ORIGINAL ARTICLE Paolo Campobasso Æ Ciro Pesce Æ Lorenzo Costa Maria Luisa Cimaglia The use of the Limberg skin flap for closure of large lumbosacral myelomeningoceles Published online: 10 February 2004 Ó Springer-Verlag 2004 Abstract Closure of the skin defect in myelomeningocele repair is an essential step that determines the quality of the surgical result. In large myelomeningoceles, however, adequate skin coverage may not be accom- plished by direct closure or skin undermining. In such cases, the skin defect is best repaired using flaps. To evaluate whether the Limberg skin flap is effective for the repair of large round or oval lumbosacral myelom- eningoceles, we studied the records of 25 children. Sur- gical repair was carried out within 24–36 hours of birth in all 25 patients, with the defect size ranging from 36– 72 cm 2 . Durable, stable soft tissue coverage of the defect was obtained in 23 of 25 patients, with a postoperative follow-up of at least 2 years. Reoperation became nec- essary in the remaining two patients, but flap necrosis occurred in only one. We suggest that Limberg flap re- pair may have some advantages in patients with large round or oval lumbosacral myelomeningoceles, includ- ing minimal invasivity, short hospitalization, and im- proved cosmetic results. Keywords Myelomeningocele Æ Limberg flap Æ Skin flap Introduction The purpose of myelomeningocele repair is twofold: 1) closure of the defect without damage to the neural tissue, and 2) tension-free skin closure. In general, small mye- lomeningoceles may be amenable to direct repair by undermining the surrounding skin. Because adequate closure is problematic in large defects, the use of various skin flaps may be helpful in these cases. There are several methods of skin coverage for large myelomeningoceles, including local skin flaps, muscu- locutaneous flap variations, and skin grafting [1]. In this paper, we report our 20-year experience with the Lim- berg skin flap for closure of large round or oval lum- bosacral myelomeningoceles. Material and methods The study group comprised 25 patients, 12 boys and 13 girls, with round or oval lumbosacral myelomeningocele defects who under- went repair at the Division of Pediatric Surgery at San Bortolo Hospital in Vicenza. All patients were operated on within the first 24–36 hours of life and had a median birth weight of 2.7 kg (range 2–3.5). Defect sizes ranged from 6·6–8·9 cm. The original 1963 study by Limberg describing the use of a rhomboid flap for the coverage of large skin defects was the basic reference [2]. A rhomboid defect was created around the myelo- meningocele, and a rhomboid flap was harvested cranially to the defect. After standard dural repair [3], a line perpendicular to the long axis of the defect was made. The length of the line, marked as < in Fig. 1, was equal to the length of one side of the rhombus. Subsequently, a second line at a 120° degree angle was drawn, making it parallel to a side of the rhomboid. The second line of the flap is indicated as >> in Fig. 1. The Limberg flap was then prepared through surgical dissection at the level of the lumbar fascia; this preserves virtually all perforator vessels to the base of flap. The edges of the defect were undermined and mobilized when necessary. Once the dissection was completed, the Limberg flap was rotated and adjusted to the myelomeningocele defect. A subcuta- neous drainage was left in place and, finally, tension-free skin closure was performed. (Fig. 2). The average operating time was 90 minutes. All patients were maintained in a prone position during the postoperative course, which lasted from 5–6 days. Feeding was started on the 1st post- operative day, and the drainage tube was removed on the 3rd. Twenty-four out of 25 patients developed hydrocephalus and required the placement of a ventriculoperitoneal shunt. We used neither musculocutaneous flaps nor the Mustarde´ technique to strengthen the dural repair [4]. In one patient, a patch of lyophilised dura mater was used with the aim of fortifying the dural closure. P. Campobasso Æ C. Pesce (&) Æ L. Costa Division of Pediatric Surgery, San Bortolo Hospital, Viale Rodolfi (I), 36100 Vicenza, Italy E-mail: ciro.pesce@libero.it Tel.: +39-444-993563 Fax: +39-444-993887 M. L. Cimaglia Division of Neurosurgery, Santobono Hospital, Naples, Italy Pediatr Surg Int (2004) 20: 144–147 DOI 10.1007/s00383-003-1056-8