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 scrotum. 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 Volume 18│Number 2│Jul-Dec 2018 37 PMJN Postgraduate Medical Journal of NAMS Penoscrotal Defects in Fournier’s Gangrene and its Reconstructive Challenges: Our Experiences 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 testicles 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 testicle 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 for the 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