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Application of vacuum-assisted closure dressing in penile skin graft reconstruction
SURGICAL TECHNIQUES IN UROLOGY
APPLICATION OF VACUUM-ASSISTED CLOSURE DRESSING IN PENILE SKIN GRAFT RECONSTRUCTION ALEX SENCHENKOV, JAMES KNOETGEN, KRISTIN L. CHROUSER,
AND
AJAY NEHRA
ABSTRACT Introduction. Skin grafting of penile defects is difficult because of the flexibility of the underlying recipient bed. This leads to disruption of the vascular ingrowth into the skin graft and compromises the results of the reconstruction. Technical Considerations. We successfully used a vacuum-assisted closure dressing with an incorporated wooden framework to secure penile skin grafts in place during the early postoperative period. Conclusions. A vacuum-assisted closure dressing can be used successfully to secure large and circumferential skin grafts, as well as skin grafts on concealed penises. UROLOGY 67: 416–419, 2006. © 2006 Elsevier Inc.
S
kin defects of the penile shaft pose a significant reconstructive problem. For years, the splitthickness skin graft (STSG) has been the mainstay of penile reconstruction. However, application of large and circumferential skin grafts and skin grafts on concealed penises in obese individuals has been technically difficult with the use of conventional bolsters for many surgeons. The main reason for failure has been graft shearing and fluid accumulation under the graft. To alleviate these problems, we have successfully used a modified vacuumassisted closure (VAC) technique. The following cases are provided for illustration. CASE 1 An otherwise healthy, 31-year-old man underwent injection of a silicon-like material into his penile shaft for augmentation purposes, as well as subcutaneous insertion of two metal balls into his coronal margin. A non-physician had performed these procedures 5 months before the referral. They were complicated by draining sinuses and infection with systemic symptoms of fever and malaise. The urethra was unaffected, and magnetic From the Departments of Plastic and Reconstructive Surgery and Urology, Mayo Clinic, Rochester, Minnesota Reprint requests: Alex Senchenkov, M.D., Department of Plastic and Reconstructive Surgery, Mayo Clinic, Mayo Building W1244, 200 First Street Southwest, Rochester, MN 55905. E-mail: [email protected] Submitted: May 5, 2005, accepted (with revisions): August 15, 2005 © 2006 ELSEVIER INC. 416
ALL RIGHTS RESERVED
resonance imaging of the region revealed the process was localized above Buck’s fascia, sparing the corpora. All conservative treatment failed, and the patient finally required full-thickness debridement of the skin of his entire shaft, as well as an approximately 1-in. radius of skin of his pubic area and upper scrotum (Fig. 1A). Local tissues were rearranged to close the skin loss of the pubic and scrotal areas. The prepubic and scrotal skin was anchored to the base of the penis with monofilament absorbable sutures. A thick (0.020-in.) STSG was harvested from the lateral thigh. It was mashed 1:1.5, oriented transversely, and draped loosely around the penile shaft with the penis on stretch to minimize contraction and preserve erectile function. The skin graft was sutured in place with 5-0 plain gut suture. To secure the skin graft in place, a framework was constructed from wooden tongue blades. The VAC GranuFoam Large Dressing (KCI USA, San Antonio, Tex, Catalog No. M6275003/5) was cut in half to match the size. Tunnels were made in the sponges with straight scissors, and the framework was placed through these tunnels into the sponge (Fig. 1B). The stretched penis was covered with Xeroform gauze and “sandwiched” between the two pieces of the prefabricated re-enforced sponge (Fig. 1C). The VAC ATS System (KCI USA) therapy unit was used with 75-mm Hg negative pressure in the continuous mode. This allowed us to secure the skin graft in place and maintained complete immobility (Fig. 1D). The patient was kept for 5 days on strict bed rest. 0090-4295/06/$32.00 doi:10.1016/j.urology.2005.08.037
FIGURE 1. Penile skin loss occurred secondary to injection of silicon-like material. (A) Intraoperative view of acquired full-thickness defect after debridement of skin of penile shaft, pubic region, and scrotum. (B) Schematic drawing of VAC dressing with incorporated wooden framework. Framework placed through tunnels in VAC sponges. Care was taken to avoid direct pressure of framework on pubic and groin skin by placing tongue blades in T shape. (C) Application of VAC dressing. Ends of tongue blades marked with arrows. (D) Appearance of dressing on second postoperative day with continuous 75-mm Hg suction and Foley catheter in place.
On the fifth postoperative day, the VAC dressing and Foley catheter were removed, and a dressing of Xeroform was applied and the patient was discharged home. At 8 weeks postoperatively, the graft take was complete, and the patient had no difficulty with urination and resumed his sexual activity (Fig. 2). CASE 2 A 59-year-old obese, circumcised man presented with a slow-growing, hyperkeratotic, itchy penile nodule near the coronal margin. The lesion was nontender, exophytic, and 1 ⫻ 1.5 ⫻ 2 cm in size. Its mass effect was interfering with sexual intercourse. The patient denied difficulties with urination or erection. Because of the obesity, his penis UROLOGY 67 (2), 2006
FIGURE 2. Complete skin graft take with restoration of function at 8 weeks. 417
FIGURE 3. (A) Acquired defect of penis after wide local excision of squamous cell carcinoma of penis with negative margins. (B) Tongue blades inserted into tunnels in small-size VAC sponge. Ends of tongue blades were cut and buried in sponge (dashed lines). (C) VAC dressing in place with continuous negative pressure securing graft in position and preventing retraction of concealed penis. (D) Completely healed skin graft with full restoration of function at 6 weeks.
had a “sucked in,” concealed appearance. Biopsy of the lesion was suggestive of lichenoid dermatitis; however, clinically it was suspicious for malignancy. An excisional biopsy of the lesion was performed. Pathologic examination revealed well-differentiated squamous cell carcinoma that was completely excised. This resulted in a 5-cm ⫻ 6-cm full-thickness defect on the ventral aspect of the penis (Fig. 3A). On confirmation of negative surgical margins with frozen section analysis, thick (0.020-in.) STSG was harvested from the anterolateral aspect of his thigh and mashed 1:1.5. The unexpanded skin graft was secured in place with 5-0 plain gut suture. A VAC GranuFoam Small Dressing sponge (KCI USA, Catalog No. M6275001/5) with incorporated wooden framework was used. Because pressure on the pubic and groin region was not of concern owing to the distal location of the defect, two precut tongue blades were simply inserted (Fig. 3B). The skin graft was secured with the VAC ATS System therapy unit (KCI USA) on the outstretched penis (Fig. 418
3C). Postoperatively, the patient was kept on bedrest with the VAC at 75 mm Hg in continuous mode. After 5 days, the VAC and Foley catheter were removed. The entire skin graft took and had healed satisfactorily at 6 weeks (Fig. 3D). His erectile function was preserved, and he was able to resume sexual activity. COMMENT Skin and soft-tissues defects of the penile region are infrequent, but challenging, problems in reconstructive surgery. They most commonly are the result of necrotizing soft-tissue infection, trauma, burns, malignancy, and lymphedema excision. Because of the paucity of local tissue, graft reconstruction is required in many cases. Skin grafting is the most common method of penile reconstruction.1,2 Although full-thickness skin grafts are widely used in urethral repair, the STSG is preferred for the resurfacing of the penile shaft because it is not hair-bearing, is easy to harvest, and has a greater chance of UROLOGY 67 (2), 2006
take. Thinner (0.014 to 0.016-in.) STSGs are used in impotent men and thicker (0.016 to 0.018-in.) grafts are preferred in potent men.3 Meshing the STSG has long been known to improve skin graft take by preventing fluid collection between the graft and recipient bed. However, expanded meshed skin grafts are known to have a greater secondary contraction rate, which is not ideal in sexually active patients. Use of meshed, but unexpended, STSGs has been reported to have good success rates and satisfactory cosmetic and functional outcome, allowing preservation of erectile function in potent men.4 Skin defects of the penis constitute a difficult location for skin grafting because of the flexible recipient bed. Obesity represents an additional challenge for successful grafting owing to retraction of the penis under or within the overlying abdominal fat pad.5 Secure apposition between the graft and recipient bed is critical for successful revascularization and take of the skin graft. Early immobilization and stretch of the penis are among the most critical elements in successful penile skin graft reconstruction. Shearing of the skin graft off its recipient bed will lead to disruption of the vascular ingrowth process and, ultimately, to failure of the skin graft. Traditionally, various bolsters, pads, foams, fluffs, multilayer compressive and rigid dressings, penile splints, protective housings, Foley traction devices, and orthopedic pulleys have been used to secure a skin graft in place and protect it, with varying success.2– 4,6 The VAC was introduced and gained popularity for the management of granulating wounds. More recently, the VAC dressing has been applied in skin grafting and has led to improved wound outcomes and a reduction in the need for repeated grafting.7 We successfully used VAC dressings to secure penile skin grafts in place with good results. In contrast to previous experience with VAC dressing of skin grafts in other areas of the body that maintain their shape, penile reconstruction presents a unique challenge for grafting a flaccid, and especially concealed, penis. Application of the VAC dressing in the standard manner can lead to collapse of the donor site and wrinkling of the skin graft and may contribute to failure. To prevent this complication, we have used sterile wooden tongue
UROLOGY 67 (2), 2006
blades, which are readily available in any operating room. The tongue blades were measured to accommodate the length of the penis and size of the skin graft and VAC sponge. Tunnels were made in the VAC sponge to incorporate the wooden framework within it. Care was taken to prevent pressure of the framework on the pubic skin. The skin-grafted penis was wrapped in Xeroform gauze and covered with the VAC sponge containing the framework. The latter prevented collapse of the sponge when continuous negative pressure was applied and also kept the penis stretched for the first 5 postoperative days and prevented graft wrinkling. CONCLUSIONS We recommend the use of unexpanded STSGs for reconstruction of penile skin defects. A VAC dressing with an incorporated wooden framework in continuous mode at 75 mm Hg should be used for the first 5 postoperative days. It provides secure apposition between the skin graft and recipient bed and promotes successful revascularization and take of the graft in this challenging location. ACKNOWLEDGMENT. To Stephen N. Boyd, M.A. and Steven D. Orwoll, M.A. for their assistance in the preparation of the illustrations. REFERENCES 1. Jordan GH: Penile reconstruction, phallic construction, and urethral reconstruction. Urol Clin North Am 26: 1–13, 1999. 2. McAninch JW: Management of genital skin loss. Urol Clin North Am 16: 387–397, 1989. 3. Morey AF, and McAninch JW: Genital skin loss and scrotal reconstruction, in Ehrlich RM and Alter GJ (Eds): Reconstructive and Plastic Surgery of the External Genitalia: Adult and Pediatric. Philadelphia, WB Saunders, 1999, vol 1, pp 414 – 422. 4. Black PC, Friedrich JB, Engrav LH, et al: Meshed unexpanded split-thickness skin grafting for reconstruction of penile skin loss. J Urol 172: 976 –979, 2004. 5. Ehrlich RM, and Alter GJ: Buried penis, in Ehrlich RM and Alter GJ (Eds): Reconstructive and Plastic Surgery of the External Genitalia: Adult and Pediatric. Philadelphia, WB Saunders, 1999, vol 1, pp 397– 401. 6. Furnas DW, and McCraw JB: Resurfacing the genital area. Clin Plast Surg 7: 235–258, 1980. 7. Scherer LA, Shiver S, Chang M, et al: The vacuum assisted closure device: a method of securing skin grafts and improving graft survival. Arch Surg 137: 930 –934, 2002.
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APPLICATION OF VACUUM-ASSISTED CLOSURE DRESSING IN PENILE SKIN GRAFT RECONSTRUCTION ALEX SENCHENKOV, JAMES KNOETGEN, KRISTIN L. CHROUSER,
AND
AJAY NEHRA
ABSTRACT Introduction. Skin grafting of penile defects is difficult because of the flexibility of the underlying recipient bed. This leads to disruption of the vascular ingrowth into the skin graft and compromises the results of the reconstruction. Technical Considerations. We successfully used a vacuum-assisted closure dressing with an incorporated wooden framework to secure penile skin grafts in place during the early postoperative period. Conclusions. A vacuum-assisted closure dressing can be used successfully to secure large and circumferential skin grafts, as well as skin grafts on concealed penises. UROLOGY 67: 416–419, 2006. © 2006 Elsevier Inc.
S
kin defects of the penile shaft pose a significant reconstructive problem. For years, the splitthickness skin graft (STSG) has been the mainstay of penile reconstruction. However, application of large and circumferential skin grafts and skin grafts on concealed penises in obese individuals has been technically difficult with the use of conventional bolsters for many surgeons. The main reason for failure has been graft shearing and fluid accumulation under the graft. To alleviate these problems, we have successfully used a modified vacuumassisted closure (VAC) technique. The following cases are provided for illustration. CASE 1 An otherwise healthy, 31-year-old man underwent injection of a silicon-like material into his penile shaft for augmentation purposes, as well as subcutaneous insertion of two metal balls into his coronal margin. A non-physician had performed these procedures 5 months before the referral. They were complicated by draining sinuses and infection with systemic symptoms of fever and malaise. The urethra was unaffected, and magnetic From the Departments of Plastic and Reconstructive Surgery and Urology, Mayo Clinic, Rochester, Minnesota Reprint requests: Alex Senchenkov, M.D., Department of Plastic and Reconstructive Surgery, Mayo Clinic, Mayo Building W1244, 200 First Street Southwest, Rochester, MN 55905. E-mail: [email protected] Submitted: May 5, 2005, accepted (with revisions): August 15, 2005 © 2006 ELSEVIER INC. 416
ALL RIGHTS RESERVED
resonance imaging of the region revealed the process was localized above Buck’s fascia, sparing the corpora. All conservative treatment failed, and the patient finally required full-thickness debridement of the skin of his entire shaft, as well as an approximately 1-in. radius of skin of his pubic area and upper scrotum (Fig. 1A). Local tissues were rearranged to close the skin loss of the pubic and scrotal areas. The prepubic and scrotal skin was anchored to the base of the penis with monofilament absorbable sutures. A thick (0.020-in.) STSG was harvested from the lateral thigh. It was mashed 1:1.5, oriented transversely, and draped loosely around the penile shaft with the penis on stretch to minimize contraction and preserve erectile function. The skin graft was sutured in place with 5-0 plain gut suture. To secure the skin graft in place, a framework was constructed from wooden tongue blades. The VAC GranuFoam Large Dressing (KCI USA, San Antonio, Tex, Catalog No. M6275003/5) was cut in half to match the size. Tunnels were made in the sponges with straight scissors, and the framework was placed through these tunnels into the sponge (Fig. 1B). The stretched penis was covered with Xeroform gauze and “sandwiched” between the two pieces of the prefabricated re-enforced sponge (Fig. 1C). The VAC ATS System (KCI USA) therapy unit was used with 75-mm Hg negative pressure in the continuous mode. This allowed us to secure the skin graft in place and maintained complete immobility (Fig. 1D). The patient was kept for 5 days on strict bed rest. 0090-4295/06/$32.00 doi:10.1016/j.urology.2005.08.037
FIGURE 1. Penile skin loss occurred secondary to injection of silicon-like material. (A) Intraoperative view of acquired full-thickness defect after debridement of skin of penile shaft, pubic region, and scrotum. (B) Schematic drawing of VAC dressing with incorporated wooden framework. Framework placed through tunnels in VAC sponges. Care was taken to avoid direct pressure of framework on pubic and groin skin by placing tongue blades in T shape. (C) Application of VAC dressing. Ends of tongue blades marked with arrows. (D) Appearance of dressing on second postoperative day with continuous 75-mm Hg suction and Foley catheter in place.
On the fifth postoperative day, the VAC dressing and Foley catheter were removed, and a dressing of Xeroform was applied and the patient was discharged home. At 8 weeks postoperatively, the graft take was complete, and the patient had no difficulty with urination and resumed his sexual activity (Fig. 2). CASE 2 A 59-year-old obese, circumcised man presented with a slow-growing, hyperkeratotic, itchy penile nodule near the coronal margin. The lesion was nontender, exophytic, and 1 ⫻ 1.5 ⫻ 2 cm in size. Its mass effect was interfering with sexual intercourse. The patient denied difficulties with urination or erection. Because of the obesity, his penis UROLOGY 67 (2), 2006
FIGURE 2. Complete skin graft take with restoration of function at 8 weeks. 417
FIGURE 3. (A) Acquired defect of penis after wide local excision of squamous cell carcinoma of penis with negative margins. (B) Tongue blades inserted into tunnels in small-size VAC sponge. Ends of tongue blades were cut and buried in sponge (dashed lines). (C) VAC dressing in place with continuous negative pressure securing graft in position and preventing retraction of concealed penis. (D) Completely healed skin graft with full restoration of function at 6 weeks.
had a “sucked in,” concealed appearance. Biopsy of the lesion was suggestive of lichenoid dermatitis; however, clinically it was suspicious for malignancy. An excisional biopsy of the lesion was performed. Pathologic examination revealed well-differentiated squamous cell carcinoma that was completely excised. This resulted in a 5-cm ⫻ 6-cm full-thickness defect on the ventral aspect of the penis (Fig. 3A). On confirmation of negative surgical margins with frozen section analysis, thick (0.020-in.) STSG was harvested from the anterolateral aspect of his thigh and mashed 1:1.5. The unexpanded skin graft was secured in place with 5-0 plain gut suture. A VAC GranuFoam Small Dressing sponge (KCI USA, Catalog No. M6275001/5) with incorporated wooden framework was used. Because pressure on the pubic and groin region was not of concern owing to the distal location of the defect, two precut tongue blades were simply inserted (Fig. 3B). The skin graft was secured with the VAC ATS System therapy unit (KCI USA) on the outstretched penis (Fig. 418
3C). Postoperatively, the patient was kept on bedrest with the VAC at 75 mm Hg in continuous mode. After 5 days, the VAC and Foley catheter were removed. The entire skin graft took and had healed satisfactorily at 6 weeks (Fig. 3D). His erectile function was preserved, and he was able to resume sexual activity. COMMENT Skin and soft-tissues defects of the penile region are infrequent, but challenging, problems in reconstructive surgery. They most commonly are the result of necrotizing soft-tissue infection, trauma, burns, malignancy, and lymphedema excision. Because of the paucity of local tissue, graft reconstruction is required in many cases. Skin grafting is the most common method of penile reconstruction.1,2 Although full-thickness skin grafts are widely used in urethral repair, the STSG is preferred for the resurfacing of the penile shaft because it is not hair-bearing, is easy to harvest, and has a greater chance of UROLOGY 67 (2), 2006
take. Thinner (0.014 to 0.016-in.) STSGs are used in impotent men and thicker (0.016 to 0.018-in.) grafts are preferred in potent men.3 Meshing the STSG has long been known to improve skin graft take by preventing fluid collection between the graft and recipient bed. However, expanded meshed skin grafts are known to have a greater secondary contraction rate, which is not ideal in sexually active patients. Use of meshed, but unexpended, STSGs has been reported to have good success rates and satisfactory cosmetic and functional outcome, allowing preservation of erectile function in potent men.4 Skin defects of the penis constitute a difficult location for skin grafting because of the flexible recipient bed. Obesity represents an additional challenge for successful grafting owing to retraction of the penis under or within the overlying abdominal fat pad.5 Secure apposition between the graft and recipient bed is critical for successful revascularization and take of the skin graft. Early immobilization and stretch of the penis are among the most critical elements in successful penile skin graft reconstruction. Shearing of the skin graft off its recipient bed will lead to disruption of the vascular ingrowth process and, ultimately, to failure of the skin graft. Traditionally, various bolsters, pads, foams, fluffs, multilayer compressive and rigid dressings, penile splints, protective housings, Foley traction devices, and orthopedic pulleys have been used to secure a skin graft in place and protect it, with varying success.2– 4,6 The VAC was introduced and gained popularity for the management of granulating wounds. More recently, the VAC dressing has been applied in skin grafting and has led to improved wound outcomes and a reduction in the need for repeated grafting.7 We successfully used VAC dressings to secure penile skin grafts in place with good results. In contrast to previous experience with VAC dressing of skin grafts in other areas of the body that maintain their shape, penile reconstruction presents a unique challenge for grafting a flaccid, and especially concealed, penis. Application of the VAC dressing in the standard manner can lead to collapse of the donor site and wrinkling of the skin graft and may contribute to failure. To prevent this complication, we have used sterile wooden tongue
UROLOGY 67 (2), 2006
blades, which are readily available in any operating room. The tongue blades were measured to accommodate the length of the penis and size of the skin graft and VAC sponge. Tunnels were made in the VAC sponge to incorporate the wooden framework within it. Care was taken to prevent pressure of the framework on the pubic skin. The skin-grafted penis was wrapped in Xeroform gauze and covered with the VAC sponge containing the framework. The latter prevented collapse of the sponge when continuous negative pressure was applied and also kept the penis stretched for the first 5 postoperative days and prevented graft wrinkling. CONCLUSIONS We recommend the use of unexpanded STSGs for reconstruction of penile skin defects. A VAC dressing with an incorporated wooden framework in continuous mode at 75 mm Hg should be used for the first 5 postoperative days. It provides secure apposition between the skin graft and recipient bed and promotes successful revascularization and take of the graft in this challenging location. ACKNOWLEDGMENT. To Stephen N. Boyd, M.A. and Steven D. Orwoll, M.A. for their assistance in the preparation of the illustrations. REFERENCES 1. Jordan GH: Penile reconstruction, phallic construction, and urethral reconstruction. Urol Clin North Am 26: 1–13, 1999. 2. McAninch JW: Management of genital skin loss. Urol Clin North Am 16: 387–397, 1989. 3. Morey AF, and McAninch JW: Genital skin loss and scrotal reconstruction, in Ehrlich RM and Alter GJ (Eds): Reconstructive and Plastic Surgery of the External Genitalia: Adult and Pediatric. Philadelphia, WB Saunders, 1999, vol 1, pp 414 – 422. 4. Black PC, Friedrich JB, Engrav LH, et al: Meshed unexpanded split-thickness skin grafting for reconstruction of penile skin loss. J Urol 172: 976 –979, 2004. 5. Ehrlich RM, and Alter GJ: Buried penis, in Ehrlich RM and Alter GJ (Eds): Reconstructive and Plastic Surgery of the External Genitalia: Adult and Pediatric. Philadelphia, WB Saunders, 1999, vol 1, pp 397– 401. 6. Furnas DW, and McCraw JB: Resurfacing the genital area. Clin Plast Surg 7: 235–258, 1980. 7. Scherer LA, Shiver S, Chang M, et al: The vacuum assisted closure device: a method of securing skin grafts and improving graft survival. Arch Surg 137: 930 –934, 2002.
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