Myelomeningocele closure: A review and decision-making guidance.

Background: Myelomeningocele, the most severe neural tube defect, results from failed neural tube closure during embryogenesis, leading to herniation of the spinal cord and meninges through a vertebral defect. Early postnatal surgical intervention remains the standard of care to prevent infection, preserve neurological function, and achieve durable soft tissue coverage. Despite advances in reconstructive techniques, wound complications remain common, and consensus on the optimal technique and flap selection remains inconclusive. Objective: This review examines current evidence on postnatal myelomeningocele closure techniques, including flap-based reconstructive methods, aiming to guide flap selection based on defect characteristics. Results: Primary skin closure remains suitable for small defects (<20-25 cm² or width <5 cm), offering low morbidity but variable complication rates, particularly in larger lesions. Skin grafting, once commonly used, is now largely abandoned due to its poor long-term durability and tendency to induce kyphotic deformities. Local fasciocutaneous flaps, including Limberg rhomboid, V-Y advancement, keystone perforator island flaps, and the butterfly flap, demonstrate reliable outcomes in moderate to large defects, with low rates of cerebrospinal fluid leak, dehiscence, and flap necrosis. More extensive defects may necessitate musculocutaneous flaps (e.g., paraspinous, latissimus dorsi, gluteus maximus), which offer solid coverage but are associated with increased operative morbidity and potential functional impairment. Conclusion: Optimal myelomeningocele reconstruction requires individualized surgical planning guided by defect-specific parameters and surgical expertise. Flap selection should prioritize tension-free closure, minimal donor-site morbidity, and durability. This review proposes an algorithmic, anatomy-informed approach to assist clinicians in achieving favorable outcomes across a wide spectrum of myelomeningocele presentations.