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Primary Versus Fasciocutaneous Bipedicle Flap Intra-uterine Closure Of Myelomeningocele Defects: A Post-moms Retrospective Cohort Study.
Matthew E. Pontell, MD1, Aaron Yengo-Kahn, MD2, Emily Taylor, WHNP-BC3, Morgan Kane, OTR/L4, J. Michael Newton, MD, PhD5, Kelly A. Bennett, MD, MS5, John C. Wellons, III, MD, MSPH6, Stephane A. Braun, MD7.
1Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA, 2Department of Neurologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA, 3The Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA, 4Pediatric Rehabilitation Services, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA, 5The Fetal Center at Vanderbilt, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA, 6Division of Pediatric Neurosurgery, The Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA, 7Department of Plastic Surgery, The Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA.

Title: Intra-uterine closure of myelomeningocele defects with primary versus bipedicle fasciocutaneous flaps: a single center post-MOMS retrospective cohort study
Authors: Matthew E. Pontell MD1, Aaron Yengo-Kahn MD2, Emily Taylor, WHNP-BC3, Morgan Kane OTR/L4, J. Michael Newton MD PhD3,5, Kelly A Bennett MD MS3,5, John C. Wellons III, MD, MSPH2,3,6, Stephane A. Braun MD1,3.
1 Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN2 Department of Neurologic Surgery, Vanderbilt University Medical Center, Nashville, TN3 The Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN4 Pediatric Rehabilitation Services, Monroe Carrell, Jr. Children’s Hospital at Vanderbilt, Nashville, TN5 Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN6The Surgical Outcomes Center for Kids Monroe Carrell, Jr. Children’s Hospital at Vanderbilt, Nashville, TN
Introduction: The Management of Myelomeningocele Study (MOMS) concluded that prenatal myelomeningocele (MMC) repair improved postnatal outcomes. Lesions too large for primary closure present a unique challenge. This study compares the use of intrauterine bipedicle fasciocutaneous flaps for closure of MMCs not amenable to primary linear repair. We hypothesized that obstetric, wound, early CSF diversion, and functional outcomes would be similar between groups.
Methods: A retrospective review was conducted of all patients who underwent in-utero MMC repair from 2011-2021 at a single institution. Univariate analysis was conducted using Chi-squared, Fisher’s exact, independent sample t and Log-Rank tests. 
Results: Twenty-two patients underwent intrauterine bipedicled fasciocutaneous flap closure, while 64 underwent primary linear closure. Median follow-up time was 1.6 years and ranged from 0-9.6 years. Maternal cohorts did not differ significantly with respect to age at time of fetal surgery, gravidity, parity, BMI, fetal lesion level or gestational age at the time of MMC repair. Operative times were longer in the flap cohort (32.5土9.93 vs. 18.7土4.88 minutes, p<0.01); however, there were no significant differences in maternal blood loss (94.32土66.44 vs. 81.11土52.64 milliliters, p=0.35), need for fetal (0%) or maternal (0%) transfusion, gestational age at delivery (231.64土31.77 vs. 240.18土17.93 days, p=0.13) or MMC repair site dehiscence (5% vs. 10.17%, p=0.67). There were no significant differences in major intra-uterine or postnatal complications. The flap cohort had a lower rate of cerebrospinal fluid diversion prior to discharge (0% vs. 7.02%, p<0.01). Rates of CSF diversion were similar at one year (33.3% vs. 38.5%, p=0.70) and overall at the most recent follow-up (50% vs 41.5%,p=0.53). There was no
difference in CSF diversion-free survival between groups (p=0.88) [Figure 1]. Of those with follow-up beyond two years, a similar proportion in each group were ambulating independently or with orthotic devices (90.0% vs 79.3%, p=0.64).
Conclusion: While fetal MMC repair has widely adopted after the results of the MOMS trial, it is difficult to identify high-tension lesions preoperatively. This study suggests that bipedicle flaps can achieve tension-free intrauterine MMC closure without increasing risks to the mother or fetus.
Figure 1.


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