Penile reconstruction with dermal template and vacuum therapy in severe skin and soft tissue defects caused by Fournier's gangrene and hidradenitis suppurativa

Abstract

The aim of this article is to improve the treatment of patients with complete skin loss of the penile shaft after Fournier's gangrene or hidradenitis suppurativa using modern biomatrices and topical negative pressure therapy.

From January 2010 to December 2011, three patients with Fournier's gangrene or hidradenitis suppurativa were treated. After initial radical debridements, topical negative pressure therapy was applied for wound stabilisation. After that dermal templates (acellular dermal matrix) were used to achieve early healing and topical negative pressure‐dressing in a special setting or a special foam compression bandage was used together with a urinary catheter. After integration of the dermal template, a split‐thickness skin graft is used for coverage and again secured with a circular total negative pressure‐dressing.

In all cases, the split‐thickness skin grafts healed very well applying this therapy concept. The patients were very satisfied with the functional as well as with the aesthetic outcome.

We suggest a new method of staged reconstruction to successfully preserve the functionality of the penis after complete loss of the skin and soft tissue of the penile shaft using modern biomatrices and topical negative pressure therapy.

Introduction

Fournier's gangrene is a rare type of rapidly progressing necrotising fasciitis of the perineum and external genital area often affecting the scrotum or the penis 1, 2. The first case was described by Baurienne in 1764, but the condition was later named by Jean Alfred Fournier in 1883. Nowadays, any occurrence of necrotising fasciitis in the perineum and genital area is considered a Fournier's gangrene.

This disease mostly affects men aged 50–60 years. Predisposing factors, such as age, diabetes, alcoholism, malnutrition and immune suppression are often present in affected patients. In most cases a urologic, colorectal or cutaneous source can be identified 3. It is a synergistic polymicrobiological infection caused by a mixture of aerobic and anaerobic microorganisms including Candida. Despite antibiotics and aggressive debridement, the mortality rate remains high. Mortality rates are about 16% overall with significantly higher rates in patients with compromised immune systems and in diabetic patients.

Induration, pain, erythema and crepitus are local symptoms of Fournier's gangrene, accompanied by fever or even sepsis in advanced stages 4. As the disease progresses, it leads to ischaemia in the affected regions caused by microthrombosis and oedema, causing necrosis of skin, subcutaneous tissue, fascia and muscle.

Radical surgical debridement is always indicated to remove affected tissue and thus reduce the microbiological load 5. Often serial debridements are necessary 6, 7, 8, 9, 10.

The hidradenitis suppurativa, also known as acne inversa, is a chronic recurrent cutaneous disease that presents with inflamed lesions on apocrine glands by follicular occlusion manifested by painful abscesses and scarring.

The first description of the disease was done by Velpeau in 1839 and named by Verneuil in 1854 who associated it with perspiratory glands 11, 12. The axilla, the inguinal and genital regions are the sites most likely to be affected. Concerning the prevalence there are different findings, with predominate occurrence in female in general and in male because of the anogenital region. The disease manifests usually after adolescence. The pathogenesis is not completely understood yet. Accepted triggers are smoking, obesity, hormonal factors and genetic predisposition 13.

In chronic hidradenitis suppurativa, there is a risk of superinfection of soft tissue and sepsis. In the genital region, stricture of the urethra or fistula, such as paraurethral fistula, can develop. The protracted course of the disease is often displeasing for the patient associated with psychological stress and limitations in everyday life.

Therapeutic options are surgical or conservative treatment. The radical debridement including all lesions shows a relatively low recurrence rate compared with other forms of treatment. After debridement, extended soft tissue defects are the result in numerous cases for which plastic reconstruction is necessary.

Methods

From January 2010 to December 2011, we successfully treated three patients. All of them initially received aggressive and repeated debridements. All received a targeted intravenous antibiotic therapy. For stabilisation of the wound, topical negative pressure therapy was applied. After that dermal templates (acellular dermal matrix) were used to achieve early healing. In two cases for stabilisation, a 360° total negative pressure‐dressing in a special setting was used together with a urinary catheter. In one case, a special foam compression bandage was applied instead. Several changes of the total negative pressure‐dressing were required for clean wound conditions. After integration of the dermal template, a split‐thickness skin graft was used for coverage and secured with a circular total negative pressure‐dressing (vacuum = 125 mmHg).

Case series

Case 1

A 39‐year‐old male patient suffering from Fournier's gangrene was otherwise healthy with no history of tobacco or recreational drug abuse. As origin of the disease he reported a small lesion on the preputium that he had thermally inflicted himself.

The early symptoms were tenderness and erythema of the preputial area, rapidly spreading proximally. He was first treated surgically after gangrenous areas occurred in a different hospital. The debridement of the skin and subcutaneous tissue included the preputium, the penile shaft, leaving Buck's fascia and glans intact, the lower portion of the mons pubis and the proximal part of the scrotum, partially exposing the testicles. Initially he was treated with serial excisions of necrotising skin and soft tissue and repeated wound revisions with additional debridements and continuous negative topical pressure therapy. After stabilisation of the overall condition, the patient was transferred to our hospital with properly conditioned wounds except for a few remnants of necrosis (Figure 1).

Figure 1.

Fournier gangrene after serial excisions and covering with dermal template (Case 1).

After 16 days of initial treatment, partial closure of the scrotal wound and complete closure of the mons pubis by an advancement flap could be achieved. To induce a pliable and potentially movable dermal template in addition to skin grafting, we attempted a directed tissue regeneration approach with a biomatrix prior to skin coverage. Therefore, to optimise the denuded status of the penile shaft a collagen matrix (Matriderm, 2 mm) was applied circumferentially to the penile shaft and secured with vacuum sealing in the same session (Figure 1). Total negative pressure was able to stabilise the dressing, hold the penile shaft in a semi‐rigid position, equally compress the matrix and allow for drainage of any exudate.

The graft was left sealed for 5 days to facilitate vascularisation. After additional changing of the vacuum dressing, the collagen matrix was completely grown in and provided a well‐vascularised layer of generated tissue overlaying the deep fascia (Figure 2).

Figure 2.

Penis shaft with well‐vascularised layer and granulation tissue and total negative pressure‐dressing for stabilisation and sealing with subjacent split‐thickness skin graft (Case 1).

The defect could then be covered with 0·2 mm split‐thickness skin graft from the right thigh. To optimise the aesthetic appearance and prevent shrinkage, we did not mesh the graft but only scarcely incised it. To avoid shear stress, dislocation and ensure optimal graft take, we again applied a vacuum dressing maintaining a semi‐rigid position of the penile shaft (Figure 2). Removal of total negative pressure‐dressing after 6 days showed a 100% graft take to the newly generated and integrated biological tissue matrix. The further course was uneventful. A follow‐up examination 2 months after discharge showed a completely healed and sufficiently mobile skin graft with great pliability (Figure 3). Remarkably, with regard to penile functionality, the patient reported to have about 80% size of the erected penis compared with before Fournier's gangrene occurred and no problems with cohabitation.

Figure 3.

Two months after complete healing (Case 1).

Case 2

We treated another patient with Fournier's gangrene, 60 years with a history of nicotine and alcohol abuse. He reported an acneiform mutation in the perineal region which had occurred 2 weeks earlier. During the course there was a progressive erythema, swelling and pain that spread to the scrotum, the mons pubis and the penile shaft.

Initial treatment was carried out by the department of urology. The debridement included the whole scrotum with exposure of the testicles, the skin of the penile shaft and parts of the mons pubis. There were a total of three debridements performed in combination with total negative pressure therapy to achieve clean wound conditions.

After 16 days of primary surgery, there were no clinical signs for an infection in the wound and adequate development of granulation tissue. The penile shaft was again covered with a collagen matrix (1 mm), parts of the mons pubis and the scrotum were treated using chipskin grafts and again a vacuum sealing was applied. After additional 5 days the sealing was carefully removed. The penile shaft presented a completely vascularised layer of granulation tissue with compensation of the tissue deficit because of the debridement. In the following, the remaining defect was covered with a 0·2 mm split‐thickness skin graft. The graft was only scarcely incised and a vacuum dressing was applied to ensure stability. For covering the still exposed left scrotum, a soft tissue cavity was created at the wound edge of the mons pubis.

In a separate operation, after 4 days the total negative pressure‐dressing was removed. The take rate of the split‐thickness skin graft was about 80%. The remaining areas healed secondarily by regular dressing changes (Figure 4). With regard to wound healing, there occurred no further complications. For further controls there were no problems and no functional limitations.

Figure 4.

After healing of the dermal template in combination with split‐thickness skin graft (Case 2 and 3).

Case 3

A 47‐year‐old man had been suffering for several years from the effects of acne inversa. Despite conservative treatment by the dermatological department, no improvement occurred. Currently, there was a worsening of symptoms with extent of the affected areas around the genitals and groin.

A radical debridement of the affected areas including the penile shaft was carried out. To improve wound conditions after the initial surgery, daily dressing changes were made with polihexanid solution. Using this method successive formation of good vascularised granulation tissue was achieved.

After 18 days of initial surgery, the scrotal and perineal wounds could be covered using chipskin grafts from the thigh. In the same operation, collagen matrix (Matriderm) was applied for covering the penile shaft in the prescribed manner. In this particular case, a special foam compression bandage was used as this suited better than a total negative pressure‐dressing. After 5 days, the compression bandage was removed. Again, we saw an excellent vascularised layer of granulation tissue containing the whole penile shaft. In a further operation, the penile shaft was occluded by a 0·3 mm split‐thickness graft from the left thigh and a special foam compression bandage was used again. When the foam bandage was removed 3 days later, the graft presented a 100% take rate. Thus, the reconstruction of the individual tissue layers could be achieved (Figure 4). No problems appeared in the further course and micturition was possible without any problems.

Discussion

The assessment of what kind of reconstructive surgery (if any) is valuable, because of the extent of the remaining defect, follows as soon as the wound is free of contamination and necrotic tissue.

Reconstructive surgery in this area poses a challenge to the surgeon, as a safe as well as functional reconstruction should be achieved.

In most cases reported in literature, at least a split‐thickness skin graft was required to cover the defect, although several reconstructions with pedicled or free flaps have been reported as well 14. Nevertheless, pedicled flaps are well suitable to reconstruct the scrotum but provide undue bulk to the penile shaft. This influences not only the aesthetic appearance but also interferes with sexual functionality.

The choice of the reconstructive procedure depends on various aspects, such as the size of defect as well as the affected structures. As in all defect wounds the principle of the ‘reconstructive ladder’ applies, although most specialised plastic surgeons tend to rather use the ‘reconstructive elevator’. This means that sometimes skipping simpler methods for more technically challenging techniques with higher quality results in terms of patient satisfaction (e.g. local perforator propeller flaps), to achieve optimum functionality and/or cosmetically better results 15. Generally, the use of reconstructive surgery in an as early stage as possible appears to reduce the length of the inpatient treatment duration and to be able to improve the psychological condition of the patient.

Research in tissue engineering and regenerative medicine strives to artificially reproduce human tissue, but its progress is not yet advanced enough to provide for soft tissue replacement in large defects, although skin reproduction is possible 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26.

Still, in the case of Fournier's gangrene or hidradenitis suppurativa, the remaining wounds after debridement often allow secondary closures or closures after mobilisation of the surrounding skin. More extended wounds, that cannot be closed directly, need coverage by either skin grafts or flaps. Various skin or muscle flaps have been propagated, but inevitably lead to a secondary donor‐site defect and morbidity. In addition, muscle flaps tend to be bulky and are only suitable for coverage of scrotum defects. There are no options to resurface the penile skin. Frequently reported flaps are the superomedial thigh flap for scrotal reconstruction and the groin flap, based on the superficial circumflex iliac artery in its pedicle, for skin replacement at the basis of the penis. Some authors suggest to temporarily implanting the penis into the scrotal skin as a method for skin reconstruction in isolated penile skin defects. This type of coverage results in a bulky and unsightly aspect. Applying a simple split‐thickness skin graft on the penile shaft is a safe and easy way to cover the most often exposed Buck's fascia. It has to be taken into consideration when simple superficial defects without soft tissue loss are present. However, by simple skin grafting a penile erection may be hindered because simple split skin grafts tamper stretching and sliding of the penile skin. As a meshed skin graft is also known to shrink while healing and skin on fascia is bound to grow onto each other to form an immobile layer, we would like to suggest using of unmeshed split‐thickness skin grafts over a separating layer of a collagen matrix between fascia and graft to allow for the desired mobility and ability to stretch. It therefore appears logical to introduce tissue engineering techniques with application of biological matrices as an addition to common standard reconstructive options. Depending on the thickness of the collagen matrix used, it may be necessary to precondition the matrix to allow for vascularisation before skin grafting.

Conclusion

For Fournier's gangrene as well as for hidradenitis suppurativa, necessary aggressive surgical treatment leads to debilitating soft tissue defects and functional problems because of the lost penile cover.

Although many cases allow for a secondary closure, reconstructive surgery should always be considered to provide a safe and functionally optimal result. Concerning the replacement of penile skin with split‐thickness skin grafts, the creation of an additional neotissue layer using biomatrices such as collagen templates appears a viable option that in our patients yielded excellent aesthetic and functional recovery. In order to advance the incorporation of an acellular dermal matrix, the application of total negative pressure has proved to be a reliable and safe tool to stabilise and secure the grafts during the initial healing phase. The use of a separating layer of collagen matrix appears to provide an additional functionality when compared with skin grafts alone and presents satisfactory results.