Scrotal reconstruction with modified pudendal thigh flaps

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Summary

Scrotal skin loss can occur following trauma, Fournier's gangrene, post tumour excision, burns, etc. There are many techniques described in the literature including residual scrotal skin mobilization, skin grafts, pedicled and free flaps. The management is complex and challenging shown by the multiplicity of flaps and techniques described in the literature.

We used a modified pudendal thigh flap to reconstruct scrotal defects in five patients. This study describes the vascularity of the flap, technique of elevation and the inset of the flap. The elevation and particularly the insetting make it different from other flaps raised on this vascular network for scrotal reconstruction. This pedicled flap is robust, reliable, resilient and produces a neo-scrotum that looks natural in appearance, offers good-quality skin cover and cushion to the testes as well as protective sensation.

Introduction

Scrotal skin loss can occur following trauma, Fournier's gangrene, post tumour excision, burns, etc. There are many techniques described in the literature including residual scrotal skin mobilization for defects of scrotal skin up to 50%, split skin graft,1, 2 thigh flaps with pouch.3 tissue expansion,4, 5 gracilis myocutaneous advancement flap,6 groin fasciocutaneous island flap,7 flaps based on inferior epigastric vessels,8 superomedial thigh flaps,9 pedicled omental flap10 and even microvascular free greater omentum flap.11 Factors that determine the choice of reconstruction include the size of defect, surgeon's preference and patient's choice. The multiplicity of techniques demonstrates that there is potentially no single favoured reconstructive technique.

The ideal reconstruction would be a single-staged technique that provides soft tissue that protects the denuded testis, maintains thermoregulation to allow spermatogenesis, non-bulky, resilient to withstand shearing forces from the thighs and develops a natural-looking scrotal ptosis with minimal donor-site morbidity. This report is the senior author's (FCI) experience with this technique that attempts to better address most of these reconstructive challenges in patients with scrotal defects. This study discusses the pros and cons of this technique and comparison with other methods.

Section snippets

Materials and methods

From June 2007 to May 2012, five patients underwent this flap procedure. Table 1 presents the demographics, causes and microbiology. Long-term outcome was based on patient's report of sensation of the skin flap, occurrence of ulceration from shearing against the thighs, walking problems and sexual function.

Technique

The patient was placed under general or spinal anaesthesia and in the lithotomy position. The size of the scrotal defect was estimated by using a large gauze swab to ‘reconstruct a hemi-scrotum’. The curved perimeter of the neo-scrotum, around the testis suspended by the spermatic cord was estimated in two axes. One axis was from the midline of the perineum in a transverse direction onto the edge of defect at the lateral margin, and the other was from the anterior aspect of the root of the

Results

Table 1 shows the early and long-term outcomes. At 18 months post-operatively, one patient happily volunteered that his wife had given birth to a baby girl which we took as an indirect confirmation on spermatogenesis.

Discussion

The rich vascular network of the perineum and the thigh was described in the past and has been revisited by several authors just to mention a few.12, 13, 14 We have not done cadaveric studies, but the vascular basis of this flap, based on the design of our flap and previous cadaveric studies,13 is the anastamotic network between the branches of the four main arteries, namely internal pudendal artery (perineal artery which after giving off the transverse perineal artery continues as the

Conflict of interest statement

None.

Funding

We received no funding for the study.

Acknowledgements

We are thankful to Mr. Niri Niranjan, Consultant Plastic and Reconstructive Surgeon, St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford for the schematic drawings in Figure 1 (using Apple studio application).

References (22)

  • G. Frohlich et al.

    Reconstruction the scrotum using a tissue expander

    Urol A

    (1994)
  • Cited by (20)

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