

Figure 10

Expansion in stages

Figure 11

Expansion in stages

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 [Figures 13, 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 [Figures 19–21]. 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.

Figure 16

Dissection of subcutaneous tissues

Figure 12

Excision of the dysplastic skin

Figure 13

Dissection of the placode

Figure 14

Separation of the Neuro structures

Figure 15

Reconstruction of dural tube

Figure 18

Wide skin defect

Figure 19

Delivering of tissue expander

Figure 21

Tissue expander fully loaded

Figure 17

Creating a bed for the repair

Figure 22

Primary closure of the skin