Medial Thigh Fasciocutaneous Flaps for Reconstruction of the Scrotum following Fournier Gangrene

Abstract

Sir: Reconstruction of the scrotum following loss of scrotal skin caused by Fournier gangrene or trauma remains a challenge for plastic surgeons. Several reconstructive options, including primary closure, skin grafting, and flaps, are available.1,2 We have attempted several techniques and now favor single-stage reconstruction of the scrotum with medial thigh fasciocutaneous advancement flaps for reconstruction after Fournier disease. The medial thigh fasciocutaneous advancement flap uses a triangular island of skin and subcutaneous tissue on the proximal aspect of the medial thigh. The dimensions of the flap vary according to the defect's requirements and can be safely measured up to 6 × 15 cm. The flap to cover the scrotal defect is raised distally, advanced cephalad, and rotated medially toward the inguinal canal (Fig. 1) to create an ipsilateral hemiscrotum. Performing this maneuver bilaterally allows for creation of a new scrotum with both flaps sutured together, creating a new midline raphe (Fig. 2). The defects on the donor sites are closed primarily in layers. A drain is left in place for 2 or 3 days. The senior author has performed scrotal reconstruction with the medial thigh fasciocutaneous advancement flap on four consecutive patients in the setting of Fournier gangrene, with no flap loss and with excellent functional and cosmetic results.Fig. 1.: Rotation of a medial thigh fasciocutaneous flap to cover the testes.Fig. 2.: The final result, showing the new scrotum created by two flaps.Medial thigh fasciocutaneous flaps allow for a more natural appearing scrotum with less bulkiness than myofasciocutaneous or free flaps.2,3 A comparison of published techniques is offered in Table 1.1–5 Our clear preference is reconstruction with the medial thigh fasciocutaneous advancement flap.Table 1: Treatment Options for Scrotal Reconstruction after Fournier GangreneIn very obese patients, the medial thigh fasciocutaneous advancement flap should be avoided to prevent an excessively thick neoscrotum. Because the donor area is closed primarily, the medial thigh fasciocutaneous advancement flap results in less donor-site morbidity than other techniques. Also, the skin of the medial thigh provides an excellent color, hair distribution, and texture match. In our experience, the cosmetic results achieved with medial thigh fasciocutaneous flaps have been far superior to other techniques. Although a unilateral medial thigh fasciocutaneous advancement flap can be used, it is our preference to use bilateral flaps for cases of complete scrotal skin loss. This requires smaller flaps on each thigh, resulting in defects that can be closed primarily with ease. Also, the neoscrotum has a more natural appearance if it is created with bilateral flaps, resulting in a tension-free closure at the midline, imitating the scrotal raphe. Finally, having attempted both a proximally and a distally based flap, we would like to make known that we prefer the proximally (cephalad) based flap. It can be raised all the way to the inguinal ligament, rotated medially, and advanced without difficulty, allowing for a tension-free closure. We believe the advantages of the medial thigh fasciocutaneous flap for reconstruction of the scrotum after Fournier gangrene include improved and unparalleled cosmetic outcome, reestablishment of a near natural environment for the testes, and minimal morbidity in a technically uncomplicated, single-stage operation. DISCLOSURE The authors have no financial disclosures. Pirko Maguina, M.D. Division of Plastic, Cosmetic, and Reconstructive Surgery; University of Illinois College of Medicine at Chicago; Chicago, Ill. Karina L. Paulius, M.D. Department of Surgery; University of Illinois College of Medicine at Chicago; Mount Sinai Hospital Program; Chicago, Ill. Santosh Kale, M.D. Division of Plastic Surgery; Washington University School of Medicine; St. Louis, Mo. Ramasamy Kalimuthu, M.D. Division of Plastic, Cosmetic, and Reconstructive Surgery; University of Illinois College of Medicine at Chicago; Chicago, Ill.