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

Pelvic and Perineal Reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Classify types of bony pelvic resections. 2. Outline reconstructive options for pelvic and perineal defects. 3. Identify advantages and drawbacks of various reconstructive techniques. 4. Recognize the functional benefits of bony and soft-tissue reconstruction.

SUMMARY

Defects of the pelvis and perineum arise from tumors, trauma, infection, congenital differences, and gender incongruence. Pelvic resections can result in bony instability and soft-tissue deficiency. The goals of reconstruction are maintenance of spinopelvic continuity, elimination of dead space, resurfacing of cutaneous defects, and prevention of hernias. Perineal reconstruction has important functional considerations. Abdominoperineal resection and pelvic exenteration defects benefit from flap reconstruction to decrease pelvic wound complications. Vulvovaginal reconstruction is performed with flaps from the perineum, thigh, or abdomen. Scrotal and superficial penile defects are most commonly reconstructed with scrotal flaps and skin grafts. Total penile reconstruction most commonly uses a radial forearm free flap.

Reverse circumcision foreskin advancement flap for reconstructing penile shaft skin defects in adults with burn injuries in the perineal region

AIM

Genital burns are rare injuries. Reconstruction of penile skin defects should consider cosmetic and functional outcomes. Skin grafts can develop scar contractures and carry hair follicles, causing unwanted results. These downsides remain unsolved issues. This work aimed to describe a new foreskin advancement flap method for completely reconstructing penile shaft skin defects in severely burned patients.

MATERIALS AND METHODS

From 2021 to 2023, four patients with third-degree burns in the genital area were enrolled in this investigation. We describe a series of cases with deep burns to the penile shaft and surrounding area that needed debridement and reconstruction using a novel technique called "reverse circumcision," which consists of tangential excision of the penis and a foreskin advancement flap without longitudinal cuts with less morbidity, preservation of function, and a better aesthetic appearance. The patients had an average follow-up of nine months.

RESULTS

The reverse circumcision technique was established for patients with severe burns in the genital area. The four patients were satisfied with the postoperative results and the aesthetic results of the procedure without reporting any complications. No scarring or contractures were observed on the glans or penile shaft after surgery.

CONCLUSIONS

Compared with other flap methods, the use of a reverse circumcision foreskin advancement flap was more straightforward, feasible, and effective. In adults, the foreskin tissue completely covers the penile shaft skin defect. It is a viable reconstructive surgical technique that is easily reproducible and has excellent aesthetic and functional results. For this surgical technique, tissue transfers, bulky regional flaps, or skin grafts were not needed.

Bilateral Pedicled Scrotal Flaps as an Alternative to Skin Graft in Penile Shaft Defects Repair

OBJECTIVE

To analyze surgical and functional outcomes of bilateral pedicled scrotal flaps for penile shaft reconstruction.

MATERIALS AND METHODS

A retrospective analysis was performed on 22 patients who underwent penile shaft reconstruction with bilateral pedicled scrotal flaps between 2009 and 2017. Demographics, peri-operative data, and surgical complications were collected. Functional outcomes were analyzed using a questionnaire made of the erection hardness score, the patient and observer scar assessment scale, and a 10-point Likert scale measuring patients... satisfaction about their skin coloration, sensitivity, elasticity and thickness, penile size, scrotal volume, erection quality, penetration ability, pain, sexual satisfaction, body image, masculinity, self-esteem, and global satisfaction.

RESULTS

Patients exhibited a wide range of indications, including buried penis (27.2%), or subcutaneous injections of foreign material (27.2%). Early complications were suture dehiscence (31.8%), infection (13.6%) and hematoma (4.6%), associated with 9.1% of surgical revisions. Late complications were skin retraction (27.3%), testicular ascension (22.7%), pyramidal shape (4.6%) or shortening (13.6%) of the penis, associated with 27.3% of surgical revisions. For the 12 patients who answered the questionnaire, median erection hardness score and patient and observer scar assessment scale score [IQR] were 3.5 out of 4 [2.5-4] and 11.5 out of 60 [9.5-22], respectively. The patients reported a positive impact of the surgery on their psychological condition, with a median score of global satisfaction of 8 [IQR 7.5-9.5].

CONCLUSION

Bilateral pedicled scrotal flaps seem.ßto be a safe alternative for shaft defects reconstruction despite a potential need of surgical revision, providing satisfactory functional outcomes.

Post-circumcision penile skin loss: reporting the outcome of one-stage anterolateral scrotal based flaps in children

Introduction

Improper penile assessment, together with carrying out circumcision by an inexperienced person, results in major complications. One of the complex complications is the complete or sub-complete penile skin loss, which in many cases, necessitates one or staged repair.

Purpose

To evaluate modified one-stage bilateral anterolateral scrotal-based flaps to compensate for penile skin loss after circumcision.

Methods

This study was performed on patients with almost penile skin loss after circumcision from February 2013 to July 2021. In all cases, one-stage modified bilateral anterolateral scrotal skin flaps were used to compensate for penile skin loss. The modification includes scrotal skin flap fashioning in a novel way, in addition to the use of penodermal fixation sutures at the penoscrotal junction, to create a stable penoscrotal junction and new penile skin coverage. Patients were discharged from the hospital on the same day of surgery. The dressing was left for 5 days. Follow-up visits were scheduled weekly in the first month, 3 and 6 months later, then annually.

Results

Forty-six children were included in this study. Their mean age was 4.5 ± 1.5 years. The mean operative time was 139.6 ± 11.5 min. No flap ischemia or necrosis was reported. One case (2.2%) developed a scrotal hematoma managed conservatively. Three (6.5%) cases presented with wound dehiscence at the penoscrotal angle. Three (6.5%) cases had self-limited penile edema. Two (4.3%) cases had dorsal midline hypertrophic scar; one improved after treatment with triamcinolone acetonide ointment, and the other needed scar revision. The mean follows up was 23.33 ± 9.13 months.

Conclusion

The modified scrotal skin flap technique provides a good substitution for stable penile skin coverage and a one-stage reconstruction of penile skin loss. It results in good parents' satisfaction with acceptable complications.

Circumferential full-thickness skin grafting: An excellent method for the treatment of short penile skin in adult men

Objective

Short penile skin due to excessive circumcision is a complex condition requiring surgical care. The study aims to investigate the effect of full-thickness skin grafting (FTSG) in treating short penile skin.

Methods

A retrospective analysis was performed on 24 patients with insufficient penile skin. The included patients underwent full-thickness skin grafting from the scrotum and the groin region in the Genital Plastic Surgery Center between February 2014 and September 2021. Morphology of the penis, length of the penis, complication, and donor area healing status was observed by the authors. Additionally, the International Index of Erectile Function Questionnaire (IIEF-5) and the patient's evaluation of penile appearance were investigated.

Results

An aesthetically pleasing appearance of the penis was obtained by FTSG in 24 patients. The length of penis was improved after surgery (5.70 cm ± 1.24 cm vs. 6.05 cm ± 1.33 cm, P value < 0.05). All patients had good healing of the penile area without serious complications. Only 2 cases showed minor partial necrosis and recovered soon after proper treatment. A high patient's evaluation of penile appearance was received (4.08 ± 0.71, mean ± SD) and the scores of IIEF-5 increased significantly after surgery (18.38 ± 2.24 vs. 21.08 ± 1.79, P-value < 0.05).

Conclusions

FTSG from the scrotum and inguinal skin provides good aesthetic and functional results for treating short penile skin. FTSG, particularly the scrotum-derived skin graft, offers a great supplement to penile skin. It could be suggested as a promising method of treating insufficient penile skin, which meets both functional and aesthetic needs.

At The Forefront of Penile Surgical Reconstruction: A Bibliometric Study of the 100 Most-Cited Articles

PURPOSE

The citation count of a scientific article is considered as the recognition it received from this field. The purpose of this bibliometric analysis was to identify the top 100 most-cited scientific articles in penile surgical reconstruction.

METHODS

The Web of Science database was used to extract the top 100 most-cited articles. Individual articles were reviewed to identify the authorship, published journal, journal impact factor (IF), primary disease, article type, institution and country of origin, and year of publication.

RESULTS

The top 100 most-cited articles were published between 1947 and 2013. The number of citations ranged from 23 to 233. Journal of Urology contributed the most articles (n = 36). Articles with a high level of evidence like prospective analysis (n = 5), systematic review and meta-analysis (n = 2), and guideline (n = 1) were all published after 2000. The average citation per year of articles published in high-IF journals was significantly higher than that of other articles (p = 0.0129). There was a positive linear correlation between citation count per year and publication year (r² = 0.26, p < 0.001). Among the top 100 articles, 74 articles were interlinked via citation of each other. The major topic of co-citation network was the application of flaps in penile reconstruction.

CONCLUSIONS

The analysis of top 100 most-cited articles facilitates the comprehensive recognition of current focus in the field of penile surgical reconstruction, which is the exploration of flaps and development of new techniques in penile reconstruction. In the future, more attention should be paid to evidence-based medicine to provide high-level evidence for research.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reconstructive Surgery for High-voltage Injury of Genitoperineal Area and Upper Extremities: The Uromanual Trauma Concept

Reconstruction of tissue defects resulting from high-voltage injuries remains a serious issue in plastic surgery. For many years it has been solved by applying autologous reconstruction with rotated and revascularized flaps. We present a series outlining reconstructive practices in treatment of patients with high-voltage “uromanual” injuries. These types of injuries include a group of upper extremities and genitoperineal high-voltage trauma due to urination on an electrical source, which are rarely discussed in the literature. This study aimed to describe the algorithm of perioperative care and surgical treatment in patients with high-voltage uromanual trauma. Three male patients (mean age 26.3 years, range: 20–35 years) with traumatic injury of the genital area and the upper extremities due to high-voltage injury underwent reconstruction with a one-stage repair of defects. In one patient, the defect of the left upper extremity was eliminated by microsurgical autotransplantation of musculocutaneous thoracodorsal artery perforator flap. The genitoperineal region was repaired using rotated scrotal flaps. In two other cases, phalloplasty with a revascularized myocutaneous thoracodorsal artery perforator flap was followed by urethroplasty with a prefabricated radial forearm free flap. Hand deformities were eliminated using split-thickness skin autografts. All flaps survived. No complications were observed in the autograft harvesting areas. All cases showed good aesthetic and functional postoperative outcomes. Management of uromanual injuries should include one-stage reconstruction of upper extremities and genitoperineal defects for restoration of satisfying functional and aesthetic components crucial for patient’s quality of life and socialization.

Necrotizing fasciitis of cryptoglandular infection treated with multiple incisions and thread-dragging therapy: A case report

BACKGROUND

Necrotizing fasciitis is a fulminant necrotizing soft tissue disease with a high fatality rate. It always starts with impact on the deep fascia rapidly and might result in secondary necrosis of the subcutaneous tissue, fascia, and muscle. Thus, timely and multiple surgical operations are needed for the treatment. Meanwhile, the damage of skin and soft tissue caused by multiple surgical operations may require dermatoplasty and other treatments as a consequence.

CASE SUMMARY

Here, we report a case of 50-year-old male patient who was admitted to our hospital with symptoms of necrotizing fasciitis caused by cryptoglandular infection in the perianal and perineal region. The symptoms of necrotizing fasciitis, also known as the cardinal features, include hyperpyrexia, excruciatingly painful lesions, demonstration gas in the tissue, an obnoxious foul odor and uroschesis. The results of postoperative pathology met the diagnosis. Based on the premise of complete debridement, multiple incisions combined with thread-dragging therapy (a traditional Chinese medicine therapy) and intensive supportive therapies including comprising antibiotics, nutrition and fluids were given. The outcome of the treatment was satisfactory. The patient recovered quickly and achieved ideal anal function and morphology.

CONCLUSION

Timely and effective debridement and multiple incisions combined with thread-dragging therapy are an integrated treatment for necrotizing fasciitis.

Comparison Between Human Amniotic/Chorionic Membrane and Cryopreserved Allografts in the Treatment of Genital Burns

BACKGROUND

Genital burns have devastating effects on patient and have been classified by the American Burn Association as major burn injury. The management of these injuries continues to challenge reconstructive surgeons. Cryopreserved skin allografts have been successfully used to manage partial-thickness skin burns; however, dehydrated human amniotic/chorionic membrane (DHACM) represents novel technology. Dehydrated human amniotic/chorionic membrane outcomes have not been sufficiently studied to guide its use on genital burns. The objective of this study was to report on the outcomes of dehydrated amniotic membrane as a biologic skin dressing on genital burns injury compared with cryopreserved allografts.

METHODS

Retrospective review of data collected from our institutional burn registry from 2012 to 2017. The study population included patients with partial-thickness genital burns admitted between 2012 and 2017 treated with either dehydrated human amniotic/chorionic membrane or cryopreserved allografts. Demographic characteristics and outcome measures were compared between the 2 groups.

RESULTS

Thirty patients with genital burns who received DHACM skin and cryopreserved allografts were included in the analysis. The mean age for the DHACM group was 27.6 years compared with 33.5 years for the cryopreserved group. The mean total body surface area was 3.8% in the DHACM group compared with 7.2% in the cryopreserved group (P = non-significant (ns)). The mean injury severity score was not significantly different between groups. Patients receiving cadaveric allografts had a higher number of skin substitute surgical reapplications as compared with the DHACM group (28% vs 0%, P ≤ 0.05). All patients who received DHACM skin substitutes healed by 2 weeks postoperative compared with 76% of patients who received cryopreserved skin allografts (P = 0.03, χ).

CONCLUSIONS

Dehydrated amniotic membrane skin substitutes are a safe alternative in the treatment of genital burns. Its use achieves comparable benefits with no major significant difference in terms of complication, supporting the safety of amniotic membrane to treat genital burns.

Scrotal Tissues: The Perfect Material for Urogenital Reconstruction

Correction of male urogenital pathology of different severity is complicated by the anatomical aspects of the penis. Skin texture, internal structures, and perfusion dynamics of the urogenital area make it a difficult area to reconstruct. We provide our experience with axial scrotal flaps for correction of penile defects of different severity and believe that these local flaps offer sufficient tissue characteristics for proper restoration of this complex region.

METHODS

Forty-eight patients were divided into 3 groups depending on penile defect genesis and severity. Axial scrotal flap reconstruction was used for the correction of defects in all cases, when necessary in combination with other flaps.

RESULTS

Axial scrotal flaps for total and subtotal penile reconstruction serve as valuable material for reconstruction of the urogenital area, and are to be combined with other flaps for restoration of bulk tissues. Localized defects of the penis and urethra reconstructed by axial scrotal flaps provide excellent aesthetic results with minimal scaring, stable perfusion dynamics, and high satisfaction rate.

CONCLUSIONS

Scrotal tissues provide an excellent reconstruction material for penile defects because of their highly similar tissue structure as that of the penis. Scrotal axial flaps do not provide excess bulking in the postoperative period and are recommended for reconstruction of urethral and localized penile defects. Multistage surgery is recommended in cases of severe tissue damage, in combination with other flaps (inguinal, thoracodorsal, and radial).

Divisional Reconstruction Strategy: The Repair of Perineal Skin Defect After Tumor Resection

BACKGROUND AND AIMS

The unique anatomical and physiological function of the perineum region makes it difficult to be repaired after tumor resection. We aim to evaluate the efficacy of PSC divisional reconstruction strategy in the reconstruction of perineal skin defect.

MATERIALS AND METHODS

This study includes patients undergoing perineal skin defect reconstruction with PSC strategy-P (penis), S (scrotum), C (circum-penoscrotal skin) divisional reconstruction strategy.

RESULTS

From August 2013 to August 2018, 47 patients were enrolled in the surgical procedure. The defect area after resection measured 2 cm × 2.5 cm, minimum, and 12 cm × 18 cm, maximum. Among them, the cases involved one, two, and three zones are 12, 10, and 25, respectively. The skin defects were divisionally repaired. All flaps were well survived without complications or scar contracture. No tumor recurrence happened.

CONCLUSION

The application of PSC divisional reconstruction strategy is a promising way to repair wounds in circum-penoscrotal skin area. Moreover, this strategy is easy to process and shows no significant complications during follow-up period.

Back to the future: The Cecil-Culp technique for salvage penile reconstructive procedures

INTRODUCTION

Re-operative penile reconstruction is challenging and requires tension-free skin closure. The repair popularized by Cecil and Culp in the 1940s, using the scrotum to provide a temporary vascularized bed for complex hypospadias repairs, fell out of favor due to temporal trends towards single-stage repairs and concern for utilizing hair-bearing skin on the penile shaft.

OBJECTIVE

It was hypothesized that a modified Cecil-Culp (CC) concept of penile scrotalization, leaving the penis attached to the scrotum for 1 year rather than 6 weeks as originally described, improves outcomes with this reconstruction for ventral skin deficiency or poor vascular support.

METHODS

Institutional Review Board-approved registries were reviewed to identify patients who underwent a CC repair during 1987-2016 at two institutions. Cecil-Culp technique was utilized in multi-stage hypospadias complication repairs or for insufficient ventral penile shaft skin coverage. Anatomic abnormality, number and type of prior surgeries, and complications before and after CC were recorded.

RESULTS

Thirty-nine patients underwent CC: 23 failed hypospadias repairs, three hypospadias after bladder exstrophy, 10 penile curvature following circumcision, and three with skin loss from trauma. Mean age at CC was 61.8 months (hypospadias), and 59.8 months (non-hypospadias). Hypospadias patients underwent a mean of 3.6 surgeries (range 1-9) prior to CC. Four of the 39 patients (10.3%) had perioperative complications after CC, including scrotal abscess, skin infections, and difficulty removing the urethral stent. Eight of 37 (21.6%) patients had longer-term complications related to their hypospadias repair, including fistulae, diverticula, dehiscence, and stricture. Mean time from CC placement to release was 345 and 473 days for hypospadias and non-hypospadias cases, respectively. There was no apparent scrotal skin transferred to the penile shaft at the final take-down. Mean follow-up was 22.3 months.

DISCUSSION

Embedding the penis into the scrotum for added vascularity and ventral skin coverage has been used effectively in cases of the most tenacious fistulas and for significant skin loss and trauma. Limitations of this study were its retrospective approach at two institutions over an extended period of time by multiple surgeons, so patient selection and procedure may have varied.

CONCLUSIONS

Modification of CC repair by delaying 9-12 months before CC take-down enhanced the benefits of a robust vascular bed for wound healing, and helped to avoid transfer of hair-bearing scrotal skin to the penile shaft. The CC technique is an important tool for penile reconstructive surgery of complex hypospadias repairs with inadequate skin, and for traumatic injuries.