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Scrotal reconstruction with a rectus abdominis muscle flap
British Journalof Plastic Surgery (1988), 41, 19C-193
0 1988 The Trustees of British Association of Plastic Surgeons
Case report Scrotal reconstruction flap
with a rectus abdominis muscle
W. A. YOUNG and J. K. WRIGHT Department of Plastic Surgery, Wilford Hall US Air Force Medical Centre, Texas, USA
Summary-The rectus abdominis muscle flap provides excellent coverage of major scrotal defects. It is a simple, reliable, one-stage procedure which covers the exposed testes and gives a satisfactory aesthetic result and is an ideal choice for covering the contaminated wound.
A major scrotal defect with exposed testes is a difficult problem for the reconstructive surgeon. The bacterial flora of the perineum, difficulty in immobilisation and the contour of the testes make aesthetic scrotal reconstruction with testicular
coverage difficult. This report presents a case of scrotal reconstruction with a rectus abdominis muscle flap following near-total scrotal skin loss secondary to Fournier’s gangrene. Alternative forms of reconstruction are briefly discussed.
Fig. 1 Figure
l--Scrotal
defect after debridement,
antibiotics
and local wound care.
190
CASE REPORT:
SCROTAL RECONSTRUCTION
WITH A RECTUS ABDOMINIS
MUSCLE FLAP
191
and the patient was discharged on the 21st postoperative day.
Discussion Major scrotal skin loss with exposed testes presents a difficult wound closure problem, especially if one attempts an aesthetically acceptable result. A simple, reliable, one-stage procedure is preferred. If the detached scrotal skin is in otherwise good condition, it can be debrided and replaced as a full thickness skin graft (Gibson, 1954). Where the detached skin is not available, other techniques have been described, including split thickness skin grafts (Schneider et al, 1986), local thigh pouches or local skin flaps (Millard, 1966), muscle flaps and omental flaps (Bostwick et al, 1979). The scrotal defect, at the time of closure, may very likely be contaminated with more than 100,000 bacteria per gram of tissue. Experimental and
Figure vated.
?-Inferiorly-based
rectus
abdominis
muscle
flap ele-
Case report A 64-year old white male presented with necrotising fasciitis of the scrotum. The patient had a 100 pack-year smoking history and insulin-dependent diabetes mellitus. Debridement involved nearly the entire scrotum, leaving only a 5 x 2 cm strip of scrotal skin on the left side. Following a 14 day course of intravenous antibiotics and a 10 day course of hyperbaric oxygen therapy, granulation tissue covered the wound base and the tunica vaginalis of both exposed testes (Fig. 1). The wound was debrided and an inferiorly based right rectus abdominis muscle flap was elevated, measuring 30 x IO cm (Fig. 2). The muscle was tunnelled under the skin of the pubis into the scrotal defect and secured to the edges of the defect over closed suction drains (Fig. 3). A split thickness skin graft was sutured to the rectus muscle. The postoperative course was uneventful (Fig. 4)
192
BRITISH JOURNAL
OF PLASTIC SURGERY
Fig. 4 Figure 4-View
of reconstructed
scrotum
one month post-operatively.
clinical observations indicate that a muscle flap achieves coverage of a heavily contaminated recipient bed more reliably than random cutaneous flaps (Calderon et al, 1986). For this reason a muscle flap may be a better choice for reconstruction in the contaminated perineum, especially in patients with impaired ability to deal with infection, such as the diabetic presented here. Use of the rectus abdominis muscle flap to close groin and perineal wounds has been previously detailed (Mathes and Bostwick, 1977). Its use in total scrotal reconstruction has not been described, but the muscle appears to be an ideal choice. The blood supply is constant and reliable and the wide, flat shape and proximity to the scrotum make it easy to inset. It gives an aesthetically acceptable result with minimal donor site morbidity. Other local muscle flaps, such as internal oblique, tensor fasciae latae and gracilis, may have inadequate
The rectus abdominis
muscle was covered
by a skin graft
muscle mass or pedicle length, precluding their use for scrotal reconstruction. References b&wick, J. 3rd, Hi, H. L. and Nahai, F. (1979). Repairs in the lower abdomen, groin, or perineum with myocutaneous or omental flaps. Plastic and Reconstructive Surgery, 63, 186. CaIderon, W., Chang, N. and Math% S. J. (1986). Comparison of the effect of bacterial inoculation in musculocutaneous flaps. Plastic and Reconstructive Surgery, 71,785. Gibson, T. (1954). Traumatic avulsion of the skin of the scrotum and penis: Use of the avulsed skin as a free graft. British Journal ofplastic Surgery, 6,283. Mathea. S. J. and Rostwick, J. (1977). A rectus abdominis myocutaneous flap to reconstruct abdominal wall defects. British Journalof Plastic Surgery, 30,282. Miiard,D. R. Jr. (1966). Scrotalconstructionand reconstruction. Plastic and Reconstructive Surgery, 38,lO. Schneider, P. R., Russ&, R. C. and Zook, E. G. (1986). Fournier’s gangrene of the penis: A report of two cases. Annals of Plastic Surgery, II, 87.
CASE REPORT:
SCROTAL RECONSTRUCTION
WITH A RECTUS ABDOMINIS
MUSCLE FLAP
The Authors William A. Young, Major, USAF, MC, Resident James K. Wright, LtCol, USAF, MC, Chief
Requests
for reprints
to LtCol. J. K. Wright
Department of Plastic Surgery, Wilford Hall US Air Force Medical Center, Lackiand Air Force Base, Texas 78236, USA.
Paper received 25 March Accepted 4 May 1987.
1987.
193
0 1988 The Trustees of British Association of Plastic Surgeons
Case report Scrotal reconstruction flap
with a rectus abdominis muscle
W. A. YOUNG and J. K. WRIGHT Department of Plastic Surgery, Wilford Hall US Air Force Medical Centre, Texas, USA
Summary-The rectus abdominis muscle flap provides excellent coverage of major scrotal defects. It is a simple, reliable, one-stage procedure which covers the exposed testes and gives a satisfactory aesthetic result and is an ideal choice for covering the contaminated wound.
A major scrotal defect with exposed testes is a difficult problem for the reconstructive surgeon. The bacterial flora of the perineum, difficulty in immobilisation and the contour of the testes make aesthetic scrotal reconstruction with testicular
coverage difficult. This report presents a case of scrotal reconstruction with a rectus abdominis muscle flap following near-total scrotal skin loss secondary to Fournier’s gangrene. Alternative forms of reconstruction are briefly discussed.
Fig. 1 Figure
l--Scrotal
defect after debridement,
antibiotics
and local wound care.
190
CASE REPORT:
SCROTAL RECONSTRUCTION
WITH A RECTUS ABDOMINIS
MUSCLE FLAP
191
and the patient was discharged on the 21st postoperative day.
Discussion Major scrotal skin loss with exposed testes presents a difficult wound closure problem, especially if one attempts an aesthetically acceptable result. A simple, reliable, one-stage procedure is preferred. If the detached scrotal skin is in otherwise good condition, it can be debrided and replaced as a full thickness skin graft (Gibson, 1954). Where the detached skin is not available, other techniques have been described, including split thickness skin grafts (Schneider et al, 1986), local thigh pouches or local skin flaps (Millard, 1966), muscle flaps and omental flaps (Bostwick et al, 1979). The scrotal defect, at the time of closure, may very likely be contaminated with more than 100,000 bacteria per gram of tissue. Experimental and
Figure vated.
?-Inferiorly-based
rectus
abdominis
muscle
flap ele-
Case report A 64-year old white male presented with necrotising fasciitis of the scrotum. The patient had a 100 pack-year smoking history and insulin-dependent diabetes mellitus. Debridement involved nearly the entire scrotum, leaving only a 5 x 2 cm strip of scrotal skin on the left side. Following a 14 day course of intravenous antibiotics and a 10 day course of hyperbaric oxygen therapy, granulation tissue covered the wound base and the tunica vaginalis of both exposed testes (Fig. 1). The wound was debrided and an inferiorly based right rectus abdominis muscle flap was elevated, measuring 30 x IO cm (Fig. 2). The muscle was tunnelled under the skin of the pubis into the scrotal defect and secured to the edges of the defect over closed suction drains (Fig. 3). A split thickness skin graft was sutured to the rectus muscle. The postoperative course was uneventful (Fig. 4)
192
BRITISH JOURNAL
OF PLASTIC SURGERY
Fig. 4 Figure 4-View
of reconstructed
scrotum
one month post-operatively.
clinical observations indicate that a muscle flap achieves coverage of a heavily contaminated recipient bed more reliably than random cutaneous flaps (Calderon et al, 1986). For this reason a muscle flap may be a better choice for reconstruction in the contaminated perineum, especially in patients with impaired ability to deal with infection, such as the diabetic presented here. Use of the rectus abdominis muscle flap to close groin and perineal wounds has been previously detailed (Mathes and Bostwick, 1977). Its use in total scrotal reconstruction has not been described, but the muscle appears to be an ideal choice. The blood supply is constant and reliable and the wide, flat shape and proximity to the scrotum make it easy to inset. It gives an aesthetically acceptable result with minimal donor site morbidity. Other local muscle flaps, such as internal oblique, tensor fasciae latae and gracilis, may have inadequate
The rectus abdominis
muscle was covered
by a skin graft
muscle mass or pedicle length, precluding their use for scrotal reconstruction. References b&wick, J. 3rd, Hi, H. L. and Nahai, F. (1979). Repairs in the lower abdomen, groin, or perineum with myocutaneous or omental flaps. Plastic and Reconstructive Surgery, 63, 186. CaIderon, W., Chang, N. and Math% S. J. (1986). Comparison of the effect of bacterial inoculation in musculocutaneous flaps. Plastic and Reconstructive Surgery, 71,785. Gibson, T. (1954). Traumatic avulsion of the skin of the scrotum and penis: Use of the avulsed skin as a free graft. British Journal ofplastic Surgery, 6,283. Mathea. S. J. and Rostwick, J. (1977). A rectus abdominis myocutaneous flap to reconstruct abdominal wall defects. British Journalof Plastic Surgery, 30,282. Miiard,D. R. Jr. (1966). Scrotalconstructionand reconstruction. Plastic and Reconstructive Surgery, 38,lO. Schneider, P. R., Russ&, R. C. and Zook, E. G. (1986). Fournier’s gangrene of the penis: A report of two cases. Annals of Plastic Surgery, II, 87.
CASE REPORT:
SCROTAL RECONSTRUCTION
WITH A RECTUS ABDOMINIS
MUSCLE FLAP
The Authors William A. Young, Major, USAF, MC, Resident James K. Wright, LtCol, USAF, MC, Chief
Requests
for reprints
to LtCol. J. K. Wright
Department of Plastic Surgery, Wilford Hall US Air Force Medical Center, Lackiand Air Force Base, Texas 78236, USA.
Paper received 25 March Accepted 4 May 1987.
1987.
193