Total scrotal reconstruction following Fournier’s gangrene with bilateral prelaminated superior medial thigh flaps

Abstract

The patient is a 45-year-old man diagnosed with Fournier’s gangrene and underwent treatment for septic shock, broad-spectrum antibiotic therapy and extensive surgical debridement of perineum, including total scrotectomy, ischiorectal fossa, abdomen and left superior thigh and flank. The patient required multiple staged complex reconstruction of the scrotum utilising prelaminated superior medial thigh flaps with use of dermal matrix, split-thickness skin grafting and pedicled gracilis muscle flap for coverage of the ischiorectal wound. The patient had full recovery and followed up 1 year postoperatively. This report discusses our technique for total scrotal reconstruction and provides review of surgical reconstructive techniques for wounds due to Fournier’s gangrene.

Background

Fournier’s gangrene is a necrotising infection of the perineum that can have a very high morbidity and mortality rate. It was first described in 1883, by Alfred Jean Fournier who described the necrotising infection that occurred in the perineum and scrotum.^1–4 Necrotising fasciitis is often polymicrobial and mortality rates range from 6% to 76%.² Founier’s gangrene has is higher incidence in men older than 50 years. Patients with medical comorbidities, including diabetes, hypertension, obesity and immunocompromising conditions, increase the risk of developing this condition.^{5 6} Accurate diagnosis with timely surgical debridement and initiation of broad-spectrum antibiotics is paramount for treatment of this disease process. The resulting wound defect can often be extensive, which can represent a challenge to the reconstructive surgeon. There have been reports of many different reconstructive options for scrotum and perineal wounds after treatment of Fournier’s gangrene, including local tissue advancement flaps, muscle flaps or pedicled fasciocutaneous flaps. The type of reconstruction is dependent on the size and location of the wound after debridement. We present a case of total scrotal reconstruction with prelaminated superior medial thigh flaps and placement of dermal matrix with skin grafting for reconstruction due to Fournier’s gangrene. The purpose of this case report is to discuss our technique for total scrotal reconstruction and provide review of literature, including demographics, histopathology and surgical techniques for reconstruction options.

Case presentation

This is a case report of a 45-year-old man with a history of polysubstance abuse, uncontrolled diabetes and medical non-compliance who initially presented to the hospital for chest pain and was found to have severe diabetic ketoacidosis with high anion gap metabolic acidosis. Cardiac workup suggested anterior wall ST-elevation myocardial infarction, but catheterisation was negative. He was found to have Fournier’s gangrene. CT scan showed extensive subcutaneous emphysema in the perineum, left anterior abdominal wall and pelvis (figure 1). The patient underwent extensive debridement of the perineum, including total scrotectomy, ischiorectal fossa and abdomen, and left lateral flank (figure 2). Initial wound cultures showed polymicrobial and fungal wound cultures. The patient was treated initially with broad-spectrum antibiotics and was narrowed to culture-specific antibiotics and antifungal medication. The patient required multiple operative debridements and diverting ostomy performed by general surgery along with prolonged treatment with vasopressors for treatment of septicaemia and septic shock. After medical stabilisation and optimisation of wound and nutrition, care was taken over by the plastic and reconstructive team for wound closure and perineal reconstruction.

Figure 1.

Preoperative CT image demonstrating subcutaneous emphysema of perineum, scrotum and left superior thigh.

Figure 2.

Postdebridement surgical wound of perineum, scrotum, ischiorectal fossa and left superior medial thigh.

Treatment

Initial surgical treatment included closure of the right groin defect with superior thigh advancement flap, creation of prelaminated bilateral superior medial thigh flap for testicular coverage and increased blood supply to testicles, and partial closure of the left lateral flank and perineum (figure 3). After 3 weeks, the bilateral prelaminated superior medial thigh flaps were mobilized, de-epithelialized and used to recreate his scrotum in a staged reconstruction with dermal matrix (figures 4–6). The patient did require further debridement of the left lateral flank dehiscence, which was treated with negative pressure wound therapy and closed primarily with fasciocutaneous flaps (figure 7). After mobilization of bilateral superior medial thigh flaps, the neoscrotum was covered with Integra dermal matrix (figure 8). The patient elected to have a final one-stage procedure that included left pedicled gracilis flap for coverage and closure of the left ischial rectal fossa defect, followed by split-thickness skin grafting of the perineum, neoscrotum and superior medial thighs (figures 9 and 10). Split-thickness skin grafts were obtained from the left anterior thigh using 10–12/1000 inch depth and meshed at 1:1.5. The patient wounds were then treated with negative pressure wound vacuum assisted closure (VAC) therapy for 1 week. The patient had near 100% take of the skin graft after final surgery and was discharged to subacute rehab facility with local wound care with non-stick dressing to skin graft donor site and surgical wound, and coverage with abdominal pads for comfort.

Figure 3.

Intraoperative image of closure of right thigh and creation of prelaminated superior thigh flap for testicular coverage.

Figure 4.

Intraoperative image of placement of dermal matrix and left prelaminated superior medial thigh flap.

Figure 5.

Intraoperative image of right superior medial thigh prelaminated flap, staged coverage with dermal matrix for scrotal reconstruction.

Figure 6.

Intraoperative image of left superior medial thigh flap mobilization and placement of dermal matrix for staged scrotal reconstruction.

Figure 7.

Intraoperative image of left thigh after primary closure with fasciocutaneous flaps.

Figure 8.

Intraoperative image of neoscrotum covered with dermal matrix after mobilization of bilateral superior medial thigh flaps.

Figure 9.

Intraoperative image of split-thickness skin graft for coverage of neoscrotum and superior medial thigh.

Figure 10.

Intraoperative image of split-thickness skin graft coverage of posterior neoscrotum, perineum and medial thighs after gracilis flap for left ischial rectal fossa defect.

Outcome and follow-up

Postoperatively, the patient was treated with negative pressure wound VAC therapy after each reconstructive surgery to decrease the oedema, improve wound blood supply and stimulate granulation tissue. The split-thickness skin graft donor sites were treated with Xeroform dressing after wound VAC removal. The wounds demonstrated good take of the split-thickness skin grafts overlying the neoscrotum, perineum and left lateral thigh. The patient did have postoperative seroma of the left gracilis donor site, which was drained and healed by secondary intention. Although the patient did have a history of medical non-compliance, he was very compliant postoperatively and played an active role in his postoperative wound care treatment. He was very motivated to obtain a full functional recovery and was able to remain abstinent from smoking and drug use, which expedited his recovery. At the patient’s 6-month follow-up, there was full take of the split-thickness skin graft of perineum overlying the gracilis flap, with minimal contracture or hypertrophic scar. There was partial dehiscence of scrotum at the base of the penis and anterior left groin (figures 11 and 12). The patient underwent closure and tissue advancement of anterior scrotum and base of penis. The patient was seen 1 year after the initial reconstructive surgery and was very pleased with the reconstruction. The neoscrotum healed very well and softened over the postoperative period. The patient had good range of motion of his lower extremity and there was minimal secondary contracture of the skin graft sites (figure 13). The patient planned to have reversal of diverting colostomy by general surgery after he completed his structured rehabilitation.

Figure 11.

Six-month postoperative image showing small amount of delayed healing of skin graft at the base of penis.

Figure 12.

Six-month postoperative image of left lateral thigh wound with complete epithelialisation of the skin graft, minimal contraction or hypertrophic scar.

Figure 13.

One-year postoperative image. Healed scrotal flap and skin graft with good cosmetic result and minimal scar or contraction.

Discussion

Goals of reconstruction following excisional debridement of Fournier’s gangrene include adequate coverage of the wound with reconstruction of the scrotum that will allow for proper restoration of function with acceptable cosmetic result. Reconstruction of new scrotum allows for thermoregulation of the testicles, which is a requirement for normal spermatogenesis and hormonal control of Leydig cells for proper testicular function.⁷ There have been numerous reconstructive options discussed within the literature for wound coverage following Fournier’s gangrene, which is dependent on the size of the defect. There is no consensus on any specific type or flap or graft; however, defects of the scrotum of less than 50% of scrotal skin loss, the use of advancement flaps and direct closure of residual scrotum have been proposed and recommended.^{1 2} For defects greater than 50%, the literature has shown that the use of coverage with local regional fasciocutaneous flaps, skin grafts or distant pedicled flaps could be utilised based on size of the defect.^1–3 The use of anterior lateral thigh flap has been proposed for total perineal reconstruction due to the size of the skin paddle, reliable blood supply from the descending branch of the lateral circumflex femoral artery, and ability to utilise vastus lateralis to fill in the wound defect, but were found to be very bulky in scrotum reconstruction.^{3 8} Another case series showed that the pudendal thigh flaps provided adequate coverage with robust blood supply, but revision surgery was needed due to lateral tethering of flap to superior thigh.⁴

The perineal and abdominal wounds along with the total scrotal loss after debridement dictated that multiple techniques be utilized for wound coverage and reconstruction of the scrotum. The use of prelaminated flap, which is the creation of layered composite flap based off an axial blood supply⁹ was used to cover bilateral testicles in preparation for reconstruction of the scrotum. The prelaminated flap is completed in multiple stages over a period of 2–4 weeks to allow for angiogenesis and adequate vascular bed.⁹ In our case, the prelaminated scrotum using superior medial thigh flaps is based off of perforators from superior pudendal, medial femoral circumflex and superficial femoral arteries. These flaps were de-epithelialized and provided adequate blood supply and coverage for the testicles. Ultimately, the wounds were covered with skin graft after use of dermal matrix and wound VAC therapy was placed. Use of postoperative negative pressure wound therapy was utilised and has been shown to optimise the wound bed by decreasing surrounding oedema, simulating granulation tissue and blood flow, leading to improved skin graft survival.^{7 10} In the presented case, the negative pressure wound VAC therapy was used after each operation and yielded near 100% take of the skin graft with good cosmetic result and minimal amount of scar contracture at follow-up.

There are numerous options for scrotal reconstruction and management of the wound following debridement of Fournier’s gangrene. The reconstruction options are dependent on the severity of the wound defect, medical comorbidities and stability of the patient. Although there is no consensus for ideal flap closure of Fournier’s gangrene defects, this case demonstrates that there can be a combination of multiple techniques used to adequately close the wounds following debridement. Our presented case shows that prelaminated thigh flaps can be utilized for obtaining adequate blood supply and coverage of exposed testicles, and reconstruction of the scrotum with adequate cosmetic result after total scrotum loss due to Fournier’s gangrene.

Learning points.

• Fournier’s gangrene is a rare polymicrobial infection that has very high mortality and morbidity if not recognised and treated with extensive surgical debridement and initiation of intravenous antibiotics.

• Surgical reconstruction following debridement of Fournier’s gangrene can be challenging and is dependent on the subsequent wound after control of infection. Multiple techniques of local tissue advancement, pedicled flaps and skin grafting are often needed.

• Goals of reconstruction include providing adequate soft tissue coverage for the perineum, scrotum and surrounding tissue with return of proper function and acceptable cosmetic result.