Original Article

Penoscrotal Defects in Fournier’s Gangrene and its Reconstructive Challenges: Our Experiences

Pokharel PB*, Dahal P**, Thapa S*** *Consultant Plastic Surgeon, NAMS, **Associate Professor, Chief Consultant, Plastic Surgeon, NAMS, National Trauma Center, ***MCh Resident Plastic Surgery, NAMS

Abt strac Introduction: Fournier’s gangrene is a necrotizing fasciitis caused by mixed aerobic and anaerobic bacteria resulting in loss of skin and subcutaneous tissues in penoscrotal and perineal areas. Reconstruction of the defects varies from secondary closure, skin graft, local mobilization of remnant scrotal skin, burying the exposed testis inside the thigh and coverage by flaps. Reconstructive option depends on size of defect, extent and depth of soft tissue loss, location of defect and availability of local tissue. In this article different modalities of reconstruction and their outcome is described. Method: From December 2016 to March 2018, ten patients (all male) were admitted to our unit. All patients were referred case from General Surgery department .The Patients’ age ranged from 22 to 73 years (mean 47.5) and all the patients suffered from Fournier’s gangrene from different predisposing factor. The average size of the scrotal defect was 77 cm2.Reconsrucive ladder was followed according to the size of defect, anatomical location of wound, extent of soft tissue loss, and availability of local tissue to cover the defects. Result: One out of Total ten patients was treated with approximation of wound margins and had achieved good result with no complication. Two cases of split thickness skin graft had satisfactory graft take. Two cases were treated with bilateral advancement of scrotal skin and one with anteromedial thigh pouches and remaining four were reconstructed with superomedial thigh flap. Overall results were satisfactory and surgical complication was minimal. Conclusion: We follow the simplest and effective mode of treatment to achieve both functional and cosmetic results. If skin loss is small to medium sized, secondary closure had an excellent outcome. If the defect is less than 50%, scrotal advancement flap is suitable. Skin graft is effective if healthy granulating wound is present and tunica vaginalis not involved. Placing the testis in anteromedial thigh pouches is suitable and effective with extensive scrotal tissue loss and scrotal advancement is not achieved. Superomedial thigh pedicled flap has the best cosmetic and functional outcome if defect size is big and extensive. Key words: Anteromedial thigh pouches; Fournier’s gangrene; Penoscrotal defects; Scrotal advancement flap; Skin graft; Superomedial thigh flap

Introduction perineal area. Even though it was first described by Baurienne in 17641, details of the diseased process Fournier’s gangrene is a necrotizing fasciitis caused were described by Jean Alfred Fournier in 1883 as a by mixed aerobic and anaerobic bacteria and results fulminant gangrene of the penis and . 2 It is in loss of skin and subcutaneous tissue in the more common in patients with diabetes mellitus, Correspondence : impaired immunity, alcoholism, inflammatory Dr. Pashupati Babu Pokharel anorectal diseases, urinary incontinence, and overall Burns and Plastic surgery unit debilitating diseases.3Generally necrosis only involves National Trauma Center, NAMS, Bir Hospital soft tissue of scrotum. Testis and spermatic cord Email: [email protected] remains intact.4Exposure of testis is common and Contact No: 9840064222 cause functional, aesthetic and physiological harm

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to the patients. 5 It is a life threatening and rapidly Surgical techniques in Fournier’s gangrene progressive process and early diagnosis and medical After meticulous debridement, exposure of and surgical interventions are the mainstay of the posed greatest challenge in male patient. Varieties treatment. Early diagnosis, administration of broad- of reconstructive procedures were described in spectrum antibiotics and timely surgical debridement literatures for scrotal wound coverage. reduce the overall mortality rate.6Defect caused by surgical debridement is sometimes small to large The best functional and cosmetic results were achieved and extensive that needs to be covered. Simple to with primary closure of remaining scrotum, though this complex reconstructive procedure are described is only possible with small defects. 9 Relocation of the in the literatures. Reconstruction of the defects exposed into an adjacent subcutaneous thigh varies from loose approximation of skin, skin graft, flap can provide a shorter hospital stay and reduce local mobilization of remnant scrotal skin (scrotal recovery time and better outcome. 10 advancement flap), burying the exposed testis inside thigh (thigh pouch) and reconstruction by flaps.7We use The advantages of covering the scrotal wound with unilateral superomedial thigh flap to cover extensive skin graft are easy to perform, graft take is usually good scrotal skin loss with exposure of both testis.8 and outcome is satisfactory. FTSG may be the better choice than STSG for improved cosmesis, but the latter The primary goal of reconstruction in patients with has better chance of take in case of suboptimal wound genital skin loss due to necrotizing fasciitis is simple bed such as infected wound. Several authors have also and efficient coverage. Successful reconstruction described the use of STSG for scrotal reconstruction means not only giving good functional, physiological and found to be a treatment of choice for scrotal and cosmetic results but also simple, cost effective defects.11,12 with shorter hospital stay and patient satisfaction. Beside these, good cosmesis and the preservation Scrotal advancement flaps provided good skin of penile function, including erection, ejaculation quality and cosmesis in small to medium sized scrotal and micturition is also a matter of concern forthe defects. Meanwhile, patients with large and deep reconstructive surgeon. For this purpose we simply perineal defects often needed a myocutaneous or 13 follow the reconstructive ladder according to the size fasciocutaneous flap to eliminate dead space. of defect, anatomical location of wound, extent of soft Spectrum of the flap coverage option for the extensive tissue loss, and availability of local tissue. scrotal defects due to Fournier’s gangrene has been Method reported such as deep inferior epigastric artery flap14, rectus abdominis muscle flap15, gracillis muscle From December 2016 to March 2018, ten patients and myocutaneos flap16, anteromedial thigh flap17, were admitted to Burns and Plastic Surgery Unit of anterolateral thigh fasciocutaneous island flap18 and National Academy of Medical Sciences. Patients age inguinal flap19.Here we use unilateral superomedial ranged from 22 to 73 years (mean 47.5 years). All thigh flap to cover the scrotal defect.8 patients were referred case from General Surgery Department after meticulous debridement with Result good granulating wound and all were noted to have Of the ten cases, one case of small scrotal skin loss different predisposing factors like diabetes mellitus, (7x5cm2) was closed primarily and achieved good chronic renal failure, hypertension and lack of personal result with no complication. hygiene. Out of ten patients, one patient had penile shaft involvement circumferentially and other had One case with only bare testis exposed with extensive dorsal penile shaft skin loss with suprapubic region scrotal tissue loss (8x8cm2) was managed by relocating involvement. Remaining eight patients had only scrotal the testis in anteromedial thigh pouches. The testes skin loss. Consents for both surgery and pre and post- were placed in anteromedial thigh pouches by bluntly operative photographs were taken. undermining the subcutaneous plane. (Fig. 1).Initial complains of mild pain and tightness over the inner thigh during the first follow up visit was resolved

38 Volume 18│Number 2│Jul-Dec 2018 PMJN Postgraduate Medical Journal of NAMS Penoscrotal Defects in Fournier’s Gangrene and its Reconstructive Challenges: Our Experiences spontaneously during subsequent visits. and hemostasis was done. Hand held pencil Doppler was used to locate the perforator at around 5-7 cm Two cases of large sized scrotal skin defect (> 50% of lateral to pubic tubercle and 7-9 cm below and parallel scrotum) with healthy wound bed and intact tunica to the inguinal ligament. Making this as the base of vaginalis were covered with split thickness graft. After flap, roughly triangular shaped flap was designed in scrapping the granulation, thorough irrigation and upper medial thigh running infero medially. Medial proper hemostasis, split thickness sheet graft was border of flap was at the base of the scrotum. Width of applied and secured with the tie over bolster dressing. flap corresponded to the height of the defect. Length Eighty% graft take was achieved and the remaining of the flap was equal to the width of defect. Dissection raw area on the wound margin healed by marginal of flap was carried out from distal to proximal in sub epithelialization and wound contracture (Fig. 2). fascial plane up to distal point of the previous marked Local scrotal advancement flap was done in two cases perforator then flap was advanced 90 degree medially as in both cases scrotal skin loss was less than 50% with to the form tension free neoscrotum. (FIG.4). All four healthy remaining scrotal skin. Firstly refreshment of flaps survived well, no total flap loss noticed. One case wound margin was done and granulation tissue was encountered distal tip necrosis and was managed by scraped, then both testes were brought together in excision and resuturing .Other case developed minor the midline. The flap was elevated in a plane close wound dehiscence due to serous fluid collection to the tunica vaginalis bilaterally to protect the main inside the flap and was managed by secondary suture. vessels and the wound was closed primarily in the Remaining two cases had no complications. Out of four midline. Both cases showed excellent results (Fig.3). cases, one case had dorsal penile shaft and suprapubic Small wound dehiscence and infection occurred in one region involvement and other had circumferential case and which was managed by daily dressing change penile shaft involvement. Sheet graft was applied on and antimicrobial ointment application. penile defect and very good graft take was observed. Surgery related mortality was not seen. The scrotal Four cases with deep and extensive scrotal skin loss contour appeared to be natural. During the follow up and exposed testes were reconstructed with unilateral periods, all patients were satisfied with the functional superomedial thigh flap. Surgical landmark and and aesthetic outcome. Details of the patients, surgical vascular anatomy of the flap was confirmed prior to procedure and postoperative complications are the surgery. Wound edge refreshment, excision of summarized below in the table. fibrotic tissue, removal of granulation tissue, irrigation

No Age/ Predisposing Defects size Procedure Complications Management sex factor

1 22/M Poor hygiene Loss of scrotal skin (7x5cm2) Primary closure None None

2 40/M Poor hygiene Loss of scrotal skin (8x8cm2) Anteromedial Tightness and Resolved thigh pouch pain in inner spontaneously thigh 3 51/M Diabetes Loss >50% of scrotum(10x10 Sheet graft Marginal loss Healed by mellitus cm2) of graft (15%) marginal epithelialization 4 55/M Diabetes Loss >60% of scrotum(11x11 Sheet graft Marginal loss Healed by mellitus cm2) of graft (20%) marginal epithelialization 5 27/M Poor hygiene Complete exposure of both Scrotal Infection Dressing change testis (10x8cm2) advancement and wound and antimicrobial flap dehiscence ointment 6 47/M Diabetes Complete exposure of both Scrotal None None mellitus testis (9x8cm2) advancement flap

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7 32/M Chronic renal Complete exposure of both Unilateral Distal tip Excision and failure testis >50 (10x9cm2)+penile superomedial necrosis resuturing shaft dorsum thigh flap 8 73/M Hypertension Complete exposure of Unilateral Wound Secondary suture testes (11x10 cm2) + superomedial dehiscence circumferential penile shaft thigh flap +suprapubic region. 9 65/M Diabetes <50% scrotal skin loss Unilateral None None melitus with both testis exposed superomedial (8x7cm2) thigh flap 10 45/M Poor hygiene <50% scrotal skin loss Unilateral None None with both testis exposed superomedial (7x7cm2) thigh flap

(a) Exposed testis due (b)Sheet graft to Fournier’s gangrene. application immediate postoperation.

Figure 1: Reconsruction by anteromedial thigh pouches. (a) Scroral skin loss due to Fourniers gangrene.

(c) Well taken graft two weeks postoperative. Figure 2: Reconstruction by skin graft.

Figure 1: (b) Relocation of testes in anteromedial (a)Exposed testis caused (b) During operation. thigh immediate postoperative. by Fournier’s gangrene.

40 Volume 18│Number 2│Jul-Dec 2018 PMJN Postgraduate Medical Journal of NAMS Penoscrotal Defects in Fournier’s Gangrene and its Reconstructive Challenges: Our Experiences

cavernosa, and urethra are usually not involved in this condition, whereas the superficial and deep fascia and the skin are destroyed.23,24 Thus variety of reconstructive option are described in the literatures and each option have their own challenges. Methods of reconstruction depend on age/sex of patients, size and extent of wound, availability of local healthy tissue and anatomical location of wound. We simply follow the reconstructive ladder (from secondary closure of wound to flap reconstruction) to manage different variety of wounds. Each method of reconstruction has its own advantage and disadvantage. (c) Final result after scrotal advancement. Figure 3: Reconstruction by scrotal advancement The only motive is to achieve good organ function, flap. aesthetic appearance and patient satisfaction. Most reconstructive techniques provide reliable coverage and protection of testicular function with an acceptable cosmetic result; and reconstruction should be single staged, cost effective with short hospital stay.25Once the infection is controlled by the application of local and systemic antibiotics and serial debridement, healthy granulation develops; this signifies the time of reconstruction to proceed.

One case was managed simply by approximating the (a) Defects and design of (b) Flap raised and inset wound edge together as the wound was small and single testis was exposed. Wound edge was easily the flap. in the defect. approximated because scrotal skin is elastic in nature and stretchable. But loose wound approximation should be avoided during debridement as it has possible risk of spreading infection. Good cosmetic result and testicular function were achieved. The only drawback of this simple technique is wound dehiscence and infection.

Two cases of Fournier’s gangrene with > than 50% scrotal skin loss with healthy granulating bed were reconstructed by split thickness sheet grafting. Skin grafting is a simple and technically easy procedure, (c) Two weeks after surgery can be performed in a single stage, and can cover Figure 4: Reconstruction done by unilateral large defects with acceptable functional and cosmetic superomedial thigh flap. results.26,12The “Replace like with like” principle is applicable in skin grafting. Very good cosmetic Discussion result can be achieved with sheet graft. Healthy granulation tissue and intact tunica vaginalis are basic Fournier’s gangrene is an acute necrotizing fasciitis requirements for a successful take of graft. Though that rapidly progresses and mainly affects the genital it has very satisfactory results, graft take is very hard and perineal regions.20 It is frequently encountered to achieve due to shearing, infection and maceration in people of low socioeconomic status poor personal of graft. Scarring and secondary contracture are long hygiene. Characteristically, synergy between aerobic term complication that can be managed by continue and anaerobic organisms results in rapid and pressure therapy and emollient application and widespread destruction of the soft tissue.21,22The massaging. testes and spermatic cord structures, corpora

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One case was managed by relocating the testis inside gracilis myofasciocutaneous flap in V-Y advancement the anteromedial thigh pouches. Placing the testis in of the entire medial aspect ofthe thigh.32 Chen et al anteromedial thigh pouches is suitable and effective if described the use of island flaps, based on perforators scrotal advancement is not achieved. Implantation of of the medial thigh region, in addition to cases using testes in subcutaneous thigh pockets has historically the anterolateral pedicle flap of the thigh.30The skin been used either for permanent coverage of testes or island of gracilis flap was also used for perineal re- as a first-stage procedure to protect the testes until construction.33Despite all these options, we chose final reconstruction is performed. 25 We choose above superomedial thigh flap because unilateral flap can mentioned method as permanent option because cover both testis and even lower abdomen. It is easy to patient couldn’t maintain personal hygiene and scrotal dissect and can easily be rotated to the defect. Donor advancement and loose approximation couldn’t defect up to 8 cm width can be closed primarily. Donor achieve. Bhatnager et al described poor cosmesis and site morbidity is less and scar is hidden because it is low patient satisfaction after medial thigh pockets in the inner thigh. Among all four cases, one patient procedure. 27. Although this method is simple and suffering from cardiac disease encountered partial carries low donor site morbidity, it is considered to tip necrosis of the flap and was managed by excision be cosmetically and functionally unacceptable due to and resuturing. One case developed minor wound concerns over temperature regulation, psychological dehiscence due to the serous fluid collection within effects, and potential for pain.28In the postoperative flap and was resolved spontaneously. period, if the testes were gradually massaged back into the residual scrotal pouch, it will act as natural tissue Conclusion 29 expander. Early debridement and soft tissue coverage is the Local scrotal advancement flap was done in two cases mainstay of the treatment. We follow the simplest and as in both cases scrotal skin loss was less than 50% with effective mode of treatment to achieve both functional healthy remaining scrotal skin. Scrotal skin has highly and cosmetic results. If skin loss is small to medium viscoelastic properties. If the defect is smaller than sized, secondary closure had an excellent outcome. half the surface area of the scrotum, successful use of If the defect is less than 50% of total scrotum, scrotal the scrotal advancement flap can be done.30Closure advancement flap is suitable as scrotal skin has highly should be tension free if the defects larger than half viscoelastic properties. Skin graft is effective if healthy the scrotum. Frequently encountered complication granulating wound is present and tunica vaginalis is partial flap loss and wound edge necrosis. One of not involved. Placing the testis in anteromedial thigh our cases was complicated by wound dehiscence pouches is suitable and effective for only bare testis and infection, which was left to heal by secondary exposure with extensive scrotal tissue loss that cannot intension. be managed by scrotal advancement. Unilateral superomedial thigh pedicled flap can cover large and Out of ten cases, four cases were reconstructed extensive scrotal defect and has best cosmetic and by unilateral superomedial thigh flap. It was first functional outcome. introduced by Hirshowitz for scrotum and vulva reconstruction8.Ths flap has very robust blood supply References from three main perforating branches i.e. deep 1. Nathan B. Fournier’s gangrene: a historical vignette. external pudendal arteries, anterior branch of the Canadian Journal of Surgery. 1998;41(1):72. obturator artery and medial circumflex femoral artery. 2. Fournier JA. Gangrene foudroyante de la verge. Semaine Thus flap survival rate is comparatively high and can be Med. 1883;4:69. safely done in patient with comorbidies. 3. Kiran RP. Fournier’s gangrene: a review of 1726 cases. BJS. 2000;87(11):1596–1596. Various reconstructive options were described by 4. Adams JR, Mata JA, Venable DZ, Culkin DJ, Bocchini different authors regarding scrotal reconstruction JA. Fourniers gangrene in children. . 1990; in Fournier’s gangrene. Mopuri et al described the 35(5):439–41. use of transposition fasciocutaneous flaps, with a 5. El-Sabbagh AH. Coverage of the scrotum after posteroinferior basis.31Hsu et al described the use of the Fournier’s gangrene. GMS Interdisciplinary plastic and reconstructive surgery DGPW. 2018;7.

42 Volume 18│Number 2│Jul-Dec 2018 PMJN Postgraduate Medical Journal of NAMS Penoscrotal Defects in Fournier’s Gangrene and its Reconstructive Challenges: Our Experiences

6. Jeong HJ, Park SC, Seo IY, Rim JS. Prognostic factors in de Fournier: análise de 10 casos. An Bras Dermatol. . International journal of urology. 2001;76(6):701–9. 2005;12(12):1041–4. 21. Miller JD. The importance of early diagnosis and surgical 7. d’Alessio E, Rossi F, d’Alessio R. Reconstruction in treatment of necrotizing fasciitis. Surgery, gynecology & traumatic avulsion of penile and scrotal skin. Annals of obstetrics. 1983;157(3):197–200. plastic surgery. 1982;9(2):120–4. 22. Meleney FL. A differential diagnosis between certain 8. Hirshowitz B, Peretz BA. Bilateral superomedial thigh types of infectious gangrene of the skin. Surg Gynecol flaps for primary reconstruction of scrotum and vulva. Obstet. 1933;56(847):11. Annals of plastic surgery. 1982;8(5):390–6. 23. DeCastro BJ, Morey AF. Fibrin sealant for the 9. Akilov O, Pompeo A, Sehrt D, Bowlin P, Molina WR, Kim reconstruction of Fournier’s gangrene sequelae. The FJ. Early scrotal approximation after hemiscrotectomy Journal of urology. 2002;167(4):1774–6. in patients with Fournier’s gangrene prevents scrotal 24. Choe JM, Battino BS, Benedict J, Bell TE. Myositis and reconstruction with skin graft. Canadian Urological myonecrosis of the thigh: an unusual complication Association Journal. 2013;7(7–8):E481. of a testicular thigh pouch. The Journal of urology. 10. Chan CC, Shahrour K, Collier RD, Welch M, Chang S, 2001;165(4):1217. Williams M. Abdominal implantation of testicles in the 25. Karian LS, Chung SY, Lee ES. Reconstruction of defects management of intractable testicular pain in Fournier after Fournier gangrene: a systematic review. Eplasty. gangrene. International surgery. 2013;98(4):367–71. 2015;15. 11. Black PC, Friedrich JB, Engrav LH, Wessells H. 26. Carvalho JP, Hazan A, Cavalcanti AG, Favorito LA. Relation Meshed unexpanded split-thickness skin grafting between the area affected by Fournier’s gangrene and for reconstruction of penile skin loss. The Journal of the type of reconstructive surgery used: a study with 80 urology. 2004;172(3):976–9. patients. International braz j urol. 2007;33(4):510–4. 12. Maguiña P, Palmieri TL, Greenhalgh DG. Split thickness 27. Bhatnagar AM, Mohite PN, Suthar M. Fournier’s skin grafting for recreation of the scrotum following gangrene: a review of 110 cases for aetiology, predisposing conditions, microorganisms, and Fournier’s gangrene. Burns. 2003;29(8):857–62. modalities for coverage of necrosed scrotum with bare 13. Chen S-Y, Fu J-P, Wang C-H, Lee T-P, Chen S-G. testes. The New Zealand Medical Journal (Online). Fournier gangrene: a review of 41 patients and 2008;121(1275). strategies for reconstruction. Annals of plastic surgery. 28. Tan B-K, Rasheed MZ, Wu WT. Scrotal reconstruction 2010;64(6):765–9. by testicular apposition and wrap-around skin grafting. 14. Zeng A, Xu J, Yan X, You L, Yang H. Pedicled deep inferior Journal of Plastic, Reconstructive & Aesthetic Surgery. epigastric perforator flap: an alternative method to 2011;64(7):944–8. repair groin and scrotal defects. Annals of plastic 29. Okwudili OA. Temporary Relocation of the Testes surgery. 2006;57(3):285–8. in Anteromedial Thigh Pouches Facilitates Delayed 15. Young WA, Wright JK. Scrotal reconstruction with a Primary Scrotal Wound Closure in Fournier Gangrene rectus abdominis muscle flap. British journal of plastic With Extensive Loss of Scrotal Skin—Experience With surgery. 1988;41(2):190–3. 12 Cases. Annals of plastic surgery. 2016;76(3):323–6. 16. Ramos RR, de Moura Andrews J, Ferreira LM. A gracilis 30. Chen S-Y, Fu J-P, Chen T-M, Chen S-G. Reconstruction myocutaneous flap for reconstruction of the scrotum. of scrotal and perineal defects in Fournier’s gangrene. British journal of plastic surgery. 1984;37(2):171–4. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2011;64(4):528–34. 17. Koshima I, Soeda S, Yamasaki M, Kyou J. The free or pedicled anteromedial thigh flap. Annals of plastic 31. Mopuri N, O’Connor EF, Iwuagwu FC. Scrotal surgery. 1988;21(5):480–5. reconstruction with modified pudendal thigh flaps. Journal of Plastic, Reconstructive & Aesthetic Surgery. 18. Yu P, Sanger JR, Matloub HS, Gosain A, Larson D. 2016;69(2):278–83. Anterolateral thigh fasciocutaneous island flaps in 32. Hsu H, Lin CM, Sun T-B, Cheng L-F, Chien S-H. Unilateral perineoscrotal reconstruction. Plastic and reconstructive gracilis myofasciocutaneous advancement flap for surgery. 2002;109(2):610–6; discussion 617-8. single stage reconstruction of scrotal and perineal 19. Cannistra C, Kirsch-Noir F, Delmas V, Marmuse JP, defects. Journal of Plastic, Reconstructive & Aesthetic Boccon-Gibod L. Scrotal reconstruction by inguinal flap Surgery. 2007;60(9):1055–9. after Fournier’s gangrene. Progres en urologie: journal 33. McCraw JB, Massey FM, Shanklin KD, Horton CE. Vaginal de l’Association francaise d’urologie et de la Societe reconstruction with gracilis myocutaneous flaps. Plastic francaise d’urologie. 2003;13(4):703–6. nd Reconstructive Surgery. 76;58(2):176–83. 20. Mordjikian EOl, Oliveira MA, Merolo Júnior J. Métodos 34. El-Sabbagh AH. Coverage of the scrotum after de reconstrução cirúrgica ulizados no tratamento Fournier’s gangrene. GMS Interdisciplinary plastic and de deformidades teciduais decorrentes da gangrena

Volume 18│Number 2│Jul-Dec 2018 43 PMJN Postgraduate Medical Journal of NAMS Penoscrotal Defects in Fournier’s Gangrene and its Reconstructive Challenges: Our Experiences

reconstructive surgery DGPW. 2018;7. de deformidades teciduais decorrentes da gangrena 35. Jeong HJ, Park SC, Seo IY, Rim JS. Prognostic factors in de Fournier: análise de 10 casos. An Bras Dermatol. Fournier gangrene. International journal of urology. 2001;76(6):701–9. 2005;12(12):1041–4. 50. Miller JD. The importance of early diagnosis and surgical 36. d’Alessio E, Rossi F, d’Alessio R. Reconstruction in treatment of necrotizing fasciitis. Surgery, gynecology & traumatic avulsion of penile and scrotal skin. Annals of obstetrics. 1983;157(3):197–200. plastic surgery. 1982;9(2):120–4. 51. Meleney FL. A differential diagnosis between certain 37. Hirshowitz B, Peretz BA. Bilateral superomedial thigh types of infectious gangrene of the skin. Surg Gynecol flaps for primary reconstruction of scrotum and vulva. Obstet. 1933;56(847):11. Annals of plastic surgery. 1982;8(5):390–6. 52. DeCastro BJ, Morey AF. Fibrin sealant for the 38. Akilov O, Pompeo A, Sehrt D, Bowlin P, Molina WR, Kim reconstruction of Fournier’s gangrene sequelae. The FJ. Early scrotal approximation after hemiscrotectomy Journal of urology. 2002;167(4):1774–6. in patients with Fournier’s gangrene prevents scrotal 53. Choe JM, Battino BS, Benedict J, Bell TE. Myositis and reconstruction with skin graft. Canadian Urological myonecrosis of the thigh: an unusual complication Association Journal. 2013;7(7–8):E481. of a testicular thigh pouch. The Journal of urology. 39. Chan CC, Shahrour K, Collier RD, Welch M, Chang S, 2001;165(4):1217. Williams M. Abdominal implantation of testicles in the management of intractable testicular pain in Fournier 54. Karian LS, Chung SY, Lee ES. Reconstruction of defects gangrene. International surgery. 2013;98(4):367–71. after Fournier gangrene: a systematic review. Eplasty. 2015;15. 40. Black PC, Friedrich JB, Engrav LH, Wessells H. Meshed unexpanded split-thickness skin grafting 55. Carvalho JP, Hazan A, Cavalcanti AG, Favorito LA. Relation for reconstruction of penile skin loss. The Journal of between the area affected by Fournier’s gangrene and urology. 2004;172(3):976–9. the type of reconstructive surgery used: a study with 80 patients. International braz j urol. 2007;33(4):510–4. 41. Maguiña P, Palmieri TL, Greenhalgh DG. Split thickness skin grafting for recreation of the scrotum following 56. Bhatnagar AM, Mohite PN, Suthar M. Fournier’s Fournier’s gangrene. Burns. 2003;29(8):857–62. gangrene: a review of 110 cases for aetiology, predisposing conditions, microorganisms, and 42. Chen S-Y, Fu J-P, Wang C-H, Lee T-P, Chen S-G. modalities for coverage of necrosed scrotum with bare Fournier gangrene: a review of 41 patients and testes. The New Zealand Medical Journal (Online). strategies for reconstruction. Annals of plastic surgery. 2008;121(1275). 2010;64(6):765–9. 57. Tan B-K, Rasheed MZ, Wu WT. Scrotal reconstruction 43. Zeng A, Xu J, Yan X, You L, Yang H. Pedicled deep inferior by testicular apposition and wrap-around skin grafting. epigastric perforator flap: an alternative method to Journal of Plastic, Reconstructive & Aesthetic Surgery. repair groin and scrotal defects. Annals of plastic 2011;64(7):944–8. surgery. 2006;57(3):285–8. 58. Okwudili OA. Temporary Relocation of the Testes 44. Young WA, Wright JK. Scrotal reconstruction with a in Anteromedial Thigh Pouches Facilitates Delayed rectus abdominis muscle flap. British journal of plastic Primary Scrotal Wound Closure in Fournier Gangrene surgery. 1988;41(2):190–3. With Extensive Loss of Scrotal Skin—Experience With 45. Ramos RR, de Moura Andrews J, Ferreira LM. A gracilis 12 Cases. Annals of plastic surgery. 2016;76(3):323–6. myocutaneous flap for reconstruction of the scrotum. 59. Chen S-Y, Fu J-P, Chen T-M, Chen S-G. Reconstruction British journal of plastic surgery. 1984;37(2):171–4. of scrotal and perineal defects in Fournier’s gangrene. 46. Koshima I, Soeda S, Yamasaki M, Kyou J. The free or Journal of Plastic, Reconstructive & Aesthetic Surgery. pedicled anteromedial thigh flap. Annals of plastic 2011;64(4):528–34. surgery. 1988;21(5):480–5. 60. Mopuri N, O’Connor EF, Iwuagwu FC. Scrotal 47. Yu P, Sanger JR, Matloub HS, Gosain A, Larson D. reconstruction with modified pudendal thigh flaps. Anterolateral thigh fasciocutaneous island flaps in Journal of Plastic, Reconstructive & Aesthetic Surgery. perineoscrotal reconstruction. Plastic and reconstructive 2016;69(2):278–83. surgery. 2002;109(2):610–6; discussion 617-8. 61. Hsu H, Lin CM, Sun T-B, Cheng L-F, Chien S-H. Unilateral 48. Cannistra C, Kirsch-Noir F, Delmas V, Marmuse JP, gracilis myofasciocutaneous advancement flap for Boccon-Gibod L. Scrotal reconstruction by inguinal flap single stage reconstruction of scrotal and perineal after Fournier’s gangrene. Progres en urologie: journal defects. Journal of Plastic, Reconstructive & Aesthetic de l’Association francaise d’urologie et de la Societe Surgery. 2007;60(9):1055–9. francaise d’urologie. 2003;13(4):703–6. 62. McCraw JB, Massey FM, Shanklin KD, Horton CE. Vaginal 49. Mordjikian EOl, Oliveira MA, Merolo Júnior J. Métodos reconstruction with gracilis myocutaneous flaps. Plastic de reconstrução cirúrgica ulizados no tratamento nd Reconstructive Surgery. 76;58(2):176–83.

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