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Perforator flaps have unique advantages that may overcome the shortcomings of conventional approaches to myelomeningocele reconstruction. However, identifying and dissecting tiny perforators in neonates is arduous. We have overcome these obstacles with a freestyle flap approach that uses duplex ultrasonography to locate perforator vessels, allowing for limited superficial dissection. This report describes the duplex ultrasonography-assisted freestyle pedicled perforator flap technique for closure of myelomeningocele defects, with long-term clinical outcomes.
The surgical technique is described in detail. Case records of surgeries between 2004 and 2017 were retrospectively reviewed, focusing on whether potential perforators for flap pedicle were identified by duplex ultrasonography and subsequently used.
Among 18 neonates who underwent repair of thoraco-lumbo-sacral myelomeningocele, 8 had reconstruction of soft tissue defects with freestyle pedicled perforator flaps. Defect size ranged from 1.6 × 2.2 cm to 6.0 × 7.0 cm. Potential flap pedicle perforators were identified by intraoperative ultrasonography and used as the vascular supply of the flap. All perforator flaps survived intact. Complications were transient and uncommon. Over a median follow-up of 1.65 years (range, 0.3–12.8 years), there was 1 transient pressure sore due to severe kyphosis with some tenderness along the flap suture line. All other reconstructions were durable and well-padded without late sequelae. Cases with a corrected age of more than 12 months could walk, stand, and crawl without muscular dysfunction due to flap surgery.
Freestyle pedicled perforator flaps combined with duplex ultrasonography delineates perforator anatomy and obviates the need for tiny perforator dissection during myelomeningocele reconstruction, achieving reliable closure with excellent long-term results.

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