Reconstruction of the external genitals and repair of skin defects of the perineal region using three types of lateral groin flap

Utilities of scrotal flap for reconstruction of penile skin defects after severe burn injury

OBJECTIVE

In the present study, we aimed to present our experience of an effective two-stage surgical approach using scrotal skin flap for patients with penile skin defects following severe burn injury.

MATERIALS AND METHODS

A total of 17 patients with penile skin defects underwent scheduled two-stage reconstruction using scrotal skin flap from January 2004 to October 2016. Patients, who were selected as eligible candidates for scrotal flap, exhibited a wide range of indications, including iatrogenic injuries (e.g., diathermy treatment after circumcision), scalding, flame injuries and electrical burns. During the first stage, the denuded penis secondary to debridement was temporally embedded in scrotal skin flap through an intrascrotal tunnel created between the skin and darto's fascia. During the second stage, the skin around the penis was separated and divided from the scrotum after incising the scrotal skin at the ventral penile base. After a mean follow-up of 30 months, the reconstructed penises yielded satisfactory aesthetic outcomes and maintained erectile function.

RESULTS

The mean age of patients was 35 years (19-55 years), and the median follow-up was 30 months (12-60 months). No major perioperative complication occurred except for dehiscence of scrotal skin after 2nd stage in three patients, and split-thickness skin grafts were applied for recovery of scrotum. Of 17 cases, 15 patients (88.2%) were in satisfactory cosmetic appearance. All patients regained penile sensation and normal voiding function in standing position. The International Index of Erectile Function (IIEF) was used to assess sexual function, with 13 patients (76.5%) reported normal erectile function, while the rest 4 reported mild erectile dysfunction. With regards to intercourse satisfaction domain, encouraging results indicated a total of 17 patients resumed sexual intercourse after surgery. In overall satisfaction domain, 11/17 (64.7%) reported a satisfaction from "very" to "moderately" with their overall sex life and sexual relationship with their partners, while only one patient reported "moderately dissatisfied" with his overall sex life.

CONCLUSIONS

We report a series of particular cases, including rare iatrogenic injury (diathermy treatment after circumcision) and severe compound electrical injury. Meanwhile, we show our successful experience that scrotal skin flap could be used as an effective surgical alternative to cover severe burn injury wound in male genitalia. The scrotal flap, with higher anti-infection ability and flexible contexture, is available for recovering penile skin defects following severe burn injury resulting in good aesthetic and sexual outcomes.

Surgical Reconstruction of Giant Penoscrotal Lymphedema in Sub-Saharan Africa

OBJECTIVE

To present management challenges, surgical technique, and outcome associated with penoscrotal reconstruction in patients with giant scrotal lymphedema in sub-Saharan Africa.

METHODS

A prospective study of all patients who had penoscrotal reconstruction for giant scrotal lymphedema at our university teaching hospital between January 2003 and December 2012 was carried out. Patients' preoperative clinical evaluation findings, operative technique, and postoperative course were reviewed after obtaining ethical approval and informed consent from the patients.

RESULTS

Nineteen patients with giant scrotal lymphedema presented to us during the period of study; out of which, 11 had surgical excision and were studied. Their mean age and median duration of symptoms were 48.5 years and 11.5 years respectively. They all had surgical reconstruction using modified Charles procedure by the same combined team of urologists and plastic surgeons. Scrotal hematoma (27.3%) and superficial surgical site infection (18.2%) were complications encountered postoperatively. One patient (9.1%) had recurrence within 24 months, requiring repeat excision.

CONCLUSION

Giant scrotal lymphedema poses severe physical challenge to the sufferer. Surgery remains the only hope to reduce penoscrotal size. Combined effort of urologic and plastic surgeons is essential for reconstruction.

Male genital lymphedema: clinical features and management in 25 pediatric patients

PURPOSE

Genital lymphedema in the pediatric population is poorly understood. The purpose of this study was to determine the epidemiology, morbidity, and treatment outcomes for males with genital lymphedema.

MATERIALS AND METHODS

Male patients with genital lymphedema evaluated at our vascular anomalies center between 1995 and 2011 were reviewed. Etiology, age-of-onset, location, morbidity, and treatment were analyzed.

RESULTS

Of the 3889 patients with vascular anomalies, 25 (0.6%) had genital lymphedema: 92% (23/25) with primary and 24.0% (6/25) with familial/syndromic lymphedema. For primary disease, the mean age-of-onset was 4.5 ± 6.3 years with 60.9% (14/23) presenting in infancy, 13.0% (3/23) in childhood, and 26.1% (6/23) in adolescence. Combined penoscrotal lymphedema was identified in 72.0% (18/25) of patients; 19 children (76.0%) had concomitant lower extremity involvement. The most common complication was cellulitis (24.0%). Surgical contouring was performed in 44.0% (11/25) of patients. Patients with operative intervention and follow-up (n=6) had sustained improvement after a median of 4.2 years (range: 0.3-11.0).

CONCLUSIONS

Lymphedema of the male genitalia is typically idiopathic. Most patients develop swelling in infancy but can present in adolescence and occasionally childhood. The penis and scrotum are usually both involved and concurrent lower-extremity swelling is common. Surgical debulking can improve symptoms and appearance.

Aesthetic scrotal reconstruction following extensive Fournier's gangrene using bilateral island pedicled sensate anterolateral thigh flaps: A case report

Achieving an aesthetic appearance of the scrotum after extensive Fournier's gangrene is a reconstructive challenge. Testicular coverage is often prioritized over scrotal cosmesis due to the comorbidities typically seen in this patient population. We describe our treatment of a young, healthy male with extensive Fournier's gangrene, with loss of the scrotum. Bilateral neurotized anterolateral thigh flaps were used to achieve a sensate and aesthetically acceptable result.

The foreskin advancement flap: an alternative technique for reconstruction of penile burns

Penile burns are devastating injuries and are frequently associated with significant functional and psychological sequelae. The goals of penile reconstruction after burn injury include: 1) skin coverage, 2) preservation of penile length, sensation and erectile function, 3) esthetic integrity, and 4) permissive for penile growth in the pediatric patient. A multitude of different techniques have been proposed, including skin grafts, local, regional, and free flaps, each of which fail to address all goals of reconstruction. We introduce the foreskin advancement flap that, when available, successfully addresses these key challenges and as such provides for an ideal reconstruction.

Thrombotic cutaneous gangrene with autoamputation of the penis: a rare extracolonic manifestation of ulcerative colitis in a child

We present a pediatric patient with ulcerative colitis who developed thrombotic cutaneous gangrene involving skin of the lower chest, abdomen, back, bilateral buttocks, bilateral thighs, perineum, and genitalia, ultimately resulting in autoamputation of the glans penis. After an extensive review of the literature, we describe the diagnosis and management of this devastating condition.

Surgical treatment of lymphedema of the penis and scrotum

PURPOSE

Lymphedema of the penis and scrotum, regardless of its etiology, is determined by reduced lymphatic flow with subsequent enlargement of the penis and scrotum. The clinical course of this condition is characterized by extreme discomfort for patients, with limitation of local hygiene, ambulation, sexual intercourse, and voiding in the standing position. The purpose of the present study is to present the experience and results of the treatment of lymphedema of the penis and scrotum by removing affected tissues and correcting the penoscrotal region.

MATERIALS AND METHODS

Seventeen patients with lymphedema of the penis and scrotum were treated with a modified Charles procedure, which consists of the excision of the affected skin followed by scrotoplasty and midline suture simulating the scrotal raphe. The penis is covered with a split-thickness skin graft by means of a zigzag suture on its ventral surface.

RESULTS

Regression of symptoms and improvement of previous clinical conditions were verified in the follow-up which ranged from 6 months to 6 years. One patient who had undergone lymphadenectomy with radiation therapy due to penile cancer had recurrent scrotum lymphedema.

CONCLUSIONS

The modified Charles procedure for the treatment of penoscrotal lymphedema is easily reproducible and allows better local hygiene, easier ambulation, voiding in the standing position, resuming sexual intercourse, and finally, better cosmetic results in the affected area with remarkable improvement in quality of life.

Penile resurfacing with vascularized fascia lata

Penis resurfacing is a challenging procedure, and should simultaneously ensure erectile function, tactile sensibility, sexual satisfaction, and aesthetic integrity. This article presents three cases with penile skin defects treated by means of a pedicled fascia lata attached either to the tensor fascia lata (one case) or an anterolateral thigh flap (two cases). The cause of the wounds included electrical burn, Fournier's gangrene, and self-mutilation. The size of flaps ranged from 10-13 cm in width and 15-30 cm in length. All flaps included vascularized fascia lata, which covered part or the circumference of the penis. All flaps survived completely. The lateral cutaneous nerve of the thigh was included in the designed flaps in all instances, and normal protective sensation was recorded postoperatively. The patients reported normal erectile function and ability to perform intercourse. The flaps, though relatively bulky and hairy, had a good color and texture match with the penis and suprapubic region. Based on our limited experience, we believe that the anterolateral thigh flap has greater dimensions with a longer pedicle, and allows for greater flexibility in flap design compared to the tensor fascia lata flap. An anterolateral thigh flap can be safely thinned in a second stage, and it is our flap of choice for penis resurfacing.

Vaginal reconstruction with the femoral veno-neuroaccompanying artery fasciocutaneous flap

The arterial anatomy of the anteromedial thigh was investigated in ten fresh cadavers that had been systemically injected with a lead oxide-gelatin mixture. The arteries accompanying the great saphenous vein and the anterior cutaneous branches of the femoral nerve were found to have branches not only to the cutaneous vein and nerve, but also to the skin. On the basis of the anatomy of these accompanying arteries, a pedicled fasciocutaneous flap containing them was developed consisting of an adipofascial pedicle and a skin island. This flap has been named the femoral veno-neuroaccompanying artery fasciocutaneous flap (the femoral V-NAF flap, the great saphenous-femoral V-NAF flap) and has been applied in three cases of vaginal reconstruction.

Phalloplasty in children and adolescents using the extended pedicle island groin flap

An operative procedure for phalloplasty is reported that uses an extended pedicle island groin flap. Forming a combined groin and lower abdominal flap based on the superficial iliac and epigastric vessels is the main characteristic of this technique. The flap consists of 3 parts: 1) the lateral narrow hairless part for the neourethra, 2) the medial wide part for neophallus shaft reconstruction and 3) the base of the flap on which a flap pedicle is formed and lengthened by de-epithelializing the skin. The pedicle includes subcutaneous tissue with blood and lymph vessels. The neourethra and neophallus shaft are reconstructed using a tube-within-tube technique. The size of the flap depends on patient build. The flap is transferred to the recipient area, that is to the level of the lower margin of symphysis. Anastomosis of the new and native urethra may be done simultaneously or during the second stage of the procedure. The donor site skin defect is closed by direct approximation. During 3 years (1991 to 1993) this flap technique was performed on 24 patients (age 12 to 18 years). There were 2 main indications for treatment: 1) complete absence of the penis, and so total reconstruction of the phallus was done and 2) small dimensions of the penis or just a penile stump, and so augmentation of the penis was done. Specific indications were female transsexualism in 4 patients, penile amputation in 2 and a small disabled penis in 18 (the exstrophy-epispadias complex, intersex and micropenis). Followup ranged from 6 to 42 months (average 29). A new phallus of satisfactory dimensions was achieved in all cases. Complications included partial necrosis of the flap in 2 patients, fistulas in 2 and stenosis of the urethral anastomosis in 1. These complications were successfully resolved by corrective surgery. The method is simple and timesaving with a minor complication rate. This technique is the available alternative to the most commonly used procedure, that is microsurgical free tissue phalloplasty.