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The "Sombrero-Shape" Super-Thin Pedicled ALT Flap for Complete Scrotal Reconstruction Following Fournier's Gangrene

  • Sapino, Gianluca (Department of Plastic and Hand Surgery, Lausanne University Hospital (CHUV), University of Lausanne) ;
  • Gonvers, Stephanie (Department of Plastic and Hand Surgery, Lausanne University Hospital (CHUV), University of Lausanne) ;
  • Cherubino, Mario (Department of Plastic, Reconstructive and Hand Surgery, Varese University Hospital) ;
  • di Summa, Pietro G. (Department of Plastic and Hand Surgery, Lausanne University Hospital (CHUV), University of Lausanne)
  • Published : 2022.05.15

Abstract

When the scrotal sac is entirely debrided following a Fournier gangrene, testes exposure poses unique challenges for the reconstructive surgeon. Despite the anterolateral thigh (ALT) flap is considered a workhorse in such context, aesthetic results are often suboptimal because of the lack of natural ptosis and patchwork appearance. We describe the use of a super-thin pedicled ALT flap for total scrotal reconstruction, modified according to a peculiar flap design and inset technique. A 42-year-old man was referred to our department for delayed total scrotal reconstruction 8 months after a Fournier gangrene extensive debridement. A super-thin pedicled ALT flap from the right thigh was designed: in the central portion of the ALT, a lateral skin paddle extension was marked to guarantee adequate posterior anchorage during insetting and ptosis of the scrotal sac. This particular flap arrangement has inspired the name "sombrero" as the shape is akin to the famous hat. No secondary refinements were needed, and the patient showed satisfying aesthetic and functional results at 12 months' follow-up. The ALT flap design "sombrero" modification proposed in this article can improve scrotum cosmesis and patient satisfaction in a single-stage single-flap procedure.

Keywords

References

  1. Lin CT, Chang SC, Chen SG, Tzeng YS. Reconstruction of perineoscrotal defects in Fournier's gangrene with pedicle anterolateral thigh perforator flap. ANZ J Surg 2016;86(12):1052-1055 https://doi.org/10.1111/ans.12782
  2. Maguina P, Palmieri TL, Greenhalgh DG. Split thickness skin grafting for recreation of the scrotum following Fournier's gangrene. Burns 2003;29(08):857-862 https://doi.org/10.1016/j.burns.2003.07.001
  3. Mopuri N, O'Connor EF, Iwuagwu FC. Scrotal reconstruction with modified pudendal thigh flaps. J Plast Reconstr Aesthet Surg 2016;69(02):278-283 https://doi.org/10.1016/j.bjps.2015.10.039
  4. Daigeler A, Behr B, Mikhail BD, Lehnhardt M, Wallner C. Bilateral pedicled gracilis flap for scrotal reconstruction. J Plast Reconstr Aesthet Surg 2016;69(09):e195-e196 https://doi.org/10.1016/j.bjps.2016.05.024
  5. Teven CM, Yu JW, Zhao LC, Levine JP. Extended medial sural artery perforator free flap for groin and scrotal reconstruction. Arch Plast Surg 2020;47(04):354-359 https://doi.org/10.5999/aps.2019.01921
  6. Makino Y, Matsumine H, Fujimaki H, Takagi M, Takeuchi M. Reconstruction of the necrotic scrotum with hydrosurgery system and pedicle DIEP flap: a case report of Fournier gangrene. Plast Reconstr Surg Glob Open 2020;8(09):e3135 https://doi.org/10.1097/GOX.0000000000003135
  7. Mahadevan V, Chandak P. The surgical anatomy of the perineum. J R Army Med Corps 2013;159(Suppl 1):i10-i14 https://doi.org/10.1136/jramc-2013-000019
  8. Hyakusoku H, Gao JH. The "super-thin" flap. Br J Plast Surg 1994;47(07):457-464 https://doi.org/10.1016/0007-1226(94)90027-2
  9. Lee SH, Rah DK, Lee WJ. Penoscrotal reconstruction with gracilis muscle flap and internal pudendal artery perforator flap transposition. Urology 2012;79(06):1390-1394 https://doi.org/10.1016/j.urology.2012.01.073
  10. El-Sabbagh AH. Coverage of the scrotum after Fournier's gangrene. GMS Interdiscip Plast Reconstr Surg DGPW 2018;7:Doc01
  11. Kadota H, Momii K, Hanada M, et al. Simultaneous deep inferior epigastric and bilateral anterolateral thigh perforator flap reconstruction of an extended perineoscrotal defect in Fournier's gangrene: a case report. Microsurgery 2019;39(03):263-266 https://doi.org/10.1002/micr.30409
  12. Khanal B, Agrawal S, Gurung R, Sah S, Gupta RK. Pudendal flap-a good option for creating neo-scrotum after Fournier's gangrene: a case series. J Surg Case Rep 2020;2020(11):a414
  13. Hong JP, Choi DH, Suh H, et al. A new plane of elevation: the superficial fascial plane for perforator flap elevation. J Reconstr Microsurg 2014;30(07):491-496 https://doi.org/10.1055/s-0034-1369807
  14. Guiotto M, Watfa W, Raffoul W, di Summa PG. Anterolateral thigh flap with vascularized fascia lata associated with thigh flaps: a case report of an all-in-one reconstruction of the suspensory ligament and penoscrotal district after Fournier gangrene. Ann Plast Surg 2020;85(06):e44-e47 https://doi.org/10.1097/SAP.0000000000002533
  15. Wang D, Wei Z, Sun G, Luo Z. Thin-trimming of the scrotal reconstruction flap: long-term follow-up shows reversal of spermatogenesis arrest. J Plast Reconstr Aesthet Surg 2009;62(11):e455-e456 https://doi.org/10.1016/j.bjps.2008.06.014
  16. Yao H, Zheng D, Wen J, et al. Reconstruction of major scrotal defects by anterolateral thigh flap. Cell Biochem Biophys 2014;70(02):1331-1335 https://doi.org/10.1007/s12013-014-0060-z
  17. di Summa PG, Sapino G, Cherubino M, et al. Reconstruction of complex soft tissue defects including tendons with anterolateral thigh flap extended to fascia lata: long term recovery and functional outcomes. Microsurgery 2019;39(05):405-415 https://doi.org/10.1002/micr.30431
  18. Spyropoulou GA, Jeng SF, Demiri E, Dionyssopoulos A, Feng KM. Reconstruction of perineoscrotal and vaginal defects with pedicled anterolateral thigh flap. Urology 2013;82(02):461-465 https://doi.org/10.1016/j.urology.2013.04.044
  19. di Summa PG, Tremp M, Meyer Zu Schwabedissen M, Schaefer DJ, Kalbermatten DF, Raffoul W. The combined pedicled anterolateral thigh and vastus lateralis flap as filler for complex perineal defects. Ann Plast Surg 2015;75(01):66-73 https://doi.org/10.1097/SAP.0b013e3182a884c8
  20. Dayan JH, Clarke-Pearson EM, Dayan E, Smith ML. Aesthetic scrotal reconstruction following extensive Fournier's gangrene using bilateral island pedicled sensate anterolateral thigh flaps: a case report. Can Urol Assoc J 2014;8(1-2):E114-E117