Closure of Meningomyelocele Defects With Sensate Medial Dorsal Intercostal Artery Perforator Flaps

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Dear Sir,
We read with interest the article by Basterzi and Teneckeci1 on the use of the dorsal intercostal artery perforator (DICAP) propeller flap for closure of large meningomyelocele defects. The authors are congratulated with their results. According to Cormack and Lamberty,2 a medial dorsal and lateral dorsal cutaneous branch arise from an intercostal artery. In our anatomical study, we found in adults the medial DICAP (MDICAP) within 3 cm from the midline.3 Recently, we published our long-term results on the use of MDICAP flaps for closure of complex midline defects after spinal surgery.4 This flap has shown to be a reliable perforator flap with great potential for midline defects.
Basterzi and Tenekecki did not differentiate between medial and lateral DICAP flaps, but we anticipate that they have used perforator flaps based on the MDICAP. The authors do not mention a possible advantage of this perforator flap. Based on a study by Davies et al5 and our own study, we have included the cutaneous nerve branch from the intercostal nerve accompanying the perforator and have created a sensate MDICAP flap to close midline defects. Our results show that protective sensibility was obtained in the reconstructed area in adults and will most likely be obtained in newborns operated with this flap for closure of meningomyelocele defects.
Similar to the authors, we have used MDICAP flaps to close defects after neural repair of meningomyeloceles.6 Although we combined this flap in these cases with the use of autologous amnion to obtain a watertight closure. We also experienced a short period with venous congestion of these flaps in the newborn that resolved spontaneously. Interestingly, this venous problem was limited to the distal half of the flap (Fig. 1). Such supports the idea that the flap consists of perforasomes of the medial and lateral DICAP.
From Figure 2 in their article, one could easily get the impression that this flap is based on the contralateral perforator. Such reminded us of the flap design by Davies and Adendorf7 using a flap based on perforators across the midline to close lumbosacral meningomyeloceles. By designing the flap in such a fashion, one may obtain an even better pivot point for rotation of the flap into the defect.
We thank the authors for their contribution and for sharing their experience in solving a difficult and challenging problem.
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