CASE REPORT

Lumbar perforator flap for closure of sacral tissuedefect after lipomyelomeningocele

Deniz Dayicioglu & Kenneth Fan & Piotr Skowronski &Wrood Kassira & Seth R. Thaller & Burak Sercan Ercin &

Allan D. Levi

Received: 29 April 2013 /Accepted: 17 September 2013 /Published online: 5 November 2013# Springer-Verlag Berlin Heidelberg 2013

Abstract Complex sacral midline defects following spinalsurgery have been traditionally closed with either muscle ormusculocutaneous flaps.We present a case with a complicatedsacral wound extending to the medulla spinalis after a lip-omeningomyelocele excision in an ambulating adult. Woundwas repaired with a lumbar perforator-based rotation flap.This well-vascularized flap is relatively easy to harvest, andresults in minimal donor site morbidity, provides adequatedimensions, and permits primary closure of donor defect. Inaddition, the flap allows for anatomic muscle approximationwithout sacrificing the muscle functions, and provides reliablesoft tissue coverage.Level of Evidence: Level V, therapeutic study.

Keywords Flap . Lipomyelomeningocele . Sacral . Defect .

Coverage . Reconstruction . Lumbar . Perforator

Introduction

The large lumbosacral meningomyelocele closure is agreat challenge for the neurosurgeon and especially theplastic surgeon. Although lumbosacral area has thin andvulnerable skin, an immediate closure is necessary becausethis is the best way to avoid meningitis originating fromthe defect area.

The defect should be closed with good and durableskin without tension. However, primary wound closure issometimes impossible. For closure of the large lumbosa-cral defects, the literature suggests a number of reconstruc-tive procedures using surrounding skin, subcutis, and mostfrequently, muscle. The perforator-based lumbar flap isanother possibility for the closure of large lumbosacraldefects which allows defect closure without sacrificingthe muscle functions.

Case report

A 54-year-old female patient presented with a 2-yearhistory of low back pain, leg pain and weakness, andurinary and bowel incontinence. A diagnosing was madeat a low-lying spinal cord ending at L3 to L4 level withan associated lipoma with dorsal tethering of the cord.Past medical history was significant for non-insulin-dependent diabetes for 5 years and two packs a day ofsmoking addiction. As an infant, the myelomeningoceledefect was noted. Attempted treatment with dry iceresulted in deep skin burns and subsequent scarringwithin the sacral region. She had no further complaintsuntil she was 54 years old.

D. Dayicioglu (*)Department of Surgery, Division of Plastic Surgery, Morsani Collegeof Medicine, University of South Florida, 12902 USF MagnoliaDrive, Tampa, FL 33612, USAe-mail: denizdayici@yahoo.com

K. FanMiller School of Medicine, University of Miami, Miami, USA

P. Skowronski :W. Kassira : S. R. ThallerDepartment of Surgery, Division of Plastic Surgery, Miller College ofMedicine, University of Miami, Miami, USA

B. S. ErcinDepartment of Plastic, Reconstructive and Aesthetic Surgery, EgeUniversity Medical School, Izmir, Turkey

A. D. LeviDepartment of Surgery, Division of Neurosurgery, Miller School ofMedicine, University of Miami, Miami, USA

Eur J Plast Surg (2014) 37:173–176DOI 10.1007/s00238-013-0894-4

Neurosurgery performed a L3–S1 laminectomy and releaseof the tethered spinal cord for management of the lipo-meningomyelocele. They then sectioned the filum terminaleand removed an intradural lipoma. Dura was repaired with theDuraGen (Integra, Plainsboro, NJ) graft. Muscle, fascia, andskin were closed primarily. Final pathology confirmed thediagnosis.

Postoperatively, wound healing problems were encoun-tered. She presented to the neurosurgery department with alow pressure headache and a necrotic wound. The physicalexam revealed a 4×5-cm open wound with maceration.Following outpatient debridement of the wound, CSF leakagewas noted. The plastic surgery service was consulted.

After consultation, the patient was brought to the operatingroom where she underwent extensive debridement. Resultantdefect that was 4×6-cm in dimensions extends into the dura witha fistula tract causing cerebrospinal fluid (CSF) leakage (Fig. 1).

Defect and the accompanying tract were completely excised,exposing the dural defect. Dura was further debrided andrepaired using a cadaveric dural graft by the neurosurgery team.

For closure of the defect, the surrounding gluteal andlumbar muscles were mobilized below the superficial fascia.They were then sutured on each other in two layers in animbricating manner using 0 polydioxanone suture (PDS).

After the muscle approximation, attention was turned toskin closure for the sacral defect. A rotation flap in the leftlumbar region was designed with dimensions of 5×10 cm.Incisions were performed by curving parallel to the superiorposterior iliac crest (Fig. 2).

This fasciocutaneous flapwas elevatedwith the electrocautery.A lumbar perforator was incorporated and preserved. Wideundermining and dissection of the flap on this perforator allowedfor increased mobility and advancement. Flap was then rotated60° and extensive contralateral undermining was also required.Extensive contralateral undermining was required. Flap was su-tured in two layers using 3-0 and 2-0 Vicryl (Ethicon, Somerville,NJ). Skin was closed using 3-0 Prolene (Ethicon, Somerville, NJ)over a suction drain (Fig. 3). Drain was removed 5 days postop-eratively. Patient developed an area of dehiscence at superiormargin, which eventually closed using local wound care.

Fig. 1 Defect in the superiorsacral area with dimension of 4×6 cm, with a vertical scar in thelumbar area. Preoperative imagesof the patient. Note themaceration of the tissues due tomedulla spinalis leak. On thesecond picture , note the tissuedefect after debridementextending to the medulla spinalis

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Discussion

Most defects resulting from myelomeningocele can be closedprimarily with adequate undermining and primary approxi-mation. However, 25 % of defects are large enough wherethey require more sophisticated techniques for closure [1].Primary approximations of these wounds are often not possi-ble [2]. In general, there are four available methods: skin graft,skin expansion, a musculocutaneous flap, and a local skin flap[3]. A vast majority of the literature on myelomeningoceledefects is reported on neonates. Children are often treated assoon as preoperative preparations can be made following birth[2]. Late presentation of this defect is unique.

Skin grafts for repair of myelomeningoceles are generallyemployed as a temporary biological dressing. Often they maybe subject to trauma, functional impairment, or meningitisfrom CSF leakage. If left for an extended period of time, theskin graft can become fibrotic and adheres to the underlyingneural tissue. This may make the graft difficult to remove atthe time of delayed definitive repair and increases the risk ofdamaging neural tissue [4].

Musculocutaneous flaps have identifiable blood supply,and this makes them a safer option for repair. This anatomicaladvantage promotes early, predictable healing [4]. However,

muscle loss and ambulatory status of the patient must beconsidered when evaluating utility [3]. Several myocutaneousflaps have been described in the literature for repair of sacraldefects. In pressure ulcers, muscle serves the important func-tion of eliminating dead space and providing increased vas-cularity to the wound. With ambulatory patients, specifictechniques must be developed to salvage maximum musclefunction. For example, the inferior gluteus maximus can bepreserved, while the superior gluteus maximus island flap isutilized to cover a sacral defect. Gluteus maximus is also usedin a V-Y flap design. Benefit of the V-Y gluteus maximus flapis that it provides coverage without sacrificing function. If alarge enough island of skin is preserved, the flap can even bereadvanced. For larger defects, the bilateral V-Yadvancementflap can be considered [5].

There are many different types of skin flaps available. Cruzdescribed the double Z-plasty [6], Bajaj described a doubletransposition flap in a yin–yang pattern [7], Habal reported abilateral bipedicle flap [2], and Ohtsuka used a modifiedrhomboid flap [8].

Rhomboid (Limberg) flap was designed by AlexanderLimberg, who first introduced it during 1963 as a means toprovide a more exact and mathematical approach to solvingwound problems as opposed to the empirical approach used inplanning flaps and Z-plasties [9]. Limberg flap utilizes arhomboid-shaped excision. This wastes less normal tissuethan a fusiform excision and closes the wound under de-creased tension [10].

Ohtsuka described a modification of Limberg flap. It isused for lumbosacral meningomyelocele defects. Instead ofcreating a parallelogram, defects were made into wide ovalsand stretched to fit the flap. Defects were repaired on neonatesfrom 6 to 29 h and varied from 4×4 to 8×8.5 cm in diameter[8].

Disadvantage of the Limberg flap is that it is only suitablefor wide ovals and horizontal defects. It is not an adequatechoice for vertical spindle or oval defects. Vertically orienteddefects can be closed utilizing the double Z-rhomboid flaptechnique. However, this is often unfavorable for many rea-sons including tension central suture line tension over thedura, leading to wound breakdown [4].

Fig. 2 Outline of the flap. Note the landmarks ischial tuberosity, poste-rior iliac spine, and the superior and inferior gluteal artery perforators,designed as a rotation flap based on the fourth lumbar artery perforator

Fig. 3 a Wide underminingallows closure of the defect. bImmediate postoperative view ofthe patient. c Eight-weekpostoperative view of the patient

Eur J Plast Surg (2014) 37:173–176 175

Skin flaps also have other several disadvantages. Due to therandom blood supply of flaps, they require wide bases.Extensive skin undermining, relaxing incisions, back cuts, ortension at skin closure can result in significant wound com-plications. Any compromise can result in wound breakdownover the dural repair. Wide skin undermining required for skinflaps give an inherently greater risk for wound edge failurethan muscle flaps [4]. Comorbidities, such as diabetes andcigarette smoking as seen in our patient, make the utilizationof flaps in the repair of myelomeningocele defects even morechallenging. Therefore, including a well-established perfora-tor into the random flap provides a more reliable result. In ourcase, lumbar artery perforator was incorporated in the flapdesign.

Perforator flaps are another option for defect reconstruc-tion. Use of the lumbar artery flap was first described by Krolland Rosenfield in 1988. With this newly discovered flap, itwas reported to be of the same benefit of enhanced bloodsupply as seen in myocutaneous flaps without associateddonor site morbidities [11]. Lumbar artery perforator flap alsoallows a substantial amount of fatty tissue in a thin patientwithout sacrificing the gluteal muscle and the muscles of thelumbar region. This leads to decreased morbidity and im-proves recovery time [12].

Despite these benefits, there has not been an extensive useof the lumbar artery as a perforator flap. This might be due tothe limited literature in regard to the vessels for that region. Inaddition, there is a wide variability in the size and position ofthe lumbar artery itself.

In 1999, Kato [13] performed dissections on the lumbararteries. He found that the lumbar perforators were penetratingthe lumbar fascia at the lateral border of the erector spinaemuscle anywhere between 5 and 9 cm from the midline with amean of 7.22 cm. The upper three arteries run laterally be-tween the quadratus lumborum and the erector spinae muscle.The fourth lumbar artery courses in front of the quadratuslumborum. The fourth lumbar artery was the only one foundto have consistent perforators; also, it had the largest vascularbundle, making it superior to the other lumbar arteries [13].

In 2009, Liu [12] characterized the lumbar perforator ves-sels via spiral CT angiography and dissection. Four pairedlumbar arteries were found originating from the descendingaorta. An average of six musculocutaneous perforators waspresent. Average diameter and area supplied were 0.7 mm and30 cm [2], respectively. The fourth lumbar artery perforatorcan be identified in a square region, with L4 as the lowerborder, 8 cm above L4 as the upper border, and 10 cm lateralfrom the midline as the lateral border [12]. Perforators of thesecond and fourth lumbar arteries were found to be moredeveloped than the others [13].

Lumbar artery perforator has many advantages. It has aconsistent blood supply from the fourth lumbar artery. It does

not sacrifice any muscle, has a large rotational arc, and pre-sents a donor site that can be closed primarily. Location of theperforators can be detected preoperatively or intraoperativelyusing Doppler ultrasound in the vicinity of the lateral border ofthe erector spinae [13].

A myocutaneous flap may not have been the best optionwhen considering the muscle loss in the still ambulatorypatient.

In conclusion, the advantages of the lumbar artery perfora-tor flap are as follows:

1 Gluteus maximus muscle is not utilized in an ambulatingpatient, preserving the muscle function and for futurecoverage if necessary,

2 Defect is closed in overlying layers with different layers,providing more stable coverage of the dura repair.

3 Flap creates minimal morbidity when raised on a singleperforator, allowing mobilization of the flap and donorarea primary closure.

Conflict of Interest None

References

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2. Habal MB, Vries JK (1977) Tension free closure of largemeningomyelocele defects. Surg Neurol 8:177–180

3. Cruz-Korchin N (2000) Soft tissue closure of myelomeningoceles:role of skin flaps—limberg and rhomboid. Oper Tech Plast ReconstrSurg 7(2):77–81

4. Ramasastry SS, Cohen M (1995) Soft tissue closure and plasticsurgical aspects of large open myelomeningoceles. Neurosurg ClinN Am 6(2):279–91

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6. Cruz NI, Ariyan S, Duncan CC et al (1983) Repair of lumbosacralmyelomeningoceles with double Z-rhomboid flaps. Technical note. JNeurosurg 59:714–717

7. Bajaj PS, Welsh F, Shadid EA (1979) Versatility of lumbar transpo-sition flaps in the closure of meningomyelocele skin defects. AnnPlast Surg 2:103–108

8. Ohtsuka H, Shioya N, Yada K (1979) Modified limberg flap forlumbosacral meningomyelocele defects. Ann Plast Surg 3:114–117

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