Anatomic Studies and Clinical Experience with Fasciocutaneous Flap Closure of Large Myelomeningoceles

Abstract

Thirteen patients have undergone reconstruction of large lumbosacral myelomeningoceles with bilateral paralumbar fasciocutaneous flaps. Fasciocutaneous flap closure is supported by a rich vascular network with three main dominant vascular territories. In the middle third of the flaps, a prominent transverse segmental vascular pattern originating from the muscular perforators and lateral cutaneous branches of the costal groove segment of the lower intercostal arteries was noted. The parascapular and scapular fascial branches of the circumflex scapular artery supplied the upper lateral portion of the flaps. Prominent lateral extensions of the superficial circumflex iliac arterial system formed the dominant fascial vasculature of the lower lateral flap, richly arborizing with the middle segmental intercostal extensions. All 13 patients tolerated the procedure without blood transfusion and without perioperative complications. Stable, durable cutaneous coverage was achieved in all patients. Two postmortem neonate humans with large lumbosacral myelomeningoceles were studied angiographically. Radiopaque silicone-rubber-lead-chrome matrix (Microfil) was infused under physiologic pressures in a 7-day neonate after successful defect closure with bilateral fasciocutaneous flaps. The flaps were reevaluated postmortem, and high-contrast, digitally enhanced computed radiographic imaging confirmed the rich vascular support of the bilateral fasciocutaneous flaps, identifying the dominant vascular pedicles. Rich vascularity was further documented by photographing the orange opaque Microfil cast vessels through the reelevated flaps. A second postmortem (stillborn) myelomeningocele specimen was studied with barium infusion with particular emphasis on the anomalous lumbar aorta. Angiographic studies provide a new understanding of the unique vascular anatomy of both the anomaly and the paralumbar fasciocutaneous flap.