Research Article| Volume 65, ISSUE 5, P578-583, May 2012

The reading man flap for closure of large meningomyelocele defects

Published:November 15, 2011DOI:



      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 accomplished by direct closure or skin undermining. In such cases, the skin defect is best repaired using flaps. The aim of this study is to evaluate the reading man procedure for closure of large meningomyelocele defect.


      In this procedure, after neurosurgical repair and closure of the placode, the defect surgically becomes a circle in shape. Then, the circular defect is closed by transposition of two skin flaps designed in an unequal Z-plasty manner. Over 5 years, the reading man procedure was used for closure of large meningomyelocele defects in seven patients (four females and three males), aged between 1.5 and 6 months. The defect size was 10.5×7.25 cm (8.5×5.3 and 12.6×9.5 cm) on average. The localisation of the lesions was thoracolumbar in two patients and lumbosacral in five patients.


      In all patients, a successful tension-free one-stage closure was obtained without dog-ear formation. Except for one patient with minimal tip necrosis, healing was uneventful without any complications. There was no patient with late breakdown of the wound during 1.5 years (8 months–4 years) of mean follow-up.


      The reading man procedure enables the surgeon to achieve a tension-free defect closure of considerably large meningomyeleocele defects. Using two well-vascularised fasciocutaneous flaps, it provides a durable coverage and soft tissue padding over the neural tissues with no suture seam at midline. With these advantages, the Reading Man Procedure seems to be a useful and safe alternative for closure of large meningomyelocele defects.


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        • Reigel D.H.
        in: Cheek W.R. Atlas of pediatric neurosurgery. 1st ed. W.B. Saunders, Philadelphia1996: 1-9
        • Cohen A.R.
        • Robinson S.
        Early management of myelomeningocele.
        in: McLone D.G. pediatric neurosurgery: surgery of the developing nervous system. Saunders, Philadelphia, PA2001: 241-259
        • Luce E.A.
        • Stigers S.
        • Vandenbrink K.D.
        • et al.
        Split-thickness skin grafting of the myelomeningocele defect: a subset at risk for late ulceration.
        Plast Reconstr Surg. 1991; 87: 116-121
        • Ulusoy M.G.
        • Kocer U.
        • Sungur N.
        • et al.
        Closure of meningomyelocele defects with bilateral modified V-Y advancement flaps.
        Ann Plast Surg. 2005; 54: 640-644
        • Lapid O.
        • Rosenberg L.
        • Cohen A.
        Meningomyelocele reconstruction with bilobed flaps.
        Br J Plast Surg. 2001; 54: 570-572
        • Ramirez O.M.
        • Ramasastry S.S.
        • Granick M.S.
        • et al.
        A new surgical approach to closure of large lumbosacral meningomyelocele defects.
        Plast Reconstr Surg. 1987; 80: 799-809
        • Duffy Jr., F.J.
        • Weprin B.E.
        • Swift D.M.
        A new approach to closure of large lumbosacral myelomeningoceles: the superior gluteal artery perforator flap.
        Plast Reconstr Surg. 2004; 53: 305-310
        • Atik B.
        • Tan O.
        • Mutaf M.
        • et al.
        Skin perforators of back region: anatomical study and clinical applications.
        Ann Plast Surg. 2008; 60: 70-75
        • Hayashi A.
        • Maruyama Y.
        Bilateral latissimus dorsi V–Y musculocutaneous flap for closure of a large meningomyelocele.
        PlastReconstr Surg. 1991; 88: 520
        • Davies D.
        • Adendorff D.J.
        A large rotation flap raised across the midline to close lumbosacral meningomyeloceles.
        Br J Plast Surg. 1977; 30: 166-168
        • Patterson T.J.
        The use of rotation flaps following excision of lumbar myelomeningoceles: an aid for the closure of large defects.
        Br J Surg. 1959; 46: 606-608
        • Luce E.A.
        • Walsh J.
        Wound closure of the myelomeningocele defect.
        Plast Reconstr Surg. 1985; 75: 389-393
        • Davila F.B.
        • Luce E.A.
        Current considerations for myelomeningocele repair.
        J Craniofac Surg. 2000; 11: 500
        • Bajaj P.S.
        • Welsh F.
        • Shadid E.A.
        Versatility of lumbar transposition flaps in the closure of meningomyelocele skin defects.
        Ann Plast Surg. 1979; 2: 103-108
        • Sarifakioglu N.
        • Bingul F.
        • Terzioglu A.
        • et al.
        Bilateral split latissimus dorsi V-Y flaps for closure of large thoracolumbar meningomyelocele defects.
        Br J Plast Surg. 2003; 56: 303-306
        • Akan I.M.
        • Ulusoy M.G.
        • Bilen B.T.
        • et al.
        Modified bilateral advancement flap: the slide-in flap.
        Ann Plast Surg. 1999; 42: 545-548
        • Mangels K.J.
        • Tulipan N.
        • Bruner J.P.
        • et al.
        Use of bipedicular advancement flaps for intrauterine closure of myeloschisis.
        Pediatr Neurosurg. 2000; 32: 52-56
        • Cruz N.I.
        • Ariyan S.
        • Duncan C.C.
        • et al.
        Repair of lumbosacral myelomeningoceles with double Z-rhomboid flaps. Technical note.
        J Neurosurg. 1983; 59: 714-717
        • Campobasso P.
        • Pesce C.
        • Costa L.
        • et al.
        The use of Limberg skin flap for closure of large lumbosacral myelomeningoceles.
        Pediatr Surg Int. 2004; 20: 144-147
        • Ohtsuka H.
        • Shioya N.
        • Yada K.
        Modified Limberg flap for lumbosacral meningomyelocele defects.
        Ann Plast Surg. 1979; 3: 114-117
        • Desperez J.D.
        • Kiehn C.L.
        • Eckstein W.
        Closure of large myelomeningocele defects by composite skin-muscle flaps.
        Plastic Reconstr Surg. 1971; 47: 234-238
        • Meuli-Simmen C.
        • Meuli M.
        Latissimus dorsi flap procedures to cover myelomeningocele in utero: a feasibility study in human fetuses.
        J Pediatr Surg. 1997; 32: 1154
        • McCraw J.B.
        • Penix J.O.
        • Freeman B.G.
        • et al.
        Soft-tissue repair of myelomeningocele defects using bilateral latissimus dorsi and trapezius musculocutaneous flaps.
        Ann Plast Surg. 1987; 18: 147-155
        • Moore T.S.
        • Dreyer T.M.
        • Bevin A.G.
        Closure of large spina bifida cystica defects with bilateral bipedicled musculocutaneous flaps.
        Plast Reconstr Surg. 1984; 73: 288-292
        • McCraw J.B.
        • Penix J.O.
        • Baker J.W.
        Repair of major defects of the chest wall and spine with the latissimus dorsi myocutaneous flap.
        Plast Reconstr Surg. 1978; 62: 197-206
        • Zide B.M.
        Spina bifida.
        in: McCarthy J.G. Plastic surgery. Saunders, Philadelphia1990: 3780-3790
        • Isik D.
        • Tekes L.
        • Eseoglu M.
        • Isik Y.
        • Bilici S.
        • Atik B.
        Closure of large myelomeningocele defects using dorsal intercostal artery perforator flap.
        Ann Plas Surg. 2010;
        • Mutaf M.
        • Bekerecioğlu M.
        • Erkutlu I.
        • Bulut Ö
        A new technique for closure of large meningomyelocele defects.
        Ann Plast Surg. 2007; 59: 538-543
      1. Mutaf M, Sunay M, Bulut Ö, et al. Reading Man procedure. Oral presentation at: the 27th Turkish National Congress of Plastic, Reconstructive and Aesthetic Surgery, Konya, Turkey; September 14–17, 2005.

        • Mutaf M.
        • Sunay M.
        • Bulut Ö
        The “reading man” procedure a new technique for the closure of circular skin defects.
        Ann Plast Surg. 2008; 60: 420-425
        • Iacobucci J.J.
        • Marks M.W.
        • Argenta L.C.
        Anatomic studies and clinical experience with fasciocutaneous flap closure of large myelomeningoceles.
        Plast Reconstr Surg. 1996; 97 (Discussion 1409–1410): 1400-1408