- Email: [email protected]
A new technique for reconstruction of the avulsed scrotum: the ‘3D- prefabricated omental flap’
410 vaginal fistula, occult bleeding, and the risk of infection. Then, a sterile vaginal stent can be replaced and a new tieover dressing can be performed, not on the skin but using the buttonhole of the ring stitches, avoiding possible stent loss and, consequently, inadequate dilatation (Figure 2). The above-described technique allowed regular dressing changes and safe vaginal stent management; it did not endanger flap viability by any compressive dressing. Also, it avoided discomfort for the patients, securing the vaginal stent not directly to the skin but to the skin-buttonhole ring stitches, thereby avoiding painful pinpricks to the patient. On the basis of our experience, we recommend the use of this simple technique for vaginal stent management in male-to-female transsexuals.
References 1. van Noort DE, Nicolai JP. Comparison of two methods of vagina construction in transsexuals. Plast Reconstr Surg 1993;91:1308e19. 2. Eldh J. Construction of a neovagina with preservation of the glans penis as a clitoris in male transsexuals. Plast Reconstr Surg 1993;91:895e907. 3. Farace F, Fois VE, Bozzo C, et al. Pedicled or free flap reconstruction of the oral cavity and tracheostomy tube management: the ring stitches. Plast Reconstr Surg 2003;15:1773e4.
L.A. Dessy M. Mazzocchi E.M. Buccheri A. Figus Department of Plastic and Reconstructive Surgery, University ‘La Sapienza’ Rome, Viale del Policlinico 155, 00161, Rome, Italy E-mail address: [email protected] ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.11.073
A new technique for reconstruction of the avulsed scrotum: the ‘3D- prefabricated omental flap’*
Correspondence and communications The omentum is used for the reconstruction of many defects because of its high vascularity and immunological properties. Additionally it has a thin, pliable texture. The omentum has two different blood supplies: the right and left gastroepiploic artery. Each of these can be used for flap creation. In this article we describe a scrotum reconstruction with a prefabricated omental flap.
Operative details A 38-year-old man sustained a skin defect to his external genital area and right medial thigh. The avulsion injury occurred in a traffic accident. Skin and dartos layers of his scrotum were avulsed by a truck’s wheel (Figure 1a). Testes, vas deferens and penile corpus were intact. The abdomen was opened. The omentum was mobilised to within 3 cm of the gastric pylorus, at which point a standard flap elevation was completed. For lengthening of the flap pedicle, the vascular arch between the two pedicles of the greater omentum was ligated and divided at the middle portion. A lengthened omental flap was prepared with right gastroepiploic vessels. A tunnel was created from the inferior peritoneal cavity to the right inguinal area. The elongated omental flap was passed through the tunnel (Figure 1b). To create a three-dimensional scrotum from the omental flap a Jackson-Pratt drain container was used. The omentum was wrapped around the bulb of the drain (400 cc) (Figure 1c), and the flap’s surface was covered with split-thickness skin grafts (Figure 1d). The testes were temporarily buried into the subcutaneous space in the inguinal region. Prefabrication (first stage) of the scrotum was finished with proper dressing. Twelve days later, the bulb of the drain was removed from the distal part of the new reconstructed scrotum. The testes were relocated into the new reconstructed scrotum and were fixed to its inner surface (Figure 1e). The patient has been followed up for more than 12 months. He has not complained of any problem with the appearance of the scrotum or his sexual function (Figure 2). Semen analysis of the patient for evaluation of spermatogenesis was performed. It was reported as fertile. However, at the 6 month follow-up examination an incisional hernia was diagnosed. Fascia detachment was repaired with a prolene mesh.
Discussion The main function of the scrotum is the preservation of the testes outside the body in an environment where the temperature is lower than body temperature. The scrotum is also important for male body image. Although various reconstructive methods have been described for the treatment of scrotal defects (e.g. skin grafting,1 musculocutaneous flaps2) each technique has its own advantages and disadvantages in specific situations.
*
This study was presented at the 29th Annual National Meeting of the Turkish Plastic Reconstructive and Aesthetic Surgery Society on 17e20 October 2007 in Eskisehir, Turkey.
Surgeons dealing with scrotal reconstruction should remember that the testes must be maintained at a temperature as close as possible to the temperature of their original location.3 When the deficiency is partial, scrotal reconstruction can be achieved with many different methods. Primary repair is preferred because of the scrotum’s expansile nature. Split-thickness skin grafting and/or implantation of the testes subcutaneously in the upper thigh have been used in the past for entire or large defects. These methods are relatively easy and the complication rate is less than with other methods. However skin grafts are neither durable nor cosmetically acceptable. Also, implantation of the testes is
Correspondence and communications
411
Figure 1 (a) Preoperative view of the patient. (b) Passing the omentum from the tunnel. (c) Coverage of the reservoir of the Jackson-Pratt drain with omental flap. (d) Posterior view of the grafted omental flap. (e) Placement of the testes into the scrotal flap. LT: left testicle RT: Right testicle.
Figure 2
The view of the reconstructed scrotum after 12 months. (a) Right side. (b) Left side.
412
Correspondence and communications
not an optimal method of reconstruction because it does not restore function and is not aesthetically acceptable. In addition, fasciocutaneous flaps are not thin enough for scrotum reconstruction. The first articles about a prefabricated omental flap were reported by Erol and Spira.4 The omentum has many perfect features (rich vascular network, thin and pliable tissue) for a successful reconstruction. The most advantageous characteristic of the omentum is its mouldable and wide structure. The omentum’s thin structure also has a similar appearance to the scrotum (it is pliable; allows natural testis drooping; thin, but secure for testes). Also prefabrication with the drain bulb supplies a three-dimensional shape of the scrotum. A disadvantage of the method is related to the omentum harvesting. Intra-abdominal infection, intra-abdominal adhesions and incisional hernias may occur. Our patient did suffer with incisional hernias. However, if a commensurable intra-abdominal operation is necessary, the use of the omentum is preferable. The omentum was used to cover over defects of the urethra, scrotum and abdominal wall in a patient with Fournier’s gangrene by Kamei et al.,5 the main differences from our study being prefabrication and the three-dimensional structure of the flap. We consider that the most favourable features for the use of the omentum are that it is soft and pliable and the reconstructed scrotum looks as close as possible to the original. In conclusion, we feel that the method described above is a suitable alternative for total scrotum reconstructions. Additionally, if a commensurable intra-abdominal operation is necessary, the use of the omentum is preferable.
References 1. Vincent MP, Horton CE, Devine Jr CJ. An evaluation of skin grafts for reconstruction of the penis and scrotum. Clin Plast Surg 1988;15:411e24. 2. Kayikcioglu A. A new technique in scrotal reconstruction: short gracilis flap. Urology 2003;61:1254e6. 3. Gencosmanoglu R, Bilkay U, Alper M, et al. Late results of split-grafted penoscrotal avulsion injuries. J Trauma 1995;39: 1201e3. 4. Erol O, Spira M. Omentum island skin graft flap. Surg Forum 1978;29:594e6. 5. Kamei Y, Aoyama H, Yokoo K, et al. Composite gastric seromuscular and omental pedicle flap for urethral and scrotal reconstruction after Fournier’s gangrene. Ann Plast Surg 1994; 33:565e8.
Tonguc ¸ Isxken Sahin Alagoz Cigdem Unal Murat Onyedi Department of Plastic and Reconstructive Surgery, Kocaeli University Faculty of Medicine, Kocaeli, Turkey E-mail address: [email protected] Zafer Utkan Department of General Surgery, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
Ozdal Dillioglugil Department of Urology, Kocaeli University Faculty of Medicine, Kocaeli, Turkey ª 2008 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. doi:10.1016/j.bjps.2008.04.065
Reconstruction of a perianal defect by means of a bilateral V-Y advancement flap based on the perforating arteries of the gluteus maximus shaped over a cicatricial area Many surgical alternatives have been proposed for perineal reconstruction, including local, muscle and fasciocutaneous skin flaps,1e3 although the presence of scars or the characteristics of the defect reduce the possibilities of choice. Here, we describe the use of the V-Y advancement flap based on the gluteal region, lifted bilaterally for the reconstruction of a perianal defect associated with scars in the gluteal region.
Case report The patient was a 61-year-old man who was operated in June 2006 for a severe hidradenitis suppurativa that affected his perianal region and the right gluteal region down to the muscle fascia. He underwent complete resection of all the skin and subcutaneous cellular tissue affected. Closure was achieved by secondary intention. The patient’s evolution was satisfactory, no relapse of the hidradenitis suppurativa being detected in subsequent check ups. However, the perianal cicatrisation developed into a progressive and severe anal stenosis (Figure 1a). Owing to this complication, 10 months after the first procedure the patient was subjected to a broad resection of the fibrosis responsible for the anal stenosis (Figure 1b). Reconstruction was performed by lifting two large V-Y advancement flaps based on the perforating arteries of the gluteus maximus muscle. The design of the flap on the right gluteal region included a scar, the sequel to the initial resection, which affected 4/5 of the length of the flap (Figure 2a). Lifting the flaps included incision of the muscle fascia of the gluteus maximus. Flap advancement was achieved in the standard way, except in the top part where the flaps were partially crossed. The patient’s evolution was satisfactory, the flaps developing adequate vascularisation and scarring. The patient was discharged 1 week after the procedure. In a check up carried out at 12 months, the result was seen to be satisfactory and the hidradenitis suppurativa had not relapsed (Figure 2b).
Discussion Hidradenitis suppurativa is a chronic and recurring inflammatory disease, the perineum being one of the areas most
References 1. van Noort DE, Nicolai JP. Comparison of two methods of vagina construction in transsexuals. Plast Reconstr Surg 1993;91:1308e19. 2. Eldh J. Construction of a neovagina with preservation of the glans penis as a clitoris in male transsexuals. Plast Reconstr Surg 1993;91:895e907. 3. Farace F, Fois VE, Bozzo C, et al. Pedicled or free flap reconstruction of the oral cavity and tracheostomy tube management: the ring stitches. Plast Reconstr Surg 2003;15:1773e4.
L.A. Dessy M. Mazzocchi E.M. Buccheri A. Figus Department of Plastic and Reconstructive Surgery, University ‘La Sapienza’ Rome, Viale del Policlinico 155, 00161, Rome, Italy E-mail address: [email protected] ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.11.073
A new technique for reconstruction of the avulsed scrotum: the ‘3D- prefabricated omental flap’*
Correspondence and communications The omentum is used for the reconstruction of many defects because of its high vascularity and immunological properties. Additionally it has a thin, pliable texture. The omentum has two different blood supplies: the right and left gastroepiploic artery. Each of these can be used for flap creation. In this article we describe a scrotum reconstruction with a prefabricated omental flap.
Operative details A 38-year-old man sustained a skin defect to his external genital area and right medial thigh. The avulsion injury occurred in a traffic accident. Skin and dartos layers of his scrotum were avulsed by a truck’s wheel (Figure 1a). Testes, vas deferens and penile corpus were intact. The abdomen was opened. The omentum was mobilised to within 3 cm of the gastric pylorus, at which point a standard flap elevation was completed. For lengthening of the flap pedicle, the vascular arch between the two pedicles of the greater omentum was ligated and divided at the middle portion. A lengthened omental flap was prepared with right gastroepiploic vessels. A tunnel was created from the inferior peritoneal cavity to the right inguinal area. The elongated omental flap was passed through the tunnel (Figure 1b). To create a three-dimensional scrotum from the omental flap a Jackson-Pratt drain container was used. The omentum was wrapped around the bulb of the drain (400 cc) (Figure 1c), and the flap’s surface was covered with split-thickness skin grafts (Figure 1d). The testes were temporarily buried into the subcutaneous space in the inguinal region. Prefabrication (first stage) of the scrotum was finished with proper dressing. Twelve days later, the bulb of the drain was removed from the distal part of the new reconstructed scrotum. The testes were relocated into the new reconstructed scrotum and were fixed to its inner surface (Figure 1e). The patient has been followed up for more than 12 months. He has not complained of any problem with the appearance of the scrotum or his sexual function (Figure 2). Semen analysis of the patient for evaluation of spermatogenesis was performed. It was reported as fertile. However, at the 6 month follow-up examination an incisional hernia was diagnosed. Fascia detachment was repaired with a prolene mesh.
Discussion The main function of the scrotum is the preservation of the testes outside the body in an environment where the temperature is lower than body temperature. The scrotum is also important for male body image. Although various reconstructive methods have been described for the treatment of scrotal defects (e.g. skin grafting,1 musculocutaneous flaps2) each technique has its own advantages and disadvantages in specific situations.
*
This study was presented at the 29th Annual National Meeting of the Turkish Plastic Reconstructive and Aesthetic Surgery Society on 17e20 October 2007 in Eskisehir, Turkey.
Surgeons dealing with scrotal reconstruction should remember that the testes must be maintained at a temperature as close as possible to the temperature of their original location.3 When the deficiency is partial, scrotal reconstruction can be achieved with many different methods. Primary repair is preferred because of the scrotum’s expansile nature. Split-thickness skin grafting and/or implantation of the testes subcutaneously in the upper thigh have been used in the past for entire or large defects. These methods are relatively easy and the complication rate is less than with other methods. However skin grafts are neither durable nor cosmetically acceptable. Also, implantation of the testes is
Correspondence and communications
411
Figure 1 (a) Preoperative view of the patient. (b) Passing the omentum from the tunnel. (c) Coverage of the reservoir of the Jackson-Pratt drain with omental flap. (d) Posterior view of the grafted omental flap. (e) Placement of the testes into the scrotal flap. LT: left testicle RT: Right testicle.
Figure 2
The view of the reconstructed scrotum after 12 months. (a) Right side. (b) Left side.
412
Correspondence and communications
not an optimal method of reconstruction because it does not restore function and is not aesthetically acceptable. In addition, fasciocutaneous flaps are not thin enough for scrotum reconstruction. The first articles about a prefabricated omental flap were reported by Erol and Spira.4 The omentum has many perfect features (rich vascular network, thin and pliable tissue) for a successful reconstruction. The most advantageous characteristic of the omentum is its mouldable and wide structure. The omentum’s thin structure also has a similar appearance to the scrotum (it is pliable; allows natural testis drooping; thin, but secure for testes). Also prefabrication with the drain bulb supplies a three-dimensional shape of the scrotum. A disadvantage of the method is related to the omentum harvesting. Intra-abdominal infection, intra-abdominal adhesions and incisional hernias may occur. Our patient did suffer with incisional hernias. However, if a commensurable intra-abdominal operation is necessary, the use of the omentum is preferable. The omentum was used to cover over defects of the urethra, scrotum and abdominal wall in a patient with Fournier’s gangrene by Kamei et al.,5 the main differences from our study being prefabrication and the three-dimensional structure of the flap. We consider that the most favourable features for the use of the omentum are that it is soft and pliable and the reconstructed scrotum looks as close as possible to the original. In conclusion, we feel that the method described above is a suitable alternative for total scrotum reconstructions. Additionally, if a commensurable intra-abdominal operation is necessary, the use of the omentum is preferable.
References 1. Vincent MP, Horton CE, Devine Jr CJ. An evaluation of skin grafts for reconstruction of the penis and scrotum. Clin Plast Surg 1988;15:411e24. 2. Kayikcioglu A. A new technique in scrotal reconstruction: short gracilis flap. Urology 2003;61:1254e6. 3. Gencosmanoglu R, Bilkay U, Alper M, et al. Late results of split-grafted penoscrotal avulsion injuries. J Trauma 1995;39: 1201e3. 4. Erol O, Spira M. Omentum island skin graft flap. Surg Forum 1978;29:594e6. 5. Kamei Y, Aoyama H, Yokoo K, et al. Composite gastric seromuscular and omental pedicle flap for urethral and scrotal reconstruction after Fournier’s gangrene. Ann Plast Surg 1994; 33:565e8.
Tonguc ¸ Isxken Sahin Alagoz Cigdem Unal Murat Onyedi Department of Plastic and Reconstructive Surgery, Kocaeli University Faculty of Medicine, Kocaeli, Turkey E-mail address: [email protected] Zafer Utkan Department of General Surgery, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
Ozdal Dillioglugil Department of Urology, Kocaeli University Faculty of Medicine, Kocaeli, Turkey ª 2008 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. doi:10.1016/j.bjps.2008.04.065
Reconstruction of a perianal defect by means of a bilateral V-Y advancement flap based on the perforating arteries of the gluteus maximus shaped over a cicatricial area Many surgical alternatives have been proposed for perineal reconstruction, including local, muscle and fasciocutaneous skin flaps,1e3 although the presence of scars or the characteristics of the defect reduce the possibilities of choice. Here, we describe the use of the V-Y advancement flap based on the gluteal region, lifted bilaterally for the reconstruction of a perianal defect associated with scars in the gluteal region.
Case report The patient was a 61-year-old man who was operated in June 2006 for a severe hidradenitis suppurativa that affected his perianal region and the right gluteal region down to the muscle fascia. He underwent complete resection of all the skin and subcutaneous cellular tissue affected. Closure was achieved by secondary intention. The patient’s evolution was satisfactory, no relapse of the hidradenitis suppurativa being detected in subsequent check ups. However, the perianal cicatrisation developed into a progressive and severe anal stenosis (Figure 1a). Owing to this complication, 10 months after the first procedure the patient was subjected to a broad resection of the fibrosis responsible for the anal stenosis (Figure 1b). Reconstruction was performed by lifting two large V-Y advancement flaps based on the perforating arteries of the gluteus maximus muscle. The design of the flap on the right gluteal region included a scar, the sequel to the initial resection, which affected 4/5 of the length of the flap (Figure 2a). Lifting the flaps included incision of the muscle fascia of the gluteus maximus. Flap advancement was achieved in the standard way, except in the top part where the flaps were partially crossed. The patient’s evolution was satisfactory, the flaps developing adequate vascularisation and scarring. The patient was discharged 1 week after the procedure. In a check up carried out at 12 months, the result was seen to be satisfactory and the hidradenitis suppurativa had not relapsed (Figure 2b).
Discussion Hidradenitis suppurativa is a chronic and recurring inflammatory disease, the perineum being one of the areas most