We retrospectively reviewed all newborns with a diagnosis of myelomeningocele (MMC) admitted to our hospital between January 1990 and September 1994 to determine methods of soft-tissue coverage, complication rates, and results. Sixty-five patients underwent repair of thoracic, lumbar, or sacral MMCs. The average size of defect repaired measured 21.3 cm2 (range, 2–80 cm2). Methods of repair included direct approximation of soft tissues with or without undermining (N = 48), Romberg-Limberg flaps (N = 8), gluteus maximus or latissimus dorsi musculocutaneous flaps (N = 5), fasciocutaneous flaps (N = 3), and V-Y advancement (N = 1). A total of 18 complications were recorded (27.7%). There were 5 major complications (7.7%) and 13 minor ones (20.0%). Major complications were defined as midline wound dehiscence overlying the neural elements or wound infection leading to meningitis or ventriculitis. All 5 major and 9 minor complications arose in patients undergoing direct soft-tissue approximation. Additionally, all major complications were recorded in defects >18 cm 2. Based on this series, it appears that MMC defects <18 cm 2 can be closed by direct approximation of soft tissues without significant risk or major wound complication. Larger wounds may be successfully closed in this manner, but the risk of major complication is substantial.