INTRODUCTION
Myelomeningocele, or spina bifida cystica, is characterized by a defect in closing
the neural tube during the 20th week of gestation. Amniotic fluid exerts deleterious effects on unprotected neural
tissue. It is the most common neural tube defect and the second cause of chronic deficiency
of the locomotor system in the pediatric age group. Its cause is multifactorial, with
risk factors such as folic acid deficiency, maternal hyperthermia during the early
stages of pregnancy, or antiepileptic drugs.1.2.
In Brazil, the incidence of myelomeningocele is 2.28 per 1000 births. It is highly
disabling, resulting in tetraparesis or paraparesis, neurogenic bladder, and cognitive
impairment. It is estimated that among those with spinal cord injury, 85% will develop
pressure ulcers. These are formed due to the constant pressure exerted by bony prominences
on the skin, leading to local ischemia and ulcerated lesion formation.
The treatment of this type of injury aims to maintain tissue functionality, eliminate
devitalized tissues and infectious processes, avoid secondary complications and allow
aesthetic improvement of the affected region when possible.3.
The technique presented uses two types of locoregional flaps to correct ulcers in
the ischial region. The first is a muscle flap made with the semimembranosus and biceps
femoris muscles, which generate a protective cushion and avoid local dead space. To
cover the muscle flap’s fixation area, we chose to use a fasciocutaneous flap from
the posterior aspect of the thigh.
Due to the high incidence of pressure injuries in bedridden patients and for generating
health problems and worsening the quality of life of these patients, it is necessary
to implement adequate prophylaxis and treatments with a lower recurrence rate.
OBJECTIVE
Therefore, this work covers the initial experience with the double flap technique,
muscular and fasciocutaneous, at the Plastic Surgery Service of Hospital São Paulo
de Muriaé, MG, Brazil.
CASE REPORT
Female, 23 years old, with multiple sequelae due to myelomeningocele, with cystostomy
and a deep ulcer in the right ischial region. According to the mother’s reports, the
lesion has about seven years of evolution, with several unsuccessful attempts at treatments.
Approximately one and a half years ago, the patient developed daily evening fever
and right gluteal hyperemia. Since then, under the guidance of an infectious disease
specialist, treatment with ciprofloxacin 500 mg orally twice a day and topical calcium
alginate has been implemented.
The patient had a deep and extensive lesion in the right ischial region, measuring
approximately eight centimeters in its greatest diameter and with underlying muscle
exposure, without signs of devitalized tissues or secretions, but with a chronic evolution
and no possibility of healing without appropriate surgical intervention. On laboratory
tests, she did not have anemia or leukocytosis (Figure 1).
Figure 1 - Ischial pressure ulcer.
Figure 1 - Ischial pressure ulcer.
The procedure was performed on April 8, 2020.
Patient in prone position under general anesthesia, asepsis and antisepsis were performed,
surgical marking with methylene blue, infiltration of an anesthetic solution containing
epinephrine and debridement with complete resection of the underlying bursa, since
its permanence is associated with a high rate of lesion recurrence (Figure 2).
Figure 2 - Total bursectomy.
Figure 2 - Total bursectomy.
An incision extended from the lower margin of the right gluteus to the lateral face
of the ipsilateral thigh, and a muscle flap was later made using the semimembranosus
and biceps femoris muscles. The flap was rotated to accommodate redundant tissue in
the trochanteric prominence to avoid trochanteric ulcers. Throughout the procedure,
careful hemostasis was maintained. There were no bony prominences in need of removal.
Afterward, the muscle flap was fixed over the ischial region (Figure 3).
Figure 3 - Muscle flap rotation.
Figure 3 - Muscle flap rotation.
To cover the exposed area, a fasciocutaneous flap was used by advancing the posterior
region of the thigh. We chose to insert a 4.8 mm Hemovac drain with its fixation by
counter-opening on the medial face of the right thigh. The synthesis was performed
in planes and ended with a local dressing (Figure 4).
Figure 4 - On the left, fasciocutaneous flap advancement. On the right, synthesis by planes and
positioning of the suction drain.
Figure 4 - On the left, fasciocutaneous flap advancement. On the right, synthesis by planes and
positioning of the suction drain.
Prophylactic antibiotic therapy was maintained during hospitalization with intravenous
cefazolin, and vascular flow optimization was performed with oral administration of
pentoxifylline 400 mg twice a day.
On the first postoperative day, the patient had an operative wound in good appearance,
with no signs of hematoma or secretions, a drain volume of 250 ml, laboratory tests
without a significant drop in hematocrit. On the second postoperative day, she was
discharged, and the family was instructed to keep the drain at home and remove it
after eight days in a hospital environment. The drainage through the drain showed
a progressive decrease, and this was removed with a flow of 25 ml of serous secretion
in 24 hours on the eighth postoperative day. The externalization hole of the drain
healed by the second intention. The patient presented adequate surgical wound healing
without removing sutures since the synthesis was performed with absorbable threads.
DISCUSSION
Patients with myelomeningocele sequelae are, in most cases, bedridden with severe
neurological and orthopedic impairments. Thus, they are more prone to the development
of pressure ulcers. Among the affected sites, the ischial region is the most frequent.4.
Several procedures are used for the surgical management of this type of injury. However,
the reduced mobility of bedridden patients and techniques that are sometimes inadequate
contribute to the high rate of recurrence.5.6.
The technique demonstrated has been used in two patients, with the case described
being the most recent. In the first experience, the patient had similar clinical conditions,
such as not being able to walk, and the results, in a year and a half of follow-up,
were satisfactory.
A key point for long-term success is adequate debridement, with tissue resection up
to the viable bone. Attention should be paid to the total resection of the bursa underlying
pressure ulcers since its permanence is a favorable factor for local recurrence. Also,
performing careful hemostasis is essential for the good evolution of the flaps and
for not causing an anemic condition in already debilitated patients. In addition,
this technique relies on the association of two types of flaps, muscular and fasciocutaneous.
As this is a bedridden patient, who does not walk and, therefore, maintains constant
pressure on the skin surfaces, a surgical technique was chosen that provides muscle
protection, preserving its arterial irrigation, associated with the fasciocutaneous
flap to form a bigger cushion,7.
CONCLUSION
The surgical technique above, using a double muscle flap and fasciocutaneous flap,
concomitantly with the total resection of the bursa under the ischial ulcer, is effective
and reproducible, with satisfactory results in the short and long term.
More patients are being submitted to the same technique to improve the statistics
and confirm the results presented here.
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1. Hospital São Paulo, Departamento de Cirurgia Plástica, Muriaé, MG, Brazil
Corresponding author: Flávia Mesquita Soares, Rua João Marcelo Santoni, 296, Parque Renato Maia, Guarulhos, SP, Brazil, Zip Code
07114-120, E-mail: flavia.soares.m93@gmail.com
Article received: September 11, 2020.
Article accepted: October 15, 2021.
Conflicts of interest: não há.
