Pedicled Gracilis Flap for Scrotal Reconstruction Following Fournier’s Gangrene. Literature Review and Technical Notes.

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Pedicled Gracilis Flap for Scrotal Reconstruction Following Fournier’s Gangrene. Literature Review and Technical Notes.

https://doi.org/10.21203/rs.3.rs-4332592/v1

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Background:

Scrotal reconstruction is needed in response to multiple conditions, such as Fournier’s Gangrene. In this scenario, thorough debridement is necessary in order to achieve definite healing, the next step being scrotal reconstruction, for which a search for optimal aesthetic and functional outcomes should be the norm. In the authors’ experience, the bilateral pedicled gracilis flap allows for the meeting of these standards.

Objective:

To revise the published literature on scrotal reconstruction using pedicled gracilis flaps after Fournier’s Gangrene, collecting data on defect size, reconstructive method and complication rates, followed by a detailed description of the technique, in which the authors share some technical notes and present a one-year follow-up case.

Design, setting and participants:

We conducted a systematic review on the published literature following PRISMA2020 recommendations, which yielded 9 studies. We analyse them for collection of previously defined variables and share the case of one patient, in order to compare our experience with the published literature.

Results:

Nine studies including 30 patients were analysed in our review. The mean age was 45.99 and mean defect size 12.25 cm x 11.5 cm. For 16 of these patients, a musculo-cutaneous flap was used, whereas in the other 14 muscle flaps were elevated and then grafted. There were no reports of flap failure or major complications in any of the studies.

Conclusions:

The pedicled gracilis flap is an excellent option for scrotal reconstruction following Fournier’s Gangrene. It provides optimal coverage and allows for a functional and aesthetic reconstruction.

FOURNIER’S GANGRENE

GRACILIS FLAP

PERINEUM

RECONSTRUCTION

SCROTAL RECONSTRUCTION

SCROTUM.

A scrotal and/or perineal reconstruction might be necessary in response to a wide variety of medical conditions, including trauma, oncologic disease or infection, such as Fournier’s Gangrene. The latter is an often polymicrobial type of necrotizing infection involving the perineal area, which has been associated with high rates of both morbidity and mortality^1,3. It typically affects males over the age of 50, although females and patients of any age could be affected².

Accurate diagnosis with early and thorough surgical debridement, as well as initiation of broad-spectrum antibiotics is paramount for treatment of this disease. The result of this necessary but usually aggressive treatment is frequently a very extensive wound defect, sometimes representing a challenge to the reconstructive surgeon³.

Various methods of scrotal and perineal reconstruction have been described in the past, ranging from direct wound closure to free flap mobilization. To date, there is no clear consensus on which reconstructive option is best. As for every other scenario in reconstructive surgery, there is no “best option” or standardized reconstruction for any defect, but the one that best fits each individual wound and patient. It appears to be clear, however, that in the case of big scrotal or perineal defects (especially those overpassing half of the scrotum or extending beyond it), flap reconstruction will provide the best results.

Indeed, although skin grafting is a popular option in the reconstruction of defects following Fournier’s gangrene, there is a possibility of graft contraction, which can be problematic and may limit reconstruction of larger defects². Furthermore, it should only be proposed in the case of having a healthy granulating bed, which is not always the case.

Flaps, on the other hand, provide adequate testicular protection, without the mentioned risk of contraction. However, some authors claim that they are cosmetically inferior to grafting due to the bulkiness the transposed tissue provides, as well as that they require more complex procedures, with longer surgery duration and higher morbidity at donor site^4,5,6,7.

We believe the pedicled gracilis muscular flap with subsequent skin grafting is the best option when facing substantial scrotal defects. Of course, skin grafting only or even direct closure can be attempted in case of small or superficial defects with clean and granulated wound beds. When the defect is asking for a flap, however, the above-mentioned is in our experience the weapon to use, as it provides durable and robust coverage, has minimal donor site morbidity and overcomes the problem of “bulkiness”, as it is not elevated with a skin island and the subcutaneous tissue and fat that travel with it, but as a pure muscle flap that will then be grafted with a split-thickness skin graft.

Search strategy

Authors searched PubMed database between the months of May, June and July of the year 2023. Bibliographies of each relevant article were also reviewed for additional sources (citation searching).

The above-mentioned search was conducted using Mesh terms: ("Scrotum"[MeSH Terms] AND "Plastic Surgery Procedures"[MeSH Terms] AND "Fournier Gangrene"[MeSH Terms]. Filters were applied limiting the search for articles published in either English, Spanish or French, all three languages being spoken by the reviewing authors.

The initial PubMed search yielded 57 studies, 10 of which were directly discarded due to the lack of an available abstract. Two authors independently reviewed the resting 47 abstracts and subsequently included or excluded studies based on the inclusion and exclusion criteria. Articles of abstracts that met criteria were reviewed as a second stage. Discrepancies between the authors were discussed, and final decisions on whether the given study should be included were made with the collaboration of a third author.

After revising the list based on our criteria (specified in the following paragraph), only three studies were eligible for our review. However, six other studies were added through backward and forward citation searching. In total, nine studies published between 1986 and 2022 were selected for inclusion in our review. The search algorithm is shown in Fig. 1.

Figure 1. PRISMA flowchart

(Attached word document)

Inclusion/exclusion criteria

The authors included studies which had been published in indexed scientific journals and provided information about patients who had undergone reconstruction for Fournier defects with muscle or musculocutaneous gracilis pedicled flaps. Only studies on adult patients (older than 18 years) were included. We excluded studies that were focused on methods of debridement or other phases of care rather than reconstruction, studies focused on negative pressure wound therapy, studies centred in reconstruction methods other than gracilis flaps, studies on perineal reconstruction for defects with an aetiology different from Fournier’s gangrene, literature reviews not collecting our outcome variables, studies not specifying at least three of our four outcome variables and articles that were published in languages other than English, Spanish or French.

Some of the discarded articles, however, specifically literature reviews, were used as a source for research citation, therefore increasing the number of articles finally included in our study.

The electronic literature search yielded 57 studies, 47 after discarding those without an available abstract, of which 44 were excluded on the basis of our criteria. Citation research allowed for the identification of 13 more papers, of which 6 were eligible for our study. Therefore, our final pool comprised 9 studies and a total of 30 patients (Table 1).

Table 1

Characteristics of included studies.
#	Author	Year	Patients (N)	Age (mean)	Study design	Level of evidence
1.	BANKS et al.⁸	1986	1	32	Single case	Level 5
2.	IOANNOVICH et al.⁹	1998	4	47.25	Retrospective case series	Level 4
3.	KAYIKÇIOGLU¹⁰	2003	2	48.5	Retrospective case series	Level 4
4.	HSU et al.¹¹	2006	8	60.5	Retrospective case series	Level 4
5.	SUG WON et al.¹²	2006	9	48.3	Retrospective case series	Level 4
6.	CHEN et al.⁷	2010	2	53.6	Retrospective case series	Level 4
7.	KATUSABE et al.¹³	2013	1	34	Single case	Level 5
8.	KARKI et al.¹⁴	2016	2	46.5	Retrospective case series	Level 4
9.	FINKELSTEIN et al.¹⁵	2022	1	43	Single case	Level 5

Four outcome variables were evaluated on the basis of data extracted from the 9 included studies: number of patients, mean age, size defect, method of reconstruction (muscle or musculo-cutaneous flaps), number of flaps (unilateral or bilateral) and complications (Table 2).

Table 2

Results.
#	Size defect (cm x cm or body surface %)	Method of reconstruction (Flap type)	Number of flaps (unilateral/bilateral)	Complication rate, % (n)
1.	Not specified	Musculo-cutaneous	Bilateral (1)	Uneventful healing (1/1)
2.	3.25% body surface (mean)	Musculo-cutaneous	Not specified (4)	Uneventful healing (4/4)
3.	11.5 cm x 8.5 cm (mean)	Musculo-cutaneous	Bilateral (2)	Uneventful healing (2/2)
4.	22.5 cm x 13.5 cm (mean)	Musculo-cutaneous	Unilateral (2) Not specified (6)	2 minor complications (25%)
5.	Not specified	Muscle flap + STSG	Unilateral (3) Bilateral (6)	Uneventful healing (9/9)
6.	5 cm x 10 cm (mean)	Musculo-cutaneous (1) Muscle flap + STSG (1)	Unilateral (2)	Uneventful healing (2/2)
7.	10 cm x 15 cm	Muscle flap + STSG	Unilateral (1)	Uneventful healing (1/1)
8.	Not specified	Muscle flap + STSG	Unilateral (2)	Uneventful healing (2/2)
9.	Not specified	Muscle flap + STSG	Bilateral (1)	Uneventful healing (1/1)

STSG – Split Thickness Skin Graft.

All of the included studies were either retrospective case series (6) or single case reports (3), with levels of evidence of 4 or 5 respectively. They report results on a total number of 30 patients who were reconstructed with a gracilis flap following Fournier’s gangrene. The mean age of these patients was 45.99 years and the mean defect size was 12.25 cm x 11.5 cm, although only four studies reported the defect size in a comparable manner.

Regarding reconstruction methods, there is a near to 1:1 ratio of studies reporting the use of musculo-cutaneous flaps and grafted muscle flaps. The total amount of patients reconstructed with a musculo-cutaneous flap was 16, while 14 patients were treated with a muscular flap and skin graft. Regarding flap number, 10 patients received a bilateral flap, while other 10 needed just one flap in order to attain wound closure; for the resting 10 patients, there was no specification of uni- or bilaterality.

There were no differences in overall flap survival between the “musculo-cutaneous flap” group and the “grafted muscle flap” group, with no reports of flap loss in the revised literature. Only two minor complications were reported in one of the studies¹¹, these being a haematoma and an abscess at donor site. None of the other articles report any minor or major complication.

Discussion and case presentation:

Fournier’s gangrene is polymicrobial type of necrotizing infection involving the perineal area, usually associated with high rates of morbidity and mortality. In this scenario, reconstruction of scrotal, penile, and perineal defects after surgical debridement can be a challenge.

The “replace like with like” principle is important for tissue functionality as well as aesthetic purposes. These organs have unique texture, colour, and contour that are difficult to recreate. The finest cosmetic and functional results are probably achieved by primary closure; however, this is only possible for very small defects allowing for closure without tension, as any tension on the closure should an indication for reconstruction⁴.

Defects might also be allowed to heal by secondary intention if they are relatively small, especially when confined to less than 50% of the scrotum. For defects larger than 50%, however, split-thickness skin grafting or flap reconstruction are usually the norm.

Skin grafting is a very simple procedure which can be performed in a single stage, and allows for coverage of large defects with acceptable functional and cosmetic results, provided that a healthy granulated wound bed is a present. However, when the wound doesn’t meet this prerequisite, flap reconstruction should be our preferred reconstructive weapon.

In our experience, the grafted gracilis muscular flap is the best option in the case of defects needing coverage with healthy vascularized tissue, which can be considered as the ones involving more than half the area of the scrotum or extending beyond it. Although various other flaps might do the work, there are several advantages to this one that make it our preferred choice:

Ease in harvesting and possibility of dissection with minimal scars (normally an incision not larger than 15 to 20 cm should be enough to harvest more than enough muscle to cover our defect) located in a usually not-visible area (medial thigh).
Thinness and broadness of the gracilis muscle, making it ideal for coverage of big areas without input excessive bulking.
Ease of expansion of the muscle by making axial incisions in its posterior fascia, which allows it to open and “fan” expand, further contributing to its adaptation to the form of the testicles.
Avoidance of using a skin island over the muscle, which would provide an excess of tissue (subcutaneous and fatty tissue) and worsen both the functional and aesthetic result.
In contrast to the previous point, the fact of grafting the muscle eliminates the risk of excessive bulking and gives a much more aesthetic and functional result, as the volume excess in that area could limit the patient’s daily life activities and cause discomfort.
Possibility of manually meshing the partial thickness skin graft, which on the one hand allows us to diminish the donor zone and, on the other, contributes to a more “realistic” aspect of the scrotum, as it mimics the wrinkles which are normally present in that area.

All of the above have made us prefer this option over others available when encountering this type of defects in our personal experience. As far as we are concerned, however, there are some technical points that the surgeon should take into account in order to attain the best result possible:

A thorough serial debridement should have taken place before the final reconstructive surgery. No signs of infection should be present at the moment of reconstruction, nor necrotic or marginally vascularized tissue. One must take time to carefully debride all the diseased tissues prior to reconstruction. Complete anatomical knowledge of the scrotal area is necessary in order to avoid damage to uninvolved vital structures.
Flap should be elevated through the smallest incision that will allow adequate exposure of the muscle and its pedicle. One should not be tempted to limit the incision in a way that it might jeopardize the reconstruction because of incomplete exposure and subsequent damage to important structures just to avoid a bigger scar, nor should one make an incision much larger than the necessary. Find the balance that suits your surgical experience.
Whenever possible, a two-surgeon team is advisable, with the intention of elevating both flaps simultaneously, therefore limiting surgical time.
We would recommend to leave a cutaneous bridge between the donor site incision and the area of reconstruction (scrotum), in such a way that the muscular flap will then be tunneled through it. This will avoid the presence of scar tissue in the inguinal area, which could cause discomfort to the patient.
Best flap insetting is achieved by mobilizing it in a “turn-over” manner, passing it through the previously mentioned subcutaneous tunnel and adapting it to the scrotum by making it “hug” the testicles. The distal part of the flap will be sutured to the uppermost part of the scrotum and the testicle will lay in between two layers of muscle.
In order to increase its coverage capacity, one can perform longitudinal axial incisions over the posterior aspect of the muscle, splitting its fascia and epimysium, which will allow for a “fan-like” opening. Special care must be taken during this step, in order to avoid damage of the flaps’ nutrient vessels.
Total or partial muscle denervation should be performed in order to avoid inadverted contraction of its fibers during leg adduction, which could give an undesired animated effect and disturb the patient.
Muscle grafting should be performed at the same surgical time in order to limit surgeries. Graft meshing will allow for a smaller donor site scar and at the same time improve the aesthetic outcome, as the mesh nearly mimics the wrinkly aspect of a normal scrotum. We prefer manual meshing rather than mechanical one in this case, in order to limit the incisions and avoid a “wicker basket” aspect.

We present the case of a 48-year-old man who was referred to our hospital after a 1-month evolution of Fournier’s Gangrene, initially treated at another center. He presented with a total scrotal defect, with exposure of tunica albuginea, as well as additional superficial wounds located at the level of his left lumbar and iliac regions (Fig. 2).

Surgery took place the day after his admission to our hospital. We first conducted a thorough and meticulous debridement of the wound bed and direct closure of the above-mentioned abdominal wounds (Fig. 3). Bilateral muscular gracilis flaps were elevated through an incision starting 2–3 cm from the inguinal fold and transposed to the defect via a subcutaneous tunnel. They were turned-over and disposed in a way that each testicle would be “hugged” by each of the flaps (Figs. 4–6). The motor nerve branches to the muscle were divided and the main pedicles of the flaps dissected as needed, to warrant no tension would apply on them when turning the flaps over.

Split thickness skin grafts were taken from the lateral border of the left thigh and manually meshed to allow for expansion. They were then fixed to the muscle flaps with staples (Fig. 7). A non-adhesive dressing was applied over the grafts and the area was carefully padded with moist gauzes and cloths.

Patient was discharged on the 10th postoperative day (Fig. 8) and has had an uneventful evolution. No wound dehiscence or suffering of the flaps were noted. At 12 months postoperatively, he shows very acceptable aesthetic and functional results (Figs. 9–10) and has not required any additional surgery.

Fournier’s Gangrene is an aggressive polymicrobial necrotising infection of the perineal and scrotal area. It usually needs wide debridement in order to achieve healing, therefore creating considerable defects that call for a sometimes-challenging reconstruction.

Although many reconstructive options have been proposed, in the authors’ experience, the pedicled gracilis muscle flap with skin grafting should be the preferred option. Its main advantages are the possibility of a total scrotal reconstruction (especially when both gracilis flaps are elevated) with minimal donor site violation, easy dissection, very low complication rates and optimal aesthetic and functional results.

Ethics approval and consent to participate

The present study is exempt from the need of an Ethics Board evaluation, it being a literature review and case presentation, with the pertinent oral and written consent from the patient to whom the presented case corresponds.

Consent for publication

The patient presented has given oral and written consent for publication of his case and associated images at scientific journals.

Availability of data and materials

The data analysed is available from the corresponding author on request.

Competing interests

Authors claim to have no competing interests.

Funding

Authors have not received any funding for the purpose of this study.

Authors' contributions

B.A. was responsible for conducting the systematic review, drafting and later correcting the article according to the other authors’ suggestions. A.S. was the main surgeon of the presented case and 2^nd reviewer in the systematic review. A.T., I.H., P.A. and MD.P. contributed during the patient’s follow-up and helped with corrections.

Daigeler A, Behr B, Mikhail BD, Lehnhardt M, Wallner C. Bilateral pedicled gracilis flap for scrotal reconstruction. J Plast Reconstr Aesthet Surg. 2016;69(9):e195–6. 10.1016/j.bjps.2016.05.024.
Insua-Pereira I, Ferreira PC, Teixeira S, Barreiro D, Silva Á. Fournier's gangrene: a review of reconstructive options. Cent Eur J Urol. 2020;73(1):74–9. 10.5173/ceju.2020.0060.
Hart J, DeSano J, Hajjar R, Lumley C. Total scrotal reconstruction following Fournier's gangrene with bilateral prelaminated superior medial thigh flaps. BMJ Case Rep. 2021;14(4):e240618. 10.1136/bcr-2020-240618. Published 2021 Apr 15.
Karian LS, Chung SY, Lee ES. Reconstruction of Defects After Fournier Gangrene: A Systematic Review. Eplasty. 2015;15:e18. Published 2015 May 26.
Ferreira PC, Reis JC, Amarante JM, et al. Fournier's gangrene: a review of 43 reconstructive cases. Plast Reconstr Surg. 2007;119(1):175–84. 10.1097/01.prs.0000244925.80290.57.
Black PC, Friedrich JB, Engrav LH, Wessells H. Meshed unexpanded split-thickness skin grafting for reconstruction of penile skin loss. J Urol. 2004;172(3):976–9. 10.1097/01.ju.0000133972.65501.44.
Chen SY, Fu JP, Chen TM, Chen SG. Reconstruction of scrotal and perineal defects in Fournier's gangrene. J Plast Reconstr Aesthet Surg. 2011;64(4):528–34. 10.1016/j.bjps.2010.07.018.
Banks DW, O'Brien DP 3rd, Amerson JR, Hester TR Jr. Gracilis musculocutaneous flap scrotal reconstruction after Fournier gangrene. Urology. 1986;28(4):275–6. 10.1016/0090-4295(86)90003-8.
Ioannovich J, Kepenekidis A, Stamatopoulus K, Matar N. [Of the use of the musculo-cutaneous internal rectus in the loss of substance of Fournier’s Gangerene. Report of four cases]. Ann Chir Plast Esthet. 1998;43(1):58–63. De l’utilisation du lambeau musculo-cutané de droit interne dans les pertes de substance de la Gangrène de Forunière. À propos de quatre cas.
Kayikçioğlu A. A new technique in scrotal reconstruction: short gracilis flap. Urology. 2003;61(6):1254–6. 10.1016/s0090-4295(03)00158-4.
Hsu H, Lin CM, Sun TB, Cheng LF, Chien SH. Unilateral gracilis myofasciocutaneous advancement flap for single stage reconstruction of scrotal and perineal defects. J Plast Reconstr Aesthet Surg. 2007;60(9):1055–9. 10.1016/j.bjps.2006.09.005.
Sug Won K, Bom Jin K, Chul Hwan S. Scrotal Reconstruction Using Gracilis Muscle Flap in Fournier's Gangrene (P71). Plast Reconstr Surg. 2006;118(4):p152–153.
Katusabe LJ, Balumuka D, Hodges A. Scrotal reconstruction with a pedicled gracilis muscle flap after debridement of fournier's gangrene: a case report. East Afr Med J. 2013;90(11):375–8.
Karki D, Patel PK, Narayan RP. Penoscrotal defect: a functional, esthetic, and psychological challenge. Plast Aesthetic Res. 2016;3:64–7. http://dx.doi.org/10.20517/2347-9264.2015.28.
Finkelstein ER, Perez-Quirante F, Panthaki Z. Reconstruction of the Scrotum With Bilateral Gracilis Muscle Rotational Flaps in a Patient With Acute Myeloid Leukemia Complicated by Fournier's Gangrene. Cureus. 2022;14(6):e25988. 10.7759/cureus.25988. Published 2022 Jun 16.

No competing interests reported.

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You are reading this latest preprint version

Pedicled Gracilis Flap for Scrotal Reconstruction Following Fournier’s Gangrene. Literature Review and Technical Notes.

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Version 1

Abstract

Figures

Introduction

Materials and Methods

Search strategy

(Attached word document)

Inclusion/exclusion criteria

Results

Discussion and case presentation:

Conclusions

Declarations

References

Additional Declarations

Status:

Version 1