Single-Stage Reconstruction of Extensive Defects After Fournier's

Fig. 5. Postoperative photograph of case 2 after 3 months. There is no severe scar, as can result from a skin graft, and the contour of the scrotum is exposed naturally due to the thin flaps and remnant scrotal skin.

pattern flap that consists of perforators of three arteries: flaps for primary reconstruction of scrotum and vulva. the external pudendal, superficial femoral, and medial Ann Plast Surg 1982;8:390-6. circumflex femoral arteries. The presence of axial 3. Hallock GG. Scrotal reconstruction following Fournier’s vessels from the medial femoral circumflex artery and gangrene using the medial thigh fasciocutaneous flap. vein has been demonstrated by transillumination at Ann Plast Surg 1990;24:86-90. the time of surgery and by cadaveric study [2,3,5]. 4. Maguina P, Paulius KL, Kale S, et al. Medial thigh Because of the longitudinal axial interconnections of fasciocutaneous flaps for reconstruction of the scrotum these three vessels above the deep fascia of the medial following Fournier gangrene. Plast Reconstr Surg thigh, preservation of only the proximal afferents of 2010;125:28e-30e. each pedicle allows for safe elevation of this large, 5. Cormack GC, Lamberty BG. The blood supply of thigh longitudinally-oriented medial thigh fasciocutaneous skin. Plast Reconstr Surg 1985;75:342-54. flap [3]. With this anatomical understanding, the flap can be medially rotated approximately 90 degrees at the lithotomy position, while preserving the axial vessels, to cover the defect. We thought bilateral flaps could maintain the scrotal shape aesthetically better than other unilateral flaps. Compared to other cases Single-Stage Reconstruction of unilateral flap coverage, the midline scar after bila- of Extensive Defects after teral flap insertion can substitute for the perineal raphe aesthetically. With thin fasciocutaneous flap coverage, Fournier's Gangrene with an the contour of the reconstructed scrotum looks similar Exposed Iliac Crest and Testes to a normal scrotum. Ki Rin Park, Tae Gon Kim, Junho Lee, Ju-Ho Ha, After flap elevation, the donor site can be closed by Yong-Ha Kim primary intention without excessive tension. Aesthe- Department of Plastic and Reconstructive Surgery, Yeungnam tically, the inner part of the thigh is relatively unex- University School of Medicine, Daegu, Korea posed. Images Correspondence: Tae Gon Kim In conclusion, bilateral medial thigh fasciocuta- Department of Plastic and Reconstructive Surgery, Yeungnam University School of Medicine, 170 Hyeonchung-ro, Nam-gu, Daegu 705-717, Korea neous flap is a safe and effective procedure in perineo- Tel: +82-53-620-3480, Fax: +82-53-626-0705 scrotal reconstruction without donor site morbidity E-mail: [email protected] for both small and large defects. No potential conflict of interest relevant to this article was reported. Received: 19 Sep 2012 • Revised: 18 Nov 2012 • Accepted: 23 Nov 2012 pISSN: 2234-6163 • eISSN: 2234-6171 References http://dx.doi.org/10.5999/aps.2013.40.1.74 • Arch Plast Surg 2013;40:74-76 Copyright 2013 The Korean Society of Plastic and Reconstructive Surgeons This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) 1. Ellabban MG, Townsend PL. Single-stage muscle flap which permits unrestricted non-commercial use, distribution, and reproduction in any reconstruction of major scrotal defects: report of two medium, provided the original work is properly cited. cases. Br J Plast Surg 2003;56:489-93. 2. Hirshowitz B, Peretz BA. Bilateral superomedial thigh

74 Vol. 40 / No. 1 / January 2013

Fournier’s gangrene (FG) is an acute necrotizing debridement was performed. However, the area of fasciitis that involves the skin and subcutaneous tissue the skin necrosis extended to the lower abdomen, on the scrotum, perineum, and abdominal wall [1]. It bilateral flank, and lower costal margin. To prevent is a potentially fatal disease, with a reported mortality wound contamination from urine, a urethral catheter rate between 3% and 67% [2]. Broad-spectrum anti- was inserted. However, the patient was unable to un- biotics, aggressive fluid therapy, and early surgical dergo a diverting colostomy because of the widespread debridement are essential for the management of FG presence of abdominal defects and inflammation. We [3]. After primary treatment, FG may produce tissue continuously treated him with debridement and wet defects of various sizes that need reconstructive pro- dressings, and to promote granulation tissue growth, cedures. We experienced a case of extensive defects we treated him with negative pressure wound therapy. involving the bilateral groin, pubic area, and scrotum Due to the repeated debridement and wound dressings, after FG, for which we performed single-stage recon- his wound condition improved with healthy granu- struction using bilateral pedicled anterolateral thigh lation tissue formation (Fig. 1). On hospital day 67, (ALT) flaps and gracilis myocutaneous flaps. the bilateral defects in the groin with an exposed iliac A 55-year-old male patient with a body mass index crest were reconstructed with bilateral pedicled ALT of 19.1 visited our hospital for treatment of inguinal flaps that were sized at 23×8 cm and 27×11 cm. We and scrotal necrosis which developed within one day then placed the flaps at each side of the groin through after the onset of scrotal edema and pain. The patient the subcutaneous tunnel. The donor sites were closed had a history of diabetes and hypertension. Seven days with a split-thickness skin graft (STSG). The defects before visiting our hospital, he was diagnosed with a of the pubic area and the scrotum were reconstructed perianal abscess at another hospital. Initially, the with bilateral gracilis myocutaneous flaps, both of patient had necrosis around the scrotum, anus, and which were sized at 19×6 cm. This was followed by groin area, which were accompanied by a foul odor the primary closure of all the donor sites. In the abdo- and pus discharge. We immediately administered minal and penile defects, we performed an STSG (Fig. broad-spectrum antibiotics and performed aggressive 2). The STSGs were stapled into place and covered fluid supplement therapy. On the second day, surgical with compression dressings. On hospital day 92,

Fig. 1. A 55-year-old man with extensive defects involving the bilateral groins, flanks, pubic area, penis, and scrotum with an exposed iliac crest and testes. (A) Gross appearance. (B) Close-up A B appearance.

Fig. 2. Immediate postoperative results. (A) Gross A B appearance. (B) Close-up appearance.

75 The pedicled ALT flap and the gracilis myocutaneous flap can be useful choices for reconstruction of extensive FG defects involving the groin, pubic area, and scrotum, where the bone and vital organs are exposed.

References

1. Yaghan RJ, Al-Jaberi TM, Bani-Hani I. Fournier’s gangrene: changing face of the disease. Dis Colon Rectum 2000;43:1300-8. 2. Corman JM, Moody JA, Aronson WJ. Fournier’s gangrene in a modern surgical setting: improved survival with aggressive management. BJU Int 1999;84:85-8. Fig. 3. Postoperative view obtained 10 months 3. Ferreira PC, Reis JC, Amarante JM, et al. Fournier’s after surgery. gangrene: a review of 43 reconstructive cases. Plast Reconstr Surg 2007;119:175-84. 4. Schaeffer AJ. Infections of the urinary tract. In: minor wound revision was performed three times. Campbell MF, Retik AB, Vaughan ED, et al., editors. During the 9-month postoperative follow-up, the Campbell’s urology. 7th ed. Philadelphia: W.B. Saunders patient had achieved normal gait patterns and urina- Co.; 1998. p. 533-614. tion (Fig. 3), but the patient had not recovered sexual 5. Chen SY, Fu JP, Chen TM, et al. Reconstruction of functions. scrotal and perineal defects in Fournier's gangrene. J FG is thought to arise from the combination of a Plast Reconstr Aesthet Surg 2011;64:528-34. polymicrobial infection and microthrombosis, result- ing from small subcutaneous arterioles. The organism probably passes through the Buck's fascia to spread along the planes of the dartos fascia of the scrotum and penis, Colles’ fascia of the perineum, and Scarpa’s fascia of the abdominal wall [4]. If FG is not recognized Reconstruction of Unexpected and treated early in its course, it may produce exten- Huge Chest Wall Defect after sive defects. Because of the widespread breakdown of skin Recurrent Breast Cancer barriers in extensive FG defects, there are high risks Excision Using a TRAM of local and systemic infections. In addition, the phy- Flap Combined with Partial sical and psychological stresses caused by extensive FG defects require a long time for complete wound Latissimus Dorsi Muscle Flap bed preparation. Therefore, a single-stage reconstruc- Jae A Jung, Yang Woo Kim, So Ra Kang tion is recommended for extensive FG defects. Department of Plastic and Reconstructive Surgery, Ewha There are various solutions for covering extensive Womans University Hospital, Ewha Womans University School of FG defects such as skin grafts and flaps [3,5]. However, Medicine, Seoul, Korea Images

skin grafts for extensive FG defects may be unsatis- Correspondence: So Ra Kang Department of Plastic and Reconstructive Surgery, Ewha Womans University factory because of 1) frequent urinary and fecal con- Hospital, Ewha Womans University School of Medicine, 1071 Anyangcheon-ro, tamination causing maceration and breakdown, and Yangcheon-gu, Seoul 158-710, Korea Tel: +82-2-2650-5149 Fax: +82-2-2651-9821 2) the exposure of bone and vital organs such as the E-mail: [email protected] iliac crest and testes. No potential conflict of interest relevant to this article was reported.

Reconstruction using the free flap in extensive FG Received: 20 Sep 2012 • Revised: 27 Nov 2012 • Accepted: 10 Dec 2012 pISSN: 2234-6163 • eISSN: 2234-6171 defects is restricted because of the difficulty of finding http://dx.doi.org/10.5999/aps.2013.40.1.76 • Arch Plast Surg 2013;40:76-79 reliable recipient vessels, given the inherent potential Copyright 2013 The Korean Society of Plastic and Reconstructive Surgeons This is an Open Access article distributed under the terms of the Creative Commons vascular complications in the wound bed and adjacent Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any tissues, and because the operation time can be exce- medium, provided the original work is properly cited. ssively prolonged during microsurgery.