{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T12:37:52Z","timestamp":1792067872468,"version":"4.4.0"},"reference-count":58,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2019,10]]},"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVE<\/jats:title>\n                    <jats:p>Many repair techniques have been proposed to treat large myelomeningocele (MMC), and although effective in many cases, some of these techniques can be complex and time consuming, with complications such as cerebrospinal fluid (CSF) leakage, flap loss, tip necrosis, and wound dehiscence. The purpose of this study was to analyze cases of large skin defects and the methods applied and to report the outcomes of the keystone design perforator island flap (KDPIF) technique for large MMC closure.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS<\/jats:title>\n                    <jats:p>The authors performed a retrospective review of all neonatal patients who had undergone KDPIF for MMC closure in the period from 2013 to 2018. All patients had a diagnosis of lumbosacral MMC based on obstetric ultrasound. The neurosurgeons and plastic surgeons had selected the cases after concluding that primary closure would be unlikely. The design of the flap is based on the randomly located vascular perforators, creating two identical opposing flaps to fashion a double keystone flap. During wound closure, V-Y advancement of each end of the double flap in the longitudinal axis creates redundancy in the central portion of the flap and reduces the horizontal tension. After discharge, both the neurosurgery and plastic surgery teams followed up all patients, tracking the results with photography.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS<\/jats:title>\n                    <jats:p>No skin flap dehiscence or necrosis, infection, or CSF leakage was detected, proving the reliability of the flap. One of the patients required further surgery for the large skin defects after insufficient intrauterine closure of the MMC and successfully underwent KDPIF treatment. Another patient (14.3%) had severe neonatal sepsis, which ultimately led to death. A ventriculoperitoneal shunt was required after the skin defect repair in 5 (83.3%) of the 6 surviving patients. Exceptional aesthetic results were achieved for all patients during the follow-up.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS<\/jats:title>\n                    <jats:p>The KDPIF technique is based on well-known vascular perforators of the intercostal, lumbar, and gluteal regions. Wound tension is widely distributed by the flap and, as a consequence, relevant tissue bulk, reliable vascularity, and important geometrical versatility are provided. In addition, most of the muscles and fascia are preserved, which is another advantage in terms of minimizing secondary morbidity to local tissue rearrangement. The use of KDPIF closure was successfully shown to be a viable alternative for more complex MMCs that present with large skin defects.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/2019.7.focus19383","type":"journal-article","created":{"date-parts":[[2019,10,4]],"date-time":"2019-10-04T19:23:37Z","timestamp":1570217017000},"page":"E19","source":"Crossref","is-referenced-by-count":16,"title":["Using the keystone design perforator island flap in large myelomeningocele closure"],"prefix":"10.3171","volume":"47","author":[{"given":"Cleiton","family":"Formentin","sequence":"first","affiliation":[{"name":"Neurosurgery Division\u2014Department of Neurology, University of Campinas (UNICAMP); and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erion Junior","family":"de Andrade","sequence":"additional","affiliation":[{"name":"Neurosurgery Division\u2014Department of Neurology, University of Campinas (UNICAMP); and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leo Gordiano","family":"Matias","sequence":"additional","affiliation":[{"name":"Neurosurgery Division\u2014Department of Neurology, University of Campinas (UNICAMP); and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrei F.","family":"Joaquim","sequence":"additional","affiliation":[{"name":"Neurosurgery Division\u2014Department of Neurology, University of Campinas (UNICAMP); and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Helder","family":"Tedeschi","sequence":"additional","affiliation":[{"name":"Neurosurgery Division\u2014Department of Neurology, University of Campinas (UNICAMP); and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"C\u00e1ssio Eduardo","family":"Raposo-Amaral","sequence":"additional","affiliation":[{"name":"Plastic and Craniofacial Institute, Sobrapar Hospital, Campinas, S\u00e3o Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Enrico","family":"Ghizoni","sequence":"additional","affiliation":[{"name":"Neurosurgery Division\u2014Department of Neurology, University of Campinas (UNICAMP); and"},{"name":"Plastic and Craniofacial Institute, Sobrapar Hospital, Campinas, S\u00e3o Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1","series-title":"N Engl J Med","doi-asserted-by":"publisher","first-page":"993","DOI":"10.1056\/NEJMoa1014379","article-title":"A randomized trial of prenatal versus postnatal repair of myelomeningocele","volume":"364","author":"Adzick NS","year":"2011","unstructured":"Adzick NS, Thom EA, Spong CY, Brock JW III, Burrows PK, Johnson MP, : A randomized trial of prenatal versus postnatal repair of myelomeningocele. N Engl J Med 364:993\u20131004, 20112130627710.1056\/NEJMoa1014379"},{"key":"b2","series-title":"Ann Plast Surg","doi-asserted-by":"publisher","first-page":"562","DOI":"10.1097\/01.sap.0000200221.27116.27","article-title":"Bilobed fasciocutaneous flap closure of large meningomyeloceles","volume":"56","author":"Atik B","year":"2006","unstructured":"Atik B, Tan O, Kiymaz N, Yilmaz N, Tekes L: Bilobed fasciocutaneous flap closure of large meningomyeloceles. Ann Plast Surg 56:562\u2013564, 20061664163710.1097\/01.sap.0000200221.27116.27"},{"key":"b3","series-title":"Dev Disabil Res Rev","doi-asserted-by":"publisher","first-page":"6","DOI":"10.1002\/ddrr.93","article-title":"Epidemiologic and genetic aspects of spina bifida and other neural tube defects","volume":"16","author":"Au KS","year":"2010","unstructured":"Au KS, Ashley-Koch A, Northrup H: Epidemiologic and genetic aspects of spina bifida and other neural tube defects. Dev Disabil Res Rev 16:6\u201315, 20102041976610.1002\/ddrr.93"},{"key":"b4","series-title":"ANZ J Surg","doi-asserted-by":"publisher","first-page":"112","DOI":"10.1046\/j.1445-2197.2003.02638.x","article-title":"The keystone design perforator island flap in reconstructive surgery","volume":"73","author":"Behan FC","year":"2003","unstructured":"Behan FC: The keystone design perforator island flap in reconstructive surgery. ANZ J Surg 73:112\u2013120, 200310.1046\/j.1445-2197.2003.02638.x12608972"},{"key":"b5","series-title":"N Engl J Med","doi-asserted-by":"publisher","first-page":"1509","DOI":"10.1056\/NEJM199911113412006","article-title":"Neural-tube defects","volume":"341","author":"Botto LD","year":"1999","unstructured":"Botto LD, Moore CA, Khoury MJ, Erickson JD: Neural-tube defects. N Engl J Med 341:1509\u20131519, 199910.1056\/NEJM19991111341200610559453"},{"issue":"1\u201313","key":"b6","series-title":"MMWR CDC Surveill Summ","article-title":"Surveillance for anencephaly and spina bifida and the impact of prenatal diagnosis\u2014United States, 1985\u20131994","volume":"44","author":"Cragan JD","year":"1995","unstructured":"Cragan JD, Roberts HE, Edmonds LD, Khoury MJ, Kirby RS, Shaw GM, : Surveillance for anencephaly and spina bifida and the impact of prenatal diagnosis\u2014United States, 1985\u20131994. MMWR CDC Surveill Summ 44:1\u201313, 19957637675"},{"issue":"28","key":"b7","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"260","DOI":"10.1097\/01.BRS.0000042234.98512.BE","article-title":"Neonatal kyphectomy in the patient with myelomeningocele","author":"Crawford AH","year":"2003","unstructured":"Crawford AH, Strub WM, Lewis R, Gabriel KR, Billmire DA, Berger T, : Neonatal kyphectomy in the patient with myelomeningocele. Spine (Phila Pa 1976) 28:260\u2013266, 200310.1097\/01.BRS.0000042234.98512.BE12567028"},{"key":"b8","series-title":"Childs Nerv Syst","doi-asserted-by":"publisher","first-page":"1459","DOI":"10.1007\/s00381-011-1448-3","article-title":"Keystone design perforator island flap for closure of myelomeningocele","volume":"27","author":"Gutman MJ","year":"2011","unstructured":"Gutman MJ, Goldschlager T, Fahardieh RD, Ying D, Xenos C, Danks RA: Keystone design perforator island flap for closure of myelomeningocele. Childs Nerv Syst 27:1459\u20131463, 201110.1007\/s00381-011-1448-321523390"},{"key":"b9","series-title":"Plast Reconstr Surg","doi-asserted-by":"publisher","first-page":"520","DOI":"10.1097\/00006534-199109000-00026","article-title":"Bilateral latissimus dorsi V-Y musculocutaneous flap for closure of a large meningomyelocele","volume":"88","author":"Hayashi A","year":"1991","unstructured":"Hayashi A, Maruyama Y: Bilateral latissimus dorsi V-Y musculocutaneous flap for closure of a large meningomyelocele. Plast Reconstr Surg 88:520\u2013523, 199110.1097\/00006534-199109000-000261871235"},{"key":"b10","series-title":"Plast Reconstr Surg Glob Open","doi-asserted-by":"publisher","first-page":"e1114","DOI":"10.1097\/GOX.0000000000001114","article-title":"Closure of a large thoracolumbar myelomeningocele using a modified bilateral keystone flap","volume":"4","author":"Jamjoom H","year":"2016","unstructured":"Jamjoom H, Alnoman H, Almadani Y: Closure of a large thoracolumbar myelomeningocele using a modified bilateral keystone flap. Plast Reconstr Surg Glob Open 4:e1114, 201610.1097\/GOX.000000000000111428293496"},{"key":"b11","series-title":"J Neurosurg Pediatr","doi-asserted-by":"publisher","first-page":"467","DOI":"10.3171\/2014.12.PEDS14133","article-title":"Alternative method for the reconstruction of meningomyelocele defects: V-Y rotation and advancement flap","volume":"15","author":"Kankaya Y","year":"2015","unstructured":"Kankaya Y, Sungur N, Aslan OC, Ozer K, Ulusoy MG, Karatay M, : Alternative method for the reconstruction of meningomyelocele defects: V-Y rotation and advancement flap. J Neurosurg Pediatr 15:467\u2013474, 20152567938110.3171\/2014.12.PEDS14133"},{"key":"b12","series-title":"Br J Plast Surg","doi-asserted-by":"publisher","first-page":"541","DOI":"10.1054\/bjps.1999.3120","article-title":"The lumbar artery perforator based island flap: anatomical study and case reports","volume":"52","author":"Kato H","year":"1999","unstructured":"Kato H, Hasegawa M, Takada T, Torii S: The lumbar artery perforator based island flap: anatomical study and case reports. Br J Plast Surg 52:541\u2013546, 199910.1054\/bjps.1999.312010658107"},{"key":"b13","series-title":"Plast Reconstr Surg","doi-asserted-by":"publisher","first-page":"1229","DOI":"10.1097\/PRS.0b013e31819f299e","article-title":"The lumbar artery perforators: a cadaveric and clinical anatomical study","volume":"123","author":"Kiil BJ","year":"2009","unstructured":"Kiil BJ, Rozen WM, Pan WR, Grinsell D, Ashton MW, Corlett RJ, : The lumbar artery perforators: a cadaveric and clinical anatomical study. Plast Reconstr Surg 123:1229\u20131238, 20091933709110.1097\/PRS.0b013e31819f299e"},{"key":"b14","series-title":"Ann Plast Surg","doi-asserted-by":"publisher","first-page":"514","DOI":"10.1097\/00000637-199312000-00007","article-title":"Surgical repair of myelomeningocele","volume":"31","author":"Lanigan MW","year":"1993","unstructured":"Lanigan MW: Surgical repair of myelomeningocele. Ann Plast Surg 31:514\u2013521, 199310.1097\/00000637-199312000-000078297082"},{"key":"b15","series-title":"Br J Plast Surg","doi-asserted-by":"publisher","first-page":"570","DOI":"10.1054\/bjps.2001.3680","article-title":"Meningomyelocele reconstruction with bilobed flaps","volume":"54","author":"Lapid O","year":"2001","unstructured":"Lapid O, Rosenberg L, Cohen A: Meningomyelocele reconstruction with bilobed flaps. Br J Plast Surg 54:570\u2013572, 20011158349210.1054\/bjps.2001.3680"},{"key":"b16","series-title":"MMWR CDC Surveill Summ","first-page":"15","article-title":"Prevalence of spina bifida at birth\u2014United States, 1983\u20131990: a comparison of two surveillance systems","volume":"45","author":"Lary JM","year":"1996","unstructured":"Lary JM, Edmonds LD: Prevalence of spina bifida at birth\u2014United States, 1983\u20131990: a comparison of two surveillance systems. MMWR CDC Surveill Summ 45:15\u201326, 19968602137"},{"key":"b17","series-title":"Lancet","doi-asserted-by":"publisher","first-page":"301","DOI":"10.1016\/S0140-6736(74)92606-3","article-title":"Effect of early surgery for spina bifida cystica on survival and quality of life","volume":"1","author":"Laurence KM","year":"1974","unstructured":"Laurence KM: Effect of early surgery for spina bifida cystica on survival and quality of life. Lancet 1:301\u2013304, 197410.1016\/S0140-6736(74)92606-34130481"},{"key":"b18","series-title":"Childs Nerv Syst","doi-asserted-by":"publisher","first-page":"1091","DOI":"10.1007\/s00381-010-1099-9","article-title":"Local and regional flap closure in myelomeningocele repair: a 15-year review","volume":"26","author":"Lien SC","year":"2010","unstructured":"Lien SC, Maher CO, Garton HJ, Kasten SJ, Muraszko KM, Buchman SR: Local and regional flap closure in myelomeningocele repair: a 15-year review. Childs Nerv Syst 26:1091\u20131095, 201010.1007\/s00381-010-1099-920195618"},{"key":"b19","series-title":"Plast Reconstr Surg","doi-asserted-by":"publisher","first-page":"389","DOI":"10.1097\/00006534-198503000-00015","article-title":"Wound closure of the myelomeningocoele defect","volume":"75","author":"Luce EA","year":"1985","unstructured":"Luce EA, Walsh J: Wound closure of the myelomeningocoele defect. Plast Reconstr Surg 75:389\u2013393, 1985388337710.1097\/00006534-198503000-00015"},{"key":"b20","series-title":"Acta Neurochir Suppl","doi-asserted-by":"publisher","first-page":"143","DOI":"10.1007\/978-3-319-39546-3_22","article-title":"Myelomeningocele repair: surgical management based on a 30-year experience","volume":"124","author":"Mattogno PP","year":"2017","unstructured":"Mattogno PP, Massimi L, Tamburrini G, Frassanito P, Di Rocco C, Caldarelli M: Myelomeningocele repair: surgical management based on a 30-year experience. Acta Neurochir Suppl 124:143\u2013148, 201710.1007\/978-3-319-39546-3_2228120066"},{"key":"b21","series-title":"Plast Reconstr Surg","doi-asserted-by":"publisher","first-page":"710e","DOI":"10.1097\/PRS.0000000000002610","article-title":"The concepts of propeller, perforator, keystone, and other local flaps and their role in the evolution of reconstruction","volume":"138","author":"Mohan AT","year":"2016","unstructured":"Mohan AT, Sur YJ, Zhu L, Morsy M, Wu PS, Moran SL, : The concepts of propeller, perforator, keystone, and other local flaps and their role in the evolution of reconstruction. Plast Reconstr Surg 138:710e\u2013729e, 201610.1097\/PRS.0000000000002610"},{"key":"b22","series-title":"Childs Nerv Syst","doi-asserted-by":"publisher","first-page":"614","DOI":"10.1007\/s00381-002-0660-6","article-title":"The significance of the percentage of the defect size in spina bifida cystica in determination of the surgical technique","volume":"18","author":"Ozveren MF","year":"2002","unstructured":"Ozveren MF, Erol FS, Topsakal C, Tiftikci MT, Akdemir I: The significance of the percentage of the defect size in spina bifida cystica in determination of the surgical technique. Childs Nerv Syst 18:614\u2013620, 200210.1007\/s00381-002-0660-612420121"},{"key":"b23","series-title":"Neurosurgery","doi-asserted-by":"publisher","first-page":"511","DOI":"10.1227\/01.NEU.0000350879.02128.80","article-title":"Long-term outcome of total and near-total resection of spinal cord lipomas and radical reconstruction of the neural placode: part I\u2014surgical technique","volume":"65","author":"Pang D","year":"2009","unstructured":"Pang D, Zovickian J, Oviedo A: Long-term outcome of total and near-total resection of spinal cord lipomas and radical reconstruction of the neural placode: part I\u2014surgical technique. Neurosurgery 65:511\u2013529, 200910.1227\/01.NEU.0000350879.02128.8019687697"},{"key":"b24","series-title":"Ann Plast Surg","doi-asserted-by":"publisher","first-page":"332","DOI":"10.1097\/SAP.0000000000000600","article-title":"An application of keystone perforator island flap for closure of lumbosacral myelomeningocele defects","volume":"77","author":"Park HS","year":"2016","unstructured":"Park HS, Morrison E, Lo C, Leong J: An application of keystone perforator island flap for closure of lumbosacral myelomeningocele defects. Ann Plast Surg 77:332\u2013336, 201610.1097\/SAP.000000000000060026418773"},{"key":"b25","series-title":"J Plast Reconstr Aesthet Surg","doi-asserted-by":"publisher","first-page":"888","DOI":"10.1016\/j.bjps.2007.03.023","article-title":"The keystone design perforator island flap. Part II: clinical applications","volume":"60","author":"Pelissier P","year":"2007","unstructured":"Pelissier P, Gardet H, Pinsolle V, Santoul M, Behan FC: The keystone design perforator island flap. Part II: clinical applications. J Plast Reconstr Aesthet Surg 60:888\u2013891, 200710.1016\/j.bjps.2007.03.02317493885"},{"key":"b26","series-title":"J Plast Reconstr Aesthet Surg","doi-asserted-by":"publisher","first-page":"883","DOI":"10.1016\/j.bjps.2007.01.072","article-title":"The keystone design perforator island flap. Part I: anatomic study","volume":"60","author":"Pelissier P","year":"2007","unstructured":"Pelissier P, Santoul M, Pinsolle V, Casoli V, Behan F: The keystone design perforator island flap. Part I: anatomic study. J Plast Reconstr Aesthet Surg 60:883\u2013887, 20071744615210.1016\/j.bjps.2007.01.072"},{"key":"b27","series-title":"Ment Retard Dev Disabil Res Rev","doi-asserted-by":"publisher","first-page":"247","DOI":"10.1002\/(SICI)1098-2779(1998)4:4<247::AID-MRDD3>3.0.CO;2-P","article-title":"Mechanisms of neural tube closure and defects","volume":"4","author":"Sadler TW","year":"1998","unstructured":"Sadler TW: Mechanisms of neural tube closure and defects. Ment Retard Dev Disabil Res Rev 4:247\u2013253, 199810.1002\/(SICI)1098-2779(1998)4:4<247::AID-MRDD3>3.0.CO;2-P"},{"key":"b28","series-title":"Turk Neurosurg","first-page":"157","article-title":"Tissue expander application in giant meningomyelocele cases","volume":"4","author":"Savac\u0131 N","year":"1994","unstructured":"Savac\u0131 N, G\u00fcney \u00d6, Erongun U: Tissue expander application in giant meningomyelocele cases. Turk Neurosurg 4:157\u2013160, 1994"},{"key":"b29","series-title":"Issues in Flap Surgery","doi-asserted-by":"publisher","first-page":"37","DOI":"10.5772\/intechopen.71270","article-title":"Perforator flaps: principles and techniques","author":"Tenekeci G","year":"2018","unstructured":"Tenekeci G: Perforator flaps: principles and techniques, in Amr S (ed): Issues in Flap Surgery. London: IntechOpen, 2018, pp 37\u20134910.5772\/intechopen.71270"},{"key":"b1","series-title":"N Engl J Med","doi-asserted-by":"publisher","first-page":"993","DOI":"10.1056\/NEJMoa1014379","article-title":"A randomized trial of prenatal versus postnatal repair of myelomeningocele","volume":"364","author":"Adzick NS","year":"2011","unstructured":"Adzick NS, Thom EA, Spong CY, Brock JW III, Burrows PK, Johnson MP, : A randomized trial of prenatal versus postnatal repair of myelomeningocele. N Engl J Med 364:993\u20131004, 20112130627710.1056\/NEJMoa1014379"},{"key":"b2","series-title":"Ann Plast Surg","doi-asserted-by":"publisher","first-page":"562","DOI":"10.1097\/01.sap.0000200221.27116.27","article-title":"Bilobed fasciocutaneous flap closure of large meningomyeloceles","volume":"56","author":"Atik B","year":"2006","unstructured":"Atik B, Tan O, Kiymaz N, Yilmaz N, Tekes L: Bilobed fasciocutaneous flap closure of large meningomyeloceles. Ann Plast Surg 56:562\u2013564, 20061664163710.1097\/01.sap.0000200221.27116.27"},{"key":"b3","series-title":"Dev Disabil Res Rev","doi-asserted-by":"publisher","first-page":"6","DOI":"10.1002\/ddrr.93","article-title":"Epidemiologic and genetic aspects of spina bifida and other neural tube defects","volume":"16","author":"Au KS","year":"2010","unstructured":"Au KS, Ashley-Koch A, Northrup H: Epidemiologic and genetic aspects of spina bifida and other neural tube defects. Dev Disabil Res Rev 16:6\u201315, 20102041976610.1002\/ddrr.93"},{"key":"b4","series-title":"ANZ J Surg","doi-asserted-by":"publisher","first-page":"112","DOI":"10.1046\/j.1445-2197.2003.02638.x","article-title":"The keystone design perforator island flap in reconstructive surgery","volume":"73","author":"Behan FC","year":"2003","unstructured":"Behan FC: The keystone design perforator island flap in reconstructive surgery. ANZ J Surg 73:112\u2013120, 200310.1046\/j.1445-2197.2003.02638.x12608972"},{"key":"b5","series-title":"N Engl J Med","doi-asserted-by":"publisher","first-page":"1509","DOI":"10.1056\/NEJM199911113412006","article-title":"Neural-tube defects","volume":"341","author":"Botto LD","year":"1999","unstructured":"Botto LD, Moore CA, Khoury MJ, Erickson JD: Neural-tube defects. N Engl J Med 341:1509\u20131519, 199910.1056\/NEJM19991111341200610559453"},{"issue":"1\u201313","key":"b6","series-title":"MMWR CDC Surveill Summ","article-title":"Surveillance for anencephaly and spina bifida and the impact of prenatal diagnosis\u2014United States, 1985\u20131994","volume":"44","author":"Cragan JD","year":"1995","unstructured":"Cragan JD, Roberts HE, Edmonds LD, Khoury MJ, Kirby RS, Shaw GM, : Surveillance for anencephaly and spina bifida and the impact of prenatal diagnosis\u2014United States, 1985\u20131994. MMWR CDC Surveill Summ 44:1\u201313, 19957637675"},{"issue":"28","key":"b7","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"260","DOI":"10.1097\/01.BRS.0000042234.98512.BE","article-title":"Neonatal kyphectomy in the patient with myelomeningocele","author":"Crawford AH","year":"2003","unstructured":"Crawford AH, Strub WM, Lewis R, Gabriel KR, Billmire DA, Berger T, : Neonatal kyphectomy in the patient with myelomeningocele. Spine (Phila Pa 1976) 28:260\u2013266, 200310.1097\/01.BRS.0000042234.98512.BE12567028"},{"key":"b8","series-title":"Childs Nerv Syst","doi-asserted-by":"publisher","first-page":"1459","DOI":"10.1007\/s00381-011-1448-3","article-title":"Keystone design perforator island flap for closure of myelomeningocele","volume":"27","author":"Gutman MJ","year":"2011","unstructured":"Gutman MJ, Goldschlager T, Fahardieh RD, Ying D, Xenos C, Danks RA: Keystone design perforator island flap for closure of myelomeningocele. Childs Nerv Syst 27:1459\u20131463, 201110.1007\/s00381-011-1448-321523390"},{"key":"b9","series-title":"Plast Reconstr Surg","doi-asserted-by":"publisher","first-page":"520","DOI":"10.1097\/00006534-199109000-00026","article-title":"Bilateral latissimus dorsi V-Y musculocutaneous flap for closure of a large meningomyelocele","volume":"88","author":"Hayashi A","year":"1991","unstructured":"Hayashi A, Maruyama Y: Bilateral latissimus dorsi V-Y musculocutaneous flap for closure of a large meningomyelocele. Plast Reconstr Surg 88:520\u2013523, 199110.1097\/00006534-199109000-000261871235"},{"key":"b10","series-title":"Plast Reconstr Surg Glob Open","doi-asserted-by":"publisher","first-page":"e1114","DOI":"10.1097\/GOX.0000000000001114","article-title":"Closure of a large thoracolumbar myelomeningocele using a modified bilateral keystone flap","volume":"4","author":"Jamjoom H","year":"2016","unstructured":"Jamjoom H, Alnoman H, Almadani Y: Closure of a large thoracolumbar myelomeningocele using a modified bilateral keystone flap. Plast Reconstr Surg Glob Open 4:e1114, 201610.1097\/GOX.000000000000111428293496"},{"key":"b11","series-title":"J Neurosurg Pediatr","doi-asserted-by":"publisher","first-page":"467","DOI":"10.3171\/2014.12.PEDS14133","article-title":"Alternative method for the reconstruction of meningomyelocele defects: V-Y rotation and advancement flap","volume":"15","author":"Kankaya Y","year":"2015","unstructured":"Kankaya Y, Sungur N, Aslan OC, Ozer K, Ulusoy MG, Karatay M, : Alternative method for the reconstruction of meningomyelocele defects: V-Y rotation and advancement flap. J Neurosurg Pediatr 15:467\u2013474, 20152567938110.3171\/2014.12.PEDS14133"},{"key":"b12","series-title":"Br J Plast Surg","doi-asserted-by":"publisher","first-page":"541","DOI":"10.1054\/bjps.1999.3120","article-title":"The lumbar artery perforator based island flap: anatomical study and case reports","volume":"52","author":"Kato H","year":"1999","unstructured":"Kato H, Hasegawa M, Takada T, Torii S: The lumbar artery perforator based island flap: anatomical study and case reports. Br J Plast Surg 52:541\u2013546, 199910.1054\/bjps.1999.312010658107"},{"key":"b13","series-title":"Plast Reconstr Surg","doi-asserted-by":"publisher","first-page":"1229","DOI":"10.1097\/PRS.0b013e31819f299e","article-title":"The lumbar artery perforators: a cadaveric and clinical anatomical study","volume":"123","author":"Kiil BJ","year":"2009","unstructured":"Kiil BJ, Rozen WM, Pan WR, Grinsell D, Ashton MW, Corlett RJ, : The lumbar artery perforators: a cadaveric and clinical anatomical study. Plast Reconstr Surg 123:1229\u20131238, 20091933709110.1097\/PRS.0b013e31819f299e"},{"key":"b14","series-title":"Ann Plast Surg","doi-asserted-by":"publisher","first-page":"514","DOI":"10.1097\/00000637-199312000-00007","article-title":"Surgical repair of myelomeningocele","volume":"31","author":"Lanigan MW","year":"1993","unstructured":"Lanigan MW: Surgical repair of myelomeningocele. Ann Plast Surg 31:514\u2013521, 199310.1097\/00000637-199312000-000078297082"},{"key":"b15","series-title":"Br J Plast Surg","doi-asserted-by":"publisher","first-page":"570","DOI":"10.1054\/bjps.2001.3680","article-title":"Meningomyelocele reconstruction with bilobed flaps","volume":"54","author":"Lapid O","year":"2001","unstructured":"Lapid O, Rosenberg L, Cohen A: Meningomyelocele reconstruction with bilobed flaps. Br J Plast Surg 54:570\u2013572, 20011158349210.1054\/bjps.2001.3680"},{"key":"b16","series-title":"MMWR CDC Surveill Summ","first-page":"15","article-title":"Prevalence of spina bifida at birth\u2014United States, 1983\u20131990: a comparison of two surveillance systems","volume":"45","author":"Lary JM","year":"1996","unstructured":"Lary JM, Edmonds LD: Prevalence of spina bifida at birth\u2014United States, 1983\u20131990: a comparison of two surveillance systems. MMWR CDC Surveill Summ 45:15\u201326, 19968602137"},{"key":"b17","series-title":"Lancet","doi-asserted-by":"publisher","first-page":"301","DOI":"10.1016\/S0140-6736(74)92606-3","article-title":"Effect of early surgery for spina bifida cystica on survival and quality of life","volume":"1","author":"Laurence KM","year":"1974","unstructured":"Laurence KM: Effect of early surgery for spina bifida cystica on survival and quality of life. Lancet 1:301\u2013304, 197410.1016\/S0140-6736(74)92606-34130481"},{"key":"b18","series-title":"Childs Nerv Syst","doi-asserted-by":"publisher","first-page":"1091","DOI":"10.1007\/s00381-010-1099-9","article-title":"Local and regional flap closure in myelomeningocele repair: a 15-year review","volume":"26","author":"Lien SC","year":"2010","unstructured":"Lien SC, Maher CO, Garton HJ, Kasten SJ, Muraszko KM, Buchman SR: Local and regional flap closure in myelomeningocele repair: a 15-year review. Childs Nerv Syst 26:1091\u20131095, 201010.1007\/s00381-010-1099-920195618"},{"key":"b19","series-title":"Plast Reconstr Surg","doi-asserted-by":"publisher","first-page":"389","DOI":"10.1097\/00006534-198503000-00015","article-title":"Wound closure of the myelomeningocoele defect","volume":"75","author":"Luce EA","year":"1985","unstructured":"Luce EA, Walsh J: Wound closure of the myelomeningocoele defect. Plast Reconstr Surg 75:389\u2013393, 1985388337710.1097\/00006534-198503000-00015"},{"key":"b20","series-title":"Acta Neurochir Suppl","doi-asserted-by":"publisher","first-page":"143","DOI":"10.1007\/978-3-319-39546-3_22","article-title":"Myelomeningocele repair: surgical management based on a 30-year experience","volume":"124","author":"Mattogno PP","year":"2017","unstructured":"Mattogno PP, Massimi L, Tamburrini G, Frassanito P, Di Rocco C, Caldarelli M: Myelomeningocele repair: surgical management based on a 30-year experience. Acta Neurochir Suppl 124:143\u2013148, 201710.1007\/978-3-319-39546-3_2228120066"},{"key":"b21","series-title":"Plast Reconstr Surg","doi-asserted-by":"publisher","first-page":"710e","DOI":"10.1097\/PRS.0000000000002610","article-title":"The concepts of propeller, perforator, keystone, and other local flaps and their role in the evolution of reconstruction","volume":"138","author":"Mohan AT","year":"2016","unstructured":"Mohan AT, Sur YJ, Zhu L, Morsy M, Wu PS, Moran SL, : The concepts of propeller, perforator, keystone, and other local flaps and their role in the evolution of reconstruction. Plast Reconstr Surg 138:710e\u2013729e, 201610.1097\/PRS.0000000000002610"},{"key":"b22","series-title":"Childs Nerv Syst","doi-asserted-by":"publisher","first-page":"614","DOI":"10.1007\/s00381-002-0660-6","article-title":"The significance of the percentage of the defect size in spina bifida cystica in determination of the surgical technique","volume":"18","author":"Ozveren MF","year":"2002","unstructured":"Ozveren MF, Erol FS, Topsakal C, Tiftikci MT, Akdemir I: The significance of the percentage of the defect size in spina bifida cystica in determination of the surgical technique. Childs Nerv Syst 18:614\u2013620, 200210.1007\/s00381-002-0660-612420121"},{"key":"b23","series-title":"Neurosurgery","doi-asserted-by":"publisher","first-page":"511","DOI":"10.1227\/01.NEU.0000350879.02128.80","article-title":"Long-term outcome of total and near-total resection of spinal cord lipomas and radical reconstruction of the neural placode: part I\u2014surgical technique","volume":"65","author":"Pang D","year":"2009","unstructured":"Pang D, Zovickian J, Oviedo A: Long-term outcome of total and near-total resection of spinal cord lipomas and radical reconstruction of the neural placode: part I\u2014surgical technique. Neurosurgery 65:511\u2013529, 200910.1227\/01.NEU.0000350879.02128.8019687697"},{"key":"b24","series-title":"Ann Plast Surg","doi-asserted-by":"publisher","first-page":"332","DOI":"10.1097\/SAP.0000000000000600","article-title":"An application of keystone perforator island flap for closure of lumbosacral myelomeningocele defects","volume":"77","author":"Park HS","year":"2016","unstructured":"Park HS, Morrison E, Lo C, Leong J: An application of keystone perforator island flap for closure of lumbosacral myelomeningocele defects. Ann Plast Surg 77:332\u2013336, 201610.1097\/SAP.000000000000060026418773"},{"key":"b25","series-title":"J Plast Reconstr Aesthet Surg","doi-asserted-by":"publisher","first-page":"888","DOI":"10.1016\/j.bjps.2007.03.023","article-title":"The keystone design perforator island flap. Part II: clinical applications","volume":"60","author":"Pelissier P","year":"2007","unstructured":"Pelissier P, Gardet H, Pinsolle V, Santoul M, Behan FC: The keystone design perforator island flap. Part II: clinical applications. J Plast Reconstr Aesthet Surg 60:888\u2013891, 200710.1016\/j.bjps.2007.03.02317493885"},{"key":"b26","series-title":"J Plast Reconstr Aesthet Surg","doi-asserted-by":"publisher","first-page":"883","DOI":"10.1016\/j.bjps.2007.01.072","article-title":"The keystone design perforator island flap. Part I: anatomic study","volume":"60","author":"Pelissier P","year":"2007","unstructured":"Pelissier P, Santoul M, Pinsolle V, Casoli V, Behan F: The keystone design perforator island flap. Part I: anatomic study. J Plast Reconstr Aesthet Surg 60:883\u2013887, 20071744615210.1016\/j.bjps.2007.01.072"},{"key":"b27","series-title":"Ment Retard Dev Disabil Res Rev","doi-asserted-by":"publisher","first-page":"247","DOI":"10.1002\/(SICI)1098-2779(1998)4:4<247::AID-MRDD3>3.0.CO;2-P","article-title":"Mechanisms of neural tube closure and defects","volume":"4","author":"Sadler TW","year":"1998","unstructured":"Sadler TW: Mechanisms of neural tube closure and defects. Ment Retard Dev Disabil Res Rev 4:247\u2013253, 199810.1002\/(SICI)1098-2779(1998)4:4<247::AID-MRDD3>3.0.CO;2-P"},{"key":"b28","series-title":"Turk Neurosurg","first-page":"157","article-title":"Tissue expander application in giant meningomyelocele cases","volume":"4","author":"Savac\u0131 N","year":"1994","unstructured":"Savac\u0131 N, G\u00fcney \u00d6, Erongun U: Tissue expander application in giant meningomyelocele cases. Turk Neurosurg 4:157\u2013160, 1994"},{"key":"b29","series-title":"Issues in Flap Surgery","doi-asserted-by":"publisher","first-page":"37","DOI":"10.5772\/intechopen.71270","article-title":"Perforator flaps: principles and techniques","author":"Tenekeci G","year":"2018","unstructured":"Tenekeci G: Perforator flaps: principles and techniques, in Amr S (ed): Issues in Flap Surgery. London: IntechOpen, 2018, pp 37\u20134910.5772\/intechopen.71270"}],"container-title":["Neurosurgical Focus"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/neurosurg-focus\/47\/4\/article-pE19.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/neurosurg-focus\/47\/4\/article-pE19.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/neurosurg-focus\/47\/4\/article-pE19.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,23]],"date-time":"2026-05-23T08:36:19Z","timestamp":1779525379000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/neurosurg-focus\/47\/4\/article-pE19.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,10]]},"references-count":58,"journal-issue":{"issue":"4"},"URL":"https:\/\/doi.org\/10.3171\/2019.7.focus19383","relation":{},"ISSN":["1092-0684"],"issn-type":[{"value":"1092-0684","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,10]]}}}