If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Major scrotal defect with exposed testes and/or spermatic cords are a challenge for the reconstructive surgeon. The bacterial flora of the perineum, difficulty of immobilisation and the contour of the testes make testicular cover a difficult task [Br. J. Plast. Surg. 41 (1988) 190].
Traditional approaches have used simple skin grafts or if not feasible, multi-staged procedures with initial burying of the testes under delayed medial thigh flaps. Better techniques then evolved to permit early single-staged coverage using flaps rather than skin grafts in these usually contaminated and unsuitable wounds to improve the cosmetic outcome of the reconstruction and reduce patient discomfort and hospital stay.
Muscle flaps represent an excellent reconstruction option in the contaminated perineum especially in patients with impaired ability to deal with infection such as diabetic or toxic patients.
We present two cases of reconstruction of the scrotum using simple, reliable single-stage muscle flap techniques with good aesthetic results and review the literature.
Major scrotal defect with exposed testes and/or spermatic cords are a challenge for the reconstructive surgeon. The bacterial flora of the perineum, difficulty of immobilisation and the contour of the testes make testicular cover a difficult task.
reflecting the challenge and complexity these defects present.
We used a single-stage muscle flap technique to reconstruct two major scrotal defects following Fournier's gangrene which proved to be safe, reliable and simple with minimal donor site morbidity.
1. Case presentations
1.1 Case 1
A 52-year-old male developed Fournier's gangrene of the scrotum and penis 3 weeks after total cystectomy and urethrectomy for recurrent advanced transitional cell carcinoma of the bladder that had temporarily responded to previous chemotherapy and radical radiotherapy.
Intravenous antibiotics were started and extensive debridement of the skin of the penile shaft and scrotum were done leaving the testicles fully exposed. One week later, he was referred to our department to reconstruct his defect. In view of the previous radiotherapy to the abdomen and pelvis and the previous abdomino-pelvic operation, a pedicled gracilis flap reconstruction was taken. The left gracilis muscle was harvested through a longitudinal thigh incision, tunnelled under upper thigh skin and wrapped around the exposed testes. The outer surface of the muscle and the raw area of the shaft of the penis were both covered with meshed split skin grafts. The patient made an excellent recovery postoperatively (Fig. 1) .
Fig. 1Reconstruction sequence for Case 1. (A) Major scrotal defect with exposed testes and part of the shaft of penis. (B) Immediate postoperative. (C) One week postoperative. (D) Two years after reconstruction.
A 64-year-old male presented in the A & E department with tender, red, swollen scrotum and general manifestations of infection. He gave a history of poorly controlled noninsulin dependent diabetes mellitus, and burning micturition for the previous four days. He was admitted and IV antibiotics administered.
The scrotum rapidly developed patches of gangrene which eventually involved the whole scrotal skin. Urgent debridement was done that left both his testes and spermatic cords viable but exposed. After discussion with the patient, we planned to reconstruct the scrotum using pedicled rectus abdominis muscle flap.
The right rectus muscle was raised through a right paramedian skin incision based on its inferior pedicle, tunnelled under the lower abdominal and pubic skin to reach the scrotum. Meshed split skin graft was applied to the outer surface of the muscle. Postoperatively, part of the skin graft was lost and the raw area was managed conservatively (Fig. 2) .
Fig. 2Reconstruction sequence for Case 2. (A) Fournier's gangrene of the scrotal with complete loss of scrotal skin. (B) Rectus muscle rose based on the inferior pedicle. (C) Muscle wrapped around the testes and cords. (D) At the end of reconstructive procedure. (E) Partial loss of the skin graft. (F) Complete healing.
When trauma is the cause of scrotal skin loss, reconstruction often can be accomplished by either primary closure if sufficient scrotal skin remains or immediate application of split skin grafts. However, these techniques may not be suitable in situations in which the scrotal covering has been lost due to infection as the defect left is usually more extensive and the testicular surface may not be suitable for grafting. In these situations a more complex reconstructive procedure will be needed.
Fournier's gangrene is an acute idiopathic gangrene frequently of insidious onset followed by a fulminant progression that may lead to significant morbidity or even mortality. Although occasionally limited in extent, it is more frequently associated with significant loss of the skin of the penis, scrotum and surrounding perineum.
Many techniques have been described for scrotal reconstruction following Fournier's gangrene. Skin grafts have been described to cover the testes and cords directly.
Transposition of the testicles and spermatic cords to a permanent subcutaneous pocket in the upper thigh has been used, but concerns over temperature regulation and future function of the testicles, psychological adverse effects and reports of testicular pain and atrophy made this technique unpopular.
Numerous thigh cutaneous or fasciocutaneous flaps have been designed for primary or secondary scrotal repair when the testicles have already been temporarily buried under thigh skin.
Although these flaps represent an excellent tool for scrotal reconstruction, they have limitations. The thigh and perineal skin may be involved in the infection process to varying degrees that do not allow early reconstruction
Some of these skin flaps require several surgical procedures and delays which mean longer hospital stay and more surgical trauma for the patient. The superomedial thigh fasciocutaneous flap is limited in its transverse dimension so that bilateral flaps are required to reconstruct the whole scrotum which results in scarring of both thighs. The medial thigh fasciocutaneous flap is usually associated with a rotation dog-ear which requires a later revision, and if an additional scrotal cover is needed a gracilis muscle flap is used to provide this cover. The anterolateral thigh flap is difficult in dissection with vascular anatomical variability and the excess subcutaneous fat in white patients makes it somewhat bulky.
The rectus abdominis muscle flap is a large and well-vascularised flap, with an extensive arc of rotation and acceptable donor site morbidity; and the gracilis muscle is an expendable muscle, being an accessory adductor of the thigh.
They are broad sheet like muscles that can be wrapped easily around the acute curves of the exposed testes and do not add much bulk to the reconstructed scrotum.
Being muscle flaps, both have the ability to survive in an infected milieu and represent a useful choice for reconstruction in the contaminated perineum, especially in diabetic and toxic patients.
The choice of which muscle to use depends on the patient's general condition, type of work, habits and hobbies. They are one-stage, simple and reliable procedures, which provide excellent cover for the exposed testes and give satisfactory protection and aesthetic outcome. We recommend their use for primary reconstruction of major scrotal defects following Fournier's gangrene.
References
Young W.A.
Wright J.K.
Scrotal reconstruction with a rectus abdominis muscle flap.
00178-4&id=gr1.jpg){kind=link}
00178-4&id=gr2.jpg){kind=link}