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case_images: (a) Ultrasound scan performed at 21 weeks gestation. Defect demonstrated by marker. (b) Fetal MRI scan confirming myelomeningocele defect.
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case_images: Antenatal diagnosis of spina bifida had been made on anomaly ultrasound scan performed at 21 weeks (Figure 1(a)) and confirmed by fetal MRI scan (Figure 1(b)).
case_images: Primary lumbosacral myelomeningocele at 1-day post-partum. Defect measured 8 x 7 cm.
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case_images: The defect was measured at 8 x 7 cm (Figure 2).
case_images: Tubularised dural repair.
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case_images: The placode was subsequently inverted and closed using 4/0 polypropylene sutures to reconstruct a neural tube (Figure 3).
case_images: First DRT layer at primary procedure, prior to application of NWPT dressing.
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case_images: ARTISS (Baxter Healthcare, Newbury, UK) fibrin sealant spray was applied to the wound bed prior to application to aid adherence and the DRT was affixed using 4/0 polypropylene sutures (Figure 4). A non-adherent silicone interface dressing (NA Ultra, Systagenix, Gargrave, UK) was applied over the NovoSorb BTM and the whole wound was sealed within a negative pressure wound therapy (NPWT) dressing (V.A.C., 3M, St Paul, Minnesota, USA).
case_images: Three weeks post-partum. DRT is integrated, with complete vascularisation (red colour) and delamination of bonded polyurethane top layer (pale areas).
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case_images: BTM. By day 19, the outer sealing membrane of the NovoSorb BTM had delaminated and the underlying foam was completely vascularised (Figures 5 and 6).
case_images: Removal of polyurethane top layer, revealing vascularised 'neo-dermis'.
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case_images: BTM. By day 19, the outer sealing membrane of the NovoSorb BTM had delaminated and the underlying foam was completely vascularised (Figures 5 and 6).
case_images: Second 'stacked' DRT layer, prior to application of NPWT dressing.
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case_images: A further sheet of NovoSorb BTM was applied at this point and the above process was repeated (Figure 7).
case_images: Full integration and vascularisation of second DRT layer.
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case_images: A further change of NWPT dressing was performed on day 26 and split skin grafting of the second DRT layer was carried out on day 40 (Figures 8 and 9).
case_images: Second layer of DRT demonstrating a vascularised wound bed with punctate bleeding.
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case_images: A further change of NWPT dressing was performed on day 26 and split skin grafting of the second DRT layer was carried out on day 40 (Figures 8 and 9).
case_images: Third reconstructive procedure: split thickness skin graft secured over second DRT layer.
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case_images: A hand-fenestrated 8/1000-inch-thick skin graft was harvested from the outer aspect of the right thigh and affixed with absorbable 4/0 sutures (Vicryl Rapide, Ethicon, Cincinnati, USA) (Figure 10).
case_images: Appearance 1-year post-partum. Stable, robust soft tissue coverage. Peripheral scar is slightly hypertrophic.
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case_images: The skin over the reconstruction was soft, pliable and maintained a good contour with the surrounding tissues (Figure 11).