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Scrotal Reconstruction following an Avulsion Injury
0022-534 7 /85/1334-0681$02.00/0 Voi. 133, April
THE JOURNAL OF UROLOGY
Copyright© 1985 by The Wiiliams & Wilkins Co.
Printed in U.S.A.
SCROTAL RECONSTRUCTION FOLLOWING AN AVULSION INJURY C. FREDRIC REID
AND
JOHN H. WRIGHT, JR.
From the Divisions of Urology and Plastic Surgery, Medical Park and Forsyth Memorial Hospital, Winston-Salem, North Carolina
ABSTRACT
Scrotal reconstruction following avulsion of the scrotal skin often is a time-consuming, multistage repair. We present an alternative method of repair using a subcutaneous soft tissue expander. A grain auger is a screw device within a cylinder used to move grain to a higher level, often for storage purposes. 1 The rotation rate is 800 to 900 revolutions per minute and grain moves through the auger at a rate of 7 feet per second. The screw device or auger blade is activated through a power takeoff over the top of the auger tube covered by a protective shield. This shield often is removed by the user, thereby exposing the power take-off to extremities and loose clothing. When a worker straddles this device his pants may catch on the rapidly rotating shaft and be torn from the victim along with the loosely anchored skin of the scrotum and penile shaft. Auger injuries typically are contaminated with grain and may involve crush injuries as well as amputation. The difficulty in reconstruction of scrotal avulsion injuries lies in the fact that the blood supply to the scrotal skin is destroyed when the skin and dartos muscle are avulsed. Occasionally, the avulsed skin has been reapplied to the denuded scrotum but with only variable results. Surgical techniques for repair differ widely. Burying the testes in thigh pouches, raising skin flaps from the thigh and skin grafts to cover the denuded testes are repair methods that have been used successfully. 2 We present a case of avulsion of the scrotum, penile shaft and pubic skin owing to an auger injury, and describe an unreported method of scrotal reconstruction.
FIG. 1.
Scrotal and penile skin avulsion injury
CASE REPORT
M. M., a 32-year-old man, presented on October 7, 1981 immediately after sustaining an injury to the scrotum and penis from a grain auger. His pants had been torn away, and the scrotum and penile shaft skin were included (fig. 1). Blood loss initially was profuse but this was controlled with direct pressure. The avulsed scrotal skin had been placed on ice shortly after the accident. In the operating room the wound was debrided and evaluation revealed that the scrotum had been avulsed completely. Numerous grain seeds were removed and after thorough irrigation of the wound the intact testes were placed in pouches beneath the subcutaneous fat of each thigh. These tissue planes were natural pockets created by the avulsion injury. Superficial thigh pouches were not developed initially because of the high risk of infection in the contaminated wound. A split thickness skin graft from the lateral thigh was used to resurface the denuded penile shaft, while a portion of the salvaged scrotal skin that had been avulsed was replanted as a full thickness graft to repair the penile base and avulsed pubic tissue (fig. 2, A). The perinea! laceration was closed vertically from the anal verge to the ventral base of the penile shaft. The incision was drained with a posteriorly placed Penrose drain. A foam bolster was secured over the skin grafts and a 14F Foley catheter was left indwelling while the bolster remained in place on the penile shaft (fig. 2, B). The grafts and wound remained free of infection, and 1 month later minor skin graft revisions were performed. On November 30 the testes were placed in more superficial thigh
FIG. 2. A, skin grafts on penile shaft and testes buried in thigh pouches. B, foam bolster dressing in place.
pouches to attain a more ambient temperature for spermatogenesis.3-4 A 250 cc capacity soft tissue expander* was inserted in the perineum (fig. 3, A). The filling port was placed in the right inguinal area and 50 cc saline were injected into the device initially (fig. 3, B). Beginning 1 week later the device was expanded further in 30 to 40 cc increments gradually over a period of 6 weeks until the expander was filled to capacity. It was left in position for 2 additional weeks to allow the weight of the device to create further skin expansion. The silicone skin expander and filling port were removed on
* Radovan, Heyer-Schulte Corp., 600 Pine Ave., Goleta, California 93017.
Accepted for publication October 29, 1984. 681
682
REID AND WRIGHT
FIG. 3. A, subcutaneous soft tissue expansion device. B, expansion device in place in perineum being expanded with saline through filling port in right inguinal area.
DISCUSSION
Traditionally, scrotal reconstruction has involved the use of thigh pouches and pedicle flaps. 5 Satisfactory results have been published using skin grafts to cover the denuded scrotum. 6 The tissue flap and skin graft methods of scrotal reconstruction often involve multiple stages, and the results are not always cosmetically acceptable. 7 Plastic surgeons are familiar with the soft tissue expanders used primarily for breast and other soft tissue reconstruction. Our application of this device in the perineum was quite successful and was performed relatively easily. The repair of the injury and the reconstruction required fewer surgical procedures than previous methods of scrotal reconstruction with less local scarring and a more aesthetic result. There was no noticeable urethral compression from the expansion device. This new method of repair of scrotal avulsion using expansion of residual perinea! skin should be considered in scrotal reconstruction and all complex genital injuries involving soft tissue loss.
REFERENCES 1. Beatty, M. E., Zook, E.G., Russell, R. C. and Kinkead, L. R.: Grain
2. 3. FIG. 4. Final result after expansion device was removed and testes were placed in neoscrotum.
June 23, 1982, and the testes were dissected from the thigh pouches and were sutured into the neoscrotum. The wound had healed 2 months postoperatively (fig. 4) and sexual function was reported as normal. A semen analysis shortly after the final surgical procedure showed only occasional sperm. Future sperm analysis will be performed.
4. 5. 6. 7.
auger injuries: the replacement of the corn picker injury? Plast. Reconstr. Surg., 69: 96, 1982. Arneri, V.: Reconstruction of the male genitalia. In: Reconstructive and Plastic Surgery, 2nd ed., vol. 7, p. 3902, 1977. Culp, D. A. and Huffman, W. C.: Temperature determination in the thigh with regard to burying the traumatically exposed testis. J. Urol., 76: 436, 1956. Huffman, W. C., Culp, D. A., Greenleaf, J. S., Flocks, R. H. and Brintnall, E. S.: Injuries to the male genitalia. Plast. Reconstr. Surg., 18: 344, 1956. Mandel, M. A.: "Hiawatha" scrotal reconstruction. Ann. Plast. Surg., 4: 238, 1980. Balakrishnan, C.: Scrotal avulsion: a new technique of reconstruction by split-skin graft. Brit. J. Plast. Surg., 9: 38, 1956. Tiwari, I. N., Seth, H. P. and Mehdiratta, K. S.: Reconstruction of the scrotum by thigh flaps. Plast. Reconstr. Surg., 66: 605, 1980.
THE JOURNAL OF UROLOGY
Copyright© 1985 by The Wiiliams & Wilkins Co.
Printed in U.S.A.
SCROTAL RECONSTRUCTION FOLLOWING AN AVULSION INJURY C. FREDRIC REID
AND
JOHN H. WRIGHT, JR.
From the Divisions of Urology and Plastic Surgery, Medical Park and Forsyth Memorial Hospital, Winston-Salem, North Carolina
ABSTRACT
Scrotal reconstruction following avulsion of the scrotal skin often is a time-consuming, multistage repair. We present an alternative method of repair using a subcutaneous soft tissue expander. A grain auger is a screw device within a cylinder used to move grain to a higher level, often for storage purposes. 1 The rotation rate is 800 to 900 revolutions per minute and grain moves through the auger at a rate of 7 feet per second. The screw device or auger blade is activated through a power takeoff over the top of the auger tube covered by a protective shield. This shield often is removed by the user, thereby exposing the power take-off to extremities and loose clothing. When a worker straddles this device his pants may catch on the rapidly rotating shaft and be torn from the victim along with the loosely anchored skin of the scrotum and penile shaft. Auger injuries typically are contaminated with grain and may involve crush injuries as well as amputation. The difficulty in reconstruction of scrotal avulsion injuries lies in the fact that the blood supply to the scrotal skin is destroyed when the skin and dartos muscle are avulsed. Occasionally, the avulsed skin has been reapplied to the denuded scrotum but with only variable results. Surgical techniques for repair differ widely. Burying the testes in thigh pouches, raising skin flaps from the thigh and skin grafts to cover the denuded testes are repair methods that have been used successfully. 2 We present a case of avulsion of the scrotum, penile shaft and pubic skin owing to an auger injury, and describe an unreported method of scrotal reconstruction.
FIG. 1.
Scrotal and penile skin avulsion injury
CASE REPORT
M. M., a 32-year-old man, presented on October 7, 1981 immediately after sustaining an injury to the scrotum and penis from a grain auger. His pants had been torn away, and the scrotum and penile shaft skin were included (fig. 1). Blood loss initially was profuse but this was controlled with direct pressure. The avulsed scrotal skin had been placed on ice shortly after the accident. In the operating room the wound was debrided and evaluation revealed that the scrotum had been avulsed completely. Numerous grain seeds were removed and after thorough irrigation of the wound the intact testes were placed in pouches beneath the subcutaneous fat of each thigh. These tissue planes were natural pockets created by the avulsion injury. Superficial thigh pouches were not developed initially because of the high risk of infection in the contaminated wound. A split thickness skin graft from the lateral thigh was used to resurface the denuded penile shaft, while a portion of the salvaged scrotal skin that had been avulsed was replanted as a full thickness graft to repair the penile base and avulsed pubic tissue (fig. 2, A). The perinea! laceration was closed vertically from the anal verge to the ventral base of the penile shaft. The incision was drained with a posteriorly placed Penrose drain. A foam bolster was secured over the skin grafts and a 14F Foley catheter was left indwelling while the bolster remained in place on the penile shaft (fig. 2, B). The grafts and wound remained free of infection, and 1 month later minor skin graft revisions were performed. On November 30 the testes were placed in more superficial thigh
FIG. 2. A, skin grafts on penile shaft and testes buried in thigh pouches. B, foam bolster dressing in place.
pouches to attain a more ambient temperature for spermatogenesis.3-4 A 250 cc capacity soft tissue expander* was inserted in the perineum (fig. 3, A). The filling port was placed in the right inguinal area and 50 cc saline were injected into the device initially (fig. 3, B). Beginning 1 week later the device was expanded further in 30 to 40 cc increments gradually over a period of 6 weeks until the expander was filled to capacity. It was left in position for 2 additional weeks to allow the weight of the device to create further skin expansion. The silicone skin expander and filling port were removed on
* Radovan, Heyer-Schulte Corp., 600 Pine Ave., Goleta, California 93017.
Accepted for publication October 29, 1984. 681
682
REID AND WRIGHT
FIG. 3. A, subcutaneous soft tissue expansion device. B, expansion device in place in perineum being expanded with saline through filling port in right inguinal area.
DISCUSSION
Traditionally, scrotal reconstruction has involved the use of thigh pouches and pedicle flaps. 5 Satisfactory results have been published using skin grafts to cover the denuded scrotum. 6 The tissue flap and skin graft methods of scrotal reconstruction often involve multiple stages, and the results are not always cosmetically acceptable. 7 Plastic surgeons are familiar with the soft tissue expanders used primarily for breast and other soft tissue reconstruction. Our application of this device in the perineum was quite successful and was performed relatively easily. The repair of the injury and the reconstruction required fewer surgical procedures than previous methods of scrotal reconstruction with less local scarring and a more aesthetic result. There was no noticeable urethral compression from the expansion device. This new method of repair of scrotal avulsion using expansion of residual perinea! skin should be considered in scrotal reconstruction and all complex genital injuries involving soft tissue loss.
REFERENCES 1. Beatty, M. E., Zook, E.G., Russell, R. C. and Kinkead, L. R.: Grain
2. 3. FIG. 4. Final result after expansion device was removed and testes were placed in neoscrotum.
June 23, 1982, and the testes were dissected from the thigh pouches and were sutured into the neoscrotum. The wound had healed 2 months postoperatively (fig. 4) and sexual function was reported as normal. A semen analysis shortly after the final surgical procedure showed only occasional sperm. Future sperm analysis will be performed.
4. 5. 6. 7.
auger injuries: the replacement of the corn picker injury? Plast. Reconstr. Surg., 69: 96, 1982. Arneri, V.: Reconstruction of the male genitalia. In: Reconstructive and Plastic Surgery, 2nd ed., vol. 7, p. 3902, 1977. Culp, D. A. and Huffman, W. C.: Temperature determination in the thigh with regard to burying the traumatically exposed testis. J. Urol., 76: 436, 1956. Huffman, W. C., Culp, D. A., Greenleaf, J. S., Flocks, R. H. and Brintnall, E. S.: Injuries to the male genitalia. Plast. Reconstr. Surg., 18: 344, 1956. Mandel, M. A.: "Hiawatha" scrotal reconstruction. Ann. Plast. Surg., 4: 238, 1980. Balakrishnan, C.: Scrotal avulsion: a new technique of reconstruction by split-skin graft. Brit. J. Plast. Surg., 9: 38, 1956. Tiwari, I. N., Seth, H. P. and Mehdiratta, K. S.: Reconstruction of the scrotum by thigh flaps. Plast. Reconstr. Surg., 66: 605, 1980.