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Quadruple Perforator Flaps for Primary Closure of Large Myelomeningoceles

An Evaluation of the Butterfly Flap Technique

Rankin, Timothy M., MD, MS*; Wormer, Blair A., MD*; Tokin, Christopher, MD*; Kaoutzanis, Christodoulos, MBBS*; Al Kassis, Salam, MD*; Wellons, John C. III, MD, MSPH; Braun, Stephane, MD*

doi: 10.1097/SAP.0000000000001668
Clinical Papers

Introduction Myelomeningocele is the most common open neural tube defect. A quadruple rotation-VY advancement flap (butterfly flap) was recently reported for closure of large myelomeningocele defects; however, no series has been reproduced to evaluate this technique. The objective of this study was to describe our experience with this technique.

Materials and Methods We reviewed all infants born with large myelomeningocele defects who underwent butterfly flap closure over a 2-year period. Demographics, defect size, operative details, and complications were used to generate descriptive statistics.

Results From June 2015 to January 2018, 7 infants met inclusion criteria. Mean defect width was 52% ± 0.11 of the back, representing 21% ± 0.09 of the total back area. Only 1 child had central breakdown. All patients had some peripheral skin dehiscence that occurred on postoperative day 12 ± 7, and these were treated with outpatient wound care. Four patients returned to the operating room for dehiscence electively. There were no incidences of total flap loss. There were no cases of meningitis or myelomeningocele dehiscence. All patients had successful closure of their myelomeningocele without the use of skin grafts.

Conclusions The butterfly flap is able to close large myelomeningocele defects and has the potential to improve contour. There are minor wound-healing complications, but in the rare event of central dehiscence, quadruple rotation-VY advancement flaps can be re-advanced. In all cases, a large myelomeningocele was successfully reconstructed with robust full-thickness flaps, and there was no need for skin grafting of donor sites.

From the *Department of Plastic and Reconstructive Surgery, and

Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN.

Received June 29, 2018, and accepted for publication, after revision August 22, 2018.

Conflicts of interest and sources of funding: none declared.

Reprints: Stephane Braun, MD, Department of Plastic Surgery, Vanderbilt University Medical Center, Department of Plastic Surgery, D-4207 Medical Center North, Nashville, TN 37232-2345. E-mail:

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