Plastic Dispensing Closure with Valve
Tension-free closure of the skin must be achieved to provide soft tissue protection for the neural elements and dural closure. This will help prevent wound breakdown, CSF leak and wound infection. Techniques used to achieve primary closure range from simple undermining of the skin with primary approximation to complex plastic surgical procedures. Historically, up to 75% [4,5,6,7] of defects are closed primarily and do not require additional plastic surgical input. Simple skin approximation requires less operative time and results in a significant reduction in blood loss. In our primary dataset, 77.4% of defects were closed by direct skin approximation.
Previous literature has suggested that the diameter of the lesion should dictate its method of closure; traditionally flap reconstruction is recommended for defects that are > 5 cm in diameter [7, 8]. Increasingly, a more tailored approach incorporating the location, shape and area, in addition to lesion length, has been reported [5, 9, 10]. Decisions on closure made on an individual basis instead of the width of the defect yield lower complication rates [5]. The condition of the skin surrounding the lesion is also an important variable to consider when deciding upon the method of closure.
Plastic surgeons contribute experience and knowledge in tissue handling. They perform direct skin closure after perforator preserving dissection with loupe magnification that conserves vascular supply to the wound edges. We believe that this improves the on-table decision-making regarding which defects can be closed by direct approximation or reverting to a flap for closure.
The perforator preserving dissection in combination with an increased understanding of the ‘junctional zone’, the thickened area of dense subcutaneous tissue at the junction of the arachnoid, dura and dermis [11], has allowed higher-tension closure in the deeper tissues without de-vascularisation of the skin edge.
Complications of MMC closure in the first 30 days postoperatively are most commonly wound complications such as dehiscence and infection [4, 12]. The literature reports complication rates between 7.7 and 33% [13,14,15,16,17,18] for this vulnerable group of patients. Our overall complication rate was 12.9%. However, only two of these were as a direct result of wound complications, one with flap edge necrosis and one due to infection. The two CSF leaks were primarily driven by the development of hydrocephalus and resolved immediately after the insertion of a VP shunt. This is certain in keeping with the published literature for MMC closures.