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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 4  |  Page : 165-170

Reconstruction of scrotum with anteromedial thigh flap


Department of Plastic Surgery, MGM Medical College and Hospital, Aurangabad, Maharashtra, India

Date of Submission02-Mar-2020
Date of Acceptance05-Mar-2020
Date of Web Publication29-Apr-2020

Correspondence Address:
Dr. Anuradha J Patil
Department of Plastic Surgery, MGM Medical College and Hospital, N6, CIDCO, Aurangabad 431003, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_18_20

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  Abstract 

Background: Reconstruction of extensive defects of the perineum and scrotal region, with exposure of the testes, following avulsion injury or severe infections represents a significant challenge. Replacement with sensate, durable cover is mandatory for functional, cosmetic, and psychological reasons. A wide range of flap techniques has been reported for this purpose with their advantages and disadvantages. We describe the use of the anteromedial thigh flap in our case series with the advantages and disadvantages. Materials and Methods: We had seven patients in our series, of which two patients were posttraumatic defects and other five were post-Fournier’s gangrene unilateral scrotal defects. We describe few case examples in the series in detail, of which the first patient was 21-year-old labor who presented with avulsion injury to penis and scrotum. He had a loss of scrotal skin near totally, except for 2cm × 2cm areas posteroinferiorly. In addition, he also had a loss of penile skin from the glans to the base of the penis. We used bilateral anteromedial thigh fasciocutaneous flap based on the longitudinal axiality of the anteromedial thigh suprafascial plexus for reconstruction. The patient had an excellent recovery, a good aesthetic result at the end of 1 year. Another posttraumatic defect was unilateral and the patient also had a good recovery.The other five patients in series were of Fournier’s gangrene. All patients underwent initially debridement and then flap cover on day 7. All of them needed unilateral scrotal reconstruction. The unilateral anteromedial flap was carried out with good recovery at the end of the 6 weeks. Results: This flap has provided nice durable cover for the testes with an acceptable aesthetic appearance, although the color match was not good in case 3 of the series. Conclusion: In conclusion, anteromedial fasciocutaneous thigh flap is a good choice for scrotal reconstruction that could provide a sensate, durable cover that fulfills patient satisfaction. It is technically easy and has favorable functional and aesthetic results.

Keywords: Anteromedial thigh flap, Fournier’s gangrene, scrotal reconstruction


How to cite this article:
Patil AJ, Yelikar A, Vichare A, Tolat T, Kulkarni J. Reconstruction of scrotum with anteromedial thigh flap. MGM J Med Sci 2019;6:165-70

How to cite this URL:
Patil AJ, Yelikar A, Vichare A, Tolat T, Kulkarni J. Reconstruction of scrotum with anteromedial thigh flap. MGM J Med Sci [serial online] 2019 [cited 2020 Oct 31];6:165-70. Available from: http://www.mgmjms.com/text.asp?2019/6/4/165/283457




  Introduction Top


Extensive penoscrotal wounds with the exposed testes represent challenging problems for the reconstructive surgeons. Although most scrotal defects occur as a result of trauma, they may also occur as a result of Fournier’s gangrene. For young males, restoration with durable, functional cover for the testes and scrotal shape is important for physiological, social, and psychological reasons.[1] Various surgical options used for the closure of major scrotal wounds include burying of testicles under the thigh,[2] expansion of the remaining scrotal and adjacent skin,[3] skin grafting,[4],[5] and using the deep inferior epigastric artery perforator (DIEP) flap,[6] omental pedicle flap,[7] or rectus abdominis muscle flap.[8] In addition, flaps such as gracilis myocutaneous flap,[9],[10] anterolateral thigh fasciocutaneous island flap,[11] unilateral adductor minimus myocutaneous flap,[12] anteromedial thigh flap,[13] or superomedial thigh flap[14] can be used in this region. Posttraumatic scrotal defects are difficult to reconstruct because of crushing components in the surrounding area. Thus, the therapeutic method chosen must be individualized and must depend not only on the severity of the injury but also on the local anatomical conditions such as the extent of a tissue defect, associated injuries, and the viability of adjacent skin.[15] The ideal choice for scrotal coverage would be an early single-stage sensate flap that provides complete and adequate protection of the exposed testicles.[16] Local pedicled fasciocutaneous flaps from the medial thigh and the groin area offer the advantages of avoiding skin-graft problems, preserving adequate sensation, and covering a large defect.[16]

This paper represents the use of anteromedial thigh flap for scrotal reconstruction based on well-developed fascial plexus, axially aligned with sartorius in anteromedial thigh region.[17]


  Materials and methods Top


We had seven patients in our series, of which two patients were posttraumatic defects and other five were post-Fournier’s gangrene unilateral scrotal defects.

The surgical technique used for all the cases was as follows: under spinal anesthesia after initial wound debridement with the patient in the supine position, thighs abducted slightly externally rotated, a proximally based longitudinally oriented rectangular thigh flap was designed bilaterally or unilaterally, to include the skin and fascia over the anteromedial thigh region. The base of the flap was at the level of the neck of the scrotum. The length of the flap covered the ipsilateral scrotal defect. The width of the flap is measured by calculating the distance between the anterior and posterior boundary of the defect. Flaps elevated were from the distal end in a subfascial plane and extended up to the base. No pedicle had to be identified at the base of the flap. The vascular supply to this flap is the rich suprafascial plexus of vessels present at the anteromedial thigh. The flaps were then inserted to scrotal defect by suturing its edges and in the midline with each other in the case of bilateral flaps and to the scrotal defect in unilateral flaps. The donor site was closed after undermining the flaps on both sides. Edges were closed in two layers. Postoperatively the patient was nursed in a supine position with thighs positioned not to compress the flap and not to apply tension on it, with antibiotics for 5 days. Drains were removed after 48h. Interrupted skin sutures were removed after 10 days. This technique was followed in the cases described below designing unilateral or bilateral flaps as needed. We performed seven cases using this technique, of which two patients were posttraumatic defects of scrotum and five cases of Fournier’s gangrene.

In the two posttraumatic cases, one patient needed bilateral reconstruction and the other unilateral scrotal reconstruction. All five cases of Fournier’s gangrene needed unilateral reconstruction. Here we describe a few examples of the cases performed.

Example case reports

Case 1

A 21-year-old male patient was admitted with a history of injury to the penis and scrotum, which occurred at work when his clothes were accidentally caught in the rotating machine belt. The patient had no significant past history. He had a loss of entire scrotal skin, except for the 2cm × 2cm posteroinferior area. In addition, there was the loss of penile skin from glans to the base of the penis [Figure 1].
Figure 1: Preoperative picture showing degloving injury of scrotum and penis

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During the initial wound debridement, under spinal anesthesia with the patient in the supine position, a longitudinally oriented proximally based rectangular thigh flap of 13.5cm × 10cm dimension was designed bilaterally [Figure 2]. Elevation of the flap was carried out from the distal end in the subfascial plane and extended up to the base. The flaps were then transposed to the scrotal defects, sutured edge to edge in the midline with each other and to the defect. The donor site was closed after undermining the flaps on both sides and edges were closed in two layers with drain. The split skin graft was carried out for the penis. Postoperative care was as mentioned in the surgical technique.
Figure 2: First picture is of flap markings and next is after flap inset

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It was observed that the flap survival was excellent on completion of 1 year and the donor site scar area was healed nicely [Figure 3]. The patient had a sensation at the site of flap surgery. Both surgeon and patient were satisfied with the aesthetic results of the surgery.
Figure 3: Postoperative showing well-settled flaps

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Case 2

A 70-year-old male patient with diabetes was admitted with Fournier’s gangrene with the loss of 12cm × 10cm of scrotal skin. The patient underwent a staged procedure. After initial debridement and stabilizing, flap surgery was planned for day 7.

Under spinal anesthesia, defect pattern of 12cm × 10cm was made on lint piece and pattern marked on left thigh. A single flap was used for the reconstruction. The flap was raised as described above and then transposed to the scrotal defect. The donor site was closed after undermining the skin flaps and edges were closed in two layers with drain. The patient showed good recovery but was lost to the follow-up [Figure 4].
Figure 4: Preoperative and intraoperative picture showing unilateral flap for scrotal defect

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Case 3

A 40-year-old male patient with diabetes was admitted with Fournier’s gangrene with a skin loss of 8cm × 6cm. The patient also underwent staged procedures.

Initially, debridement of the wound was carried out. Flap cover for the defect was planned on day 7 after stabilization of the patient and control of blood sugar. Under spinal anesthesia defect pattern of 8cm × 6cm was made on the lint piece and flap marked on the left thigh anteromedial region. The flap was raised and carried out to the defect. The donor area was closed primarily in layers. The patient was followed up for a period of 6 weeks during which flap survival was found to be a good and donor area healed well.

The patient was satisfied with the reconstruction, although the color match for the scrotal skin could not be achieved [Figure 5].
Figure 5: Preoperative and intraoperative picture with follow-up showing unilateral flap for scrotal defect

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  Results Top


This flap has provided nice durable cover for the testes with an acceptable aesthetic appearance, although the color match was not good in case 3 of the series.


  Discussion Top


For functional and aesthetic reconstruction, an ideal flap should be a single-stage procedure, reliable, sensate with a potential for normal function, minimal donor site morbidity. Skin graft for exposed testes was first established by Balakrishanan,[4] as a two-stage procedure. The main requirements are healthy granulation tissue and intact tunica vaginalis.[4],[18] In spite of good cosmetic results of the skin grafting procedure, the patient was not fully satisfied because of contractions, less mobility, and poor protection of the underlying testicles.[18]

Placement of the bare testes into the subcutaneous pouch of the thigh followed later by local skin mobilization along with the testes was used to reconstruct the scrotum.[19] The limitation of this technique is constant pain caused by mechanical trauma,[20] unsuitable environment for testicular function with possible atrophy, feminine appearance, and fullness sensations.[21]

The dartos musculocutaneous flap has been used for small to medium-sized defects.[22] Myocutaneous flaps as the rectus abdominis myocutaneous flap,[8] gracilis myocutaneous flap,[23] adductor minimus myocutaneous flap,[24] composite gastric seromuscular, and omental pedicle flaps[7] are reliable in contaminated wounds but can be technically challenging and bulky. Perforator-based thin cutaneous flaps as island anteromedial thigh flap[25] and pedicle deep inferior epigastric perforator flap[6] are aesthetically and functionally optimum, but the surgery is technically difficult and blood supply is less predictable. Fasciocutaneous flaps give an excellent cosmetic result and are simple to perform with minimal donor morbidity. These fasciocutaneous flaps include medial thigh fasciocutaneous flap,[16] superomedial thigh flap,[26] superiorly and laterally based thigh pedicle flap,[27] anterolateral island thigh fasciocutaneous flap,[11] Singapore flap,[20] and V-Y fasciocutaneous pudendal thigh flap.[28]

Medial thigh fasciocutaneous flap is nourished by the suprafascial plexus of the medial thigh from septocutaneous branches of the superficial femoral artery and musculocutaneous branches through the adductor muscles.[16]

The superomedial thigh flap is oriented in the horizontal direction and is based on the anterior branch of the deep external pudendal artery, the obturator artery, and the medial femoral circumflex artery. The main disadvantage is the transverse dimension.[29]

The anteromedial flap is similar in principle and technique of elevation to the medial thigh fasciocutaneous flap of Hallock[16] for scrotal reconstruction. On the contrary, these two flaps differ in being designed on the anteromedial thigh. The anteromedial flap has advantages over medial thigh flap such as more accessible dissection, arc of rotation being less acute, less kink at the pedicle, easier inset, small dog ear, and donor scar site away from friction areas in the medial thighs. It also has all the advantages of the medial thigh flap.

At the same time, it did not have any disadvantages of transverse dimensions. Hence, the anteromedial flap was preferred over standard medial thigh flap. The anteromedial flap could be easily elevated, transposed, and inset into the defect. No compromise to the circulation was encountered and the donor site could be closed primarily in both cases leaving a nicely healed scar. This flap could be used in both trauma and infection situations. Wound debridement and stabilization of the general condition of the patient was carried out before reconstruction.

Another possible disadvantage could be about not achieving an exact color match as had happened in case 3 of this series. The anteromedial flap may have limitations in fat patients where it will be bulky and may affect spermatogenesis.

This study has a disadvantage of having a limited number of cases observed. Apart from it, the aforementioned good sensory recovery is based on subjective assessment. This study needs further objective evaluation, which has not been carried out.


  Conclusion Top


It can be concluded from this study that the anteromedial flap is reliable for coverage of major scrotal defects and allows sensate to cover with good aesthetic appearance. This technique provides a better option for reconstruction; however, it needs further evaluation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Ethical policy and institutional review board statement

This study has been approved by the appropriate ethics committee and has therefore been performed in accordance with the ethical standards set forth in 1964 Declaration of Helsinki and its later amendments.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ashok MB, Prashant NM, Manoj S. Fournier’s gangrene: Review of 110 cases for etiology, predisposing conditions, microorganisms, and modalities for coverage of necrosed scrotum with bare testes. J New Zealand Med Ass2008;121:46-56.  Back to cited text no. 1
    
2.
d’Alessio E, Rossi F, d’Alessio R. Reconstruction in traumatic avulsion of penile and scrotal skin. Ann Plast Surg 1982;9:120-4.  Back to cited text no. 2
    
3.
Por Y, Tan B, Hong S, Chia S, Cheng CWS, Foo C, et al. Use of the scrotal remnant as a tissue-expanding musculocutaneous flap for scrotal reconstruction in Paget's disease. Ann Plast Surg 2003;51:155-60.  Back to cited text no. 3
    
4.
Balakrishanan C. Scrotal avulsion: A new technique of reconstruction by split skin graft. Br J Plast Surg 1958;9:38.  Back to cited text no. 4
    
5.
Maguiña P, Palmieri TL, Greenhalgh DG. Split thickness skin grafting for recreation of the scrotum following Fournier's gangrene. Burns 2003;29:857-62.  Back to cited text no. 5
    
6.
Zeng A, Xu J, Yan X, You L, Yang H. Pedicled deep inferior epigastric perforator flap: An alternative method to repair groin and scrotal defects. Ann Plast Surg 2006;57:285-8.  Back to cited text no. 6
    
7.
Kamei Y, Aoyama H, Yokoo K, Fujii K, Kondo C, Sato T, et al. Composite gastric seromuscular and omental pedicle flap for urethral and scrotal reconstruction after Fournier’s gangrene. Ann Plast Surg 1994;33:565-8.  Back to cited text no. 7
    
8.
Young WA, Wright JK. Scrotal reconstruction with a rectus abdominis muscle flap. Br J Plast Surg 1988;41:190-3.  Back to cited text no. 8
    
9.
Westfall CT, Keller HB. Scrotal reconstruction utilizing bilateral gracilis myocutaneous flaps. Plast Reconstr Surg 1981;68:945-7.  Back to cited text no. 9
    
10.
Ramos RR, Andrews JM, Ferreira LM. A gracilis myocutaneous flap for reconstruction of the scrotum. Br J Plast Surg 1984;37:171-4.  Back to cited text no. 10
    
11.
Yu P, Sanger JR, Matloub HS, Gosain A, Larson D. Anterolateral thigh fasciocutaneous island flaps in perinioscrotal reconstruction. Plast Recosntr Surg 2002;109:610-6.  Back to cited text no. 11
    
12.
Di Geronimo EM. Scrotal reconstruction utilizing a unilateral adductor minimus myocutaneous flap. Plast Reconstr Surg 1982;70:749.  Back to cited text no. 12
    
13.
Koshima I, Soeda S, Yamasaki M, Kyou J. The free or pedicled anteromedial thigh flap. Ann Plast Surg 1988;21:480-5.  Back to cited text no. 13
    
14.
Hirshowitz B, Peretz BA. Bilateral superomedial thigh flaps for primary reconstruction of scrotum and vulva. Ann Plast Surg 1982;8:390-6.  Back to cited text no. 14
    
15.
Kim KS, Noh BK, Kim DY, Lee SY, Cho BH. Thin paraumbilical perforator-based cutaneous island flap for scrotal resurfacing. Plast Reconstr Surg 2001;108:447-51.  Back to cited text no. 15
    
16.
Hallock GG. The conjoint extensor digitorum brevis muscle and dorsalis pedis osteocutaneous island flap. Ann Plast Surg 1990;24: 371-7.  Back to cited text no. 16
    
17.
Cormack GC, Lamberty BGH. The Fasciocutaneous System of Vessels, the Blood Supply to the Skin by Regions-Thigh. In: The Arterial Anatomy of Skin Flaps. 2nd ed. New York: Churchill-Livingstone; 1994. p. 229-230.  Back to cited text no. 17
    
18.
Finical SJ, Arnold PG. Care of the degloved penis and scrotum: A 25-year experience. Plast Reconstr Surg 1999;104:2074-8.  Back to cited text no. 18
    
19.
Gonzalez-Ulloa M. Severe avulsion of the scrotum in a bullfighter: Reconstructive procedure. Br J Plast Surg 1963;16:154-9.  Back to cited text no. 19
    
20.
Maharaj D, Naraynsingh V, Perry A, Ramdass M. The scrotal reconstruction using the “Singapore sling”. Plast Reconstr Surg 2002;110:203-5.  Back to cited text no. 20
    
21.
Tiwari IN, Seth HP, Mehdiratta KS. Reconstruction of the scrotum by thigh flaps. Plast Reconstr Surg 1980;66:605-7.  Back to cited text no. 21
    
22.
Tiwari VK, Kumar P, Sharma RK. The dartos musculocutaneous flap. Br J Plast Surg 1991;44:33-5.  Back to cited text no. 22
    
23.
Ramos RR, Andrews JM, Ferreira LM. A gracilis myocutaneous flap for reconstruction of the scrotum. Br J Plast Surg 1984;37:171-4.  Back to cited text no. 23
    
24.
Di Geronimo EM. Scrotal reconstruction utilizing a unilateral adductor minimus myocutaneous flap. Plast Reconstr Surg 1982;70:749.  Back to cited text no. 24
    
25.
Koshima I, Soeda S, Yamasaki M, Kyou J. The free or pedicled anteromedial thigh flap. Ann Plast Surg 1988;21:480-5.  Back to cited text no. 25
    
26.
Hirshowitz B, Moscona R, Kaufman T, Pnini A. One-stage reconstruction of the scrotum following Fournier’s syndrome using a probable arterial flap. Plast Reconstr Surg 1980;66:608-12.  Back to cited text no. 26
    
27.
McDougal WS. Scrotal reconstruction using thigh pedicle flaps. J Urol 1983;129:757-9.  Back to cited text no. 27
    
28.
El-Khatib HA. V-Y fasciocutaneous pudendal thigh flap for repair of perineum and genital region after necrotizing fasciitis: Modification and new indication. Ann Plast Surg 2002;48:370-5.  Back to cited text no. 28
    
29.
Ferreira PC, Reis JC, Amarante JM, Silva AC, Pinho CJ, Oliveira IC, et al. Fournier’s gangrene: A review of 43 reconstructive cases. Plast Reconstr Surg 2007;119:175-84.  Back to cited text no. 29
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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