Eur J Plast Surg (1992) 15:303 305 European ' l "~ ' l l , , j l Journal of P l ~ l Q r l £ b

© Springer-Verlag 1992

Combined use of medial thigh skin flaps and gracilis musculocutaneous flaps for the reconstruction of scrotum K. Sevin, M. Emiroglu and E. Yormuk

Ankara University, Medical Faculty, Department of Plastic and Reconstructive Surgery, Ankara, Turkey

Summary. A case o f combined use o f bilateral medial thigh skin flaps and gracilis muscu locu taneous flaps for the reconst ruct ion o f a scrotal defect resulting f rom Fournier ' s gangrene is presented. The procedure pro- vided a sac-like scrotum, and the d o n o r sites were suc- cessfully reconstructed using bilateral gracilis musculo- cutaneous V - Y advancement flaps.

Key words: Medial thigh flap Gracilis muscu locu tan- eous flap - Fournier ' s gangrene

Various methods have been p roposed for the t rea tment o f exposed testicles. Some authors formed the neoscro- turn f rom skin grafts, and a few placed the testicles in subcutaneous pouches prepared bilaterally on the medial thigh [1, 4, 5]. Suprapubic and poster ior scrotal skin flaps were used by Yormuk et al. to create a more reliable sac for the testicles [6]. Hirshowitz successfully used su- perior pedicled medial thigh flaps for scrotal reconstruc- t ion [3]. However , when medial thigh flaps are used in a young patient, p r imary closure o f the d o n o r sites m a y be difficult. For this reason, we used gracilis musculocu- taneous V - Y advancement flaps to close the d o n o r sites and, thus, eliminate the tension on the medial thigh flaps.

Case report

A 35-year-old man was treated for Fournier's gangrene at another institution one week prior to presentation. When seen in our de- partment, he had a total scrotal defect with exposure of the testicles (Fig. 1). After elimination of infection, the scrotum was recon- structed by using bilateral superiorly pedicled medial thigh skin flaps (Fig. 2). The donor sites were closed by bilateral gracilis mus-

Correspondence to." K. Sevin, MD, Associate Professor, Turgutlu sok. 8/2, Gaziosmanpasa 06700, Ankara, Turkey

culocutaneous V-Y advancement flaps (Figs. 3, 4). The postopera- tive period was uneventful. The functional and cosmetic results of the operation were successful. Two months later, the patient was able to return to his normal activities (Fig. 5).

Surgical procedure

The patient was placed on the operating table in the lithotomy position. The medial thigh flaps were outlined adjacent to the scro- tal defect (Fig. 2). The base of the flap overlay the adductor longus muscle, while distally it reached lateral to the perineum (Fig. 3 a). The width of the flaps were planned to correspond to the antero- posterior width of the scrotal defect. At the distal end, the flaps were raised off the underlying fat to prepare a thin flap distally, proximally it was thicker. At the base of the flap, blunt dissection was used to avoid damaging any large perforating vessels. The distal ends of the flaps and the lateral margins were sutured togeth- er in the midline to form a sac (Fig. 3 b). Bilateral gracilis musculo- cutaneous flaps were prepared. The cutaneous component of the flaps were planned as triangles to facilitate the reconstruction of the donor sites by V Y advancement (Fig. 4a, b).

Discussion

Different techniques have been used for the reconstruc- t ion o f scrotal defects to create a new bed to preserve testicular function. W h e n the testicles were skin grafted, testicular funct ion was inhibited because o f altered testi- cular thermoregula t ion [4].

Some authors placed the testicles in subcutaneous pouches prepared bilaterally on the medial thigh, but these pouches also failed to preserve thermoregula t ion [1, 5]. Y o r m u k et al. used suprapubic and poster ior scro- tal skin flaps to create a more reliable sac for the testicles [6]. However , in a total scrotal defect, this me thod is also useless, because there m a y not be enough tissue to prepare a poster ior scrotal flap. A gracilis musculocu- taneous flap has also been used, but one theoretical dis- advantage o f this technique is the thickness o f subcuta- neous tissue and muscle. I f the temperature in the pouch

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Fig. 1. Preoperative view illustrating total scrotal defect

Fig. 2. Preoperative planning of medial thigh and gracilis V-Y ad- vancement flaps

Fig. 3. a Medial thigh flaps are elevated, b Distal ends of the flaps are sutured together in the midline firstly to obtain a sac-like form

Fig. 4. a Bilateral gracilis musculocutaneous flaps are prepared. Cutaneous component of the flaps are planned as triangles, b The donor sites are closed by V Y advancement

Fig. 5. Two months later, the tissues were soft, and the patient was able to return to his normal activities

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approaches core temperature, spermatogenesis may be adversely affected [2]. The best med ium for the integrity o f spermatogenesis is the normal scrotal locat ion [6]. For this reason, we have used bilateral medial thigh skin flaps to reconstruct the scrotum.

Hirshowitz successfully used superior pedicled medial thigh flaps to reconstruct total scrotal defects. This flap has also been reported as providing a good sensation [3]. However , in a y o u n g patient, it m a y not be possible to close the d o n o r sites primarily, as this m a y cause tension on the flaps. A l though skin grafts m a y be used to cover the d o n o r site defects, the use o f gracilis V - Y advancement muscu locu taneous flaps have decreased the postoperat ive hospital izat ion time and provided a better funct ional and cosmetic result.

References

1. Bruner JM (1950) Traumatic avulsion of skin of the male exter- nal genitalia. Plast Reconstr Surg 6 : 334

2. Carson CC, Barwick WJ (1987) Penoscrotal lymphedema. In: Georgiade NG (ed) Essentials of plastic, maxillofacial, and re- constructive surgery. Williams and Wilkins, Baltimore, p 809

3. Hirshowitz B, Moscona R, Kaufman T, Pnini A (1980) One stage reconstruction of scrotum following Fournier's syndrome using a probable arterial flap. Plast Reconstr Surg 66 : 608

4. Malloy TY, Wein AJ, Gross P (1983) Scrotal and penile lymphe- dema: surgical consideration and management. J Urol 130 : 263

5. May H (1950) Reconstruction of scrotum and skin of the penis. Plast Reconstr Surg 6:134

6. Yormuk E, Sevin K, Emiroglu M, Turker M (1990) A new surgi- cal approach in genital lymphedema. Plast Reconstr Surg 86:1~94