title: Intraoperative acute tissue expansion for the closure of large myelomeningoceles.
abstract: OBJECTIVE
  Skin closure has always been the main challenge in treating myelomeningoceles (MMCs). Most cutaneous defects can be treated with the simple undermining and primary suture of the wound edges. This is the ideal treatment, but it is not adequate in cases in which the lesions are greater than 5 cm in diameter. Numerous reconstructive procedures have been described and the results have been satisfactory. The need to mobilize large skin areas and the fact of excessive blood loss, however, are major problems in newborns. Moreover, the tissue undermining destroys most of the skin's vascularization and can harm the adaptation of the skin flaps. The authors describe a technique for primary closure of large MMC skin defects in which they use acute skin expansion during the surgical procedure.
  
  
  METHODS
  Skin expansion was achieved by traction of the wound edges with U-shaped sutures and without the need of skin flaps. Sixteen patients with MMCs greater than 5 cm in diameter were evaluated.
  
  
  RESULTS
  The MMC areas ranged from 30 to 64 cm2 (mean 45 cm2). Two suture systems were developed based on the quality of the skin edge and the size of the skin defect. Wound edge traction was performed in 10-minute periods. The edges were gradually approximated and this allowed the primary closure of the wound without undermining the tissue in all patients. In one patient skin necrosis developed, which was associated with compression of the malformed underlying vertebrae.
  
  
  CONCLUSIONS
  Simplicity, low cost, and satisfactory results were the main advantages of the method and an increase in operative time was a disadvantage. The goal of this technique is not to replace the other methods, but the technique constitutes an effective option in the treatment of large MMCs.
authors.affiliation: Department of Pediatric Neurosurgery, Hospital das Clinicas, Federal University of Minas Gerais, Brazil. henriques_jgb@hotmail.com
authors.forename: José Gilberto
authors.initials: JG
authors.lastname: De Brito Henriques
authors.forename: Geraldo Pianetti
authors.initials: GP
authors.lastname: Filho
authors.forename: Sebastião Nataniel Silva
authors.initials: SN
authors.lastname: Gusmão
authors.forename: Karina Santos Wandeck
authors.initials: KS
authors.lastname: Henriques
authors.forename: Marcelo Eller
authors.initials: ME
authors.lastname: Miranda
mesh_terms: D062109:Dermatologic Surgical Procedures; D005500:Follow-Up Studies; D006801:Humans; D007231:Infant, Newborn; D007234:Infant, Premature; D008591:Meningomyelocele / Q000473:pathology / Q000601:surgery*; D011126:Polypropylenes; D012867:Skin / Q000473:pathology; D013536:Suture Techniques; D013537:Sutures; D015626:Tissue Expansion / Q000295:instrumentation*; D016896:Treatment Outcome; D014546:Urinary Catheterization / Q000295:instrumentation*; D014945:Wound Healing
chemical_list: D011126:Polypropylenes