INTRODUCTION
Fournier's gangrene is a necrotizing fasciitis,
caused by multiple infecting organisms resulting
in gangrene of the skin and subcutaneous tissue of
the scrotal, penis, groin, perineum and gluteal
region [1].
It is more common in immune compromised
patients with chronic debilitating diseases [2]. The
etiological identification was reviewed by Eke et
al., 2000 [3]. They reported the etiological factors
167
in more than 90% of the cases, with dermatological
infections (24%) followed by anorectal (21%) and
urological (19%) cases.
Reconstruction of the scrotum is crucial for its
functional, esthetic and psychological impact [4].
Our goal is to do one stage reconstruction and
maintain the physiological testicular function,
pliable skin coverage, preserving adequate sensation,
minimal donor site morbidity and reach natural
esthetic results [5,6].
In major scrotal and perineal defects local
fasciocutanous flaps [7-9] provides adequate coverage,
avoid skin graft problems and preserve
adequate sensation [10]. Medial thigh “SMT” flap
or scrotal reconstruction has been described, with
anatomical variation based on the deep external
pudendal, anterior branch of obturator, and medial
circumflex femoral artery [7-9,11-15]. Anatomical
studies of the perineal region [16,17] and gluteal
fold flap shown nourishment by the internal pudendal
artery [18,19]. Clinical uses and flaps based
on the internal pudendal artery perforators “IPAP”
for vaginal reconstruction have been published
[20,21]. Searching the literature, we did not find
any studies comparing the reliability and outcome
of these two fasciocutanous flaps.
The purpose of this study is to evaluate and
compare the internal pudendal artery perforator
and superior medial thigh flaps for reconstruction
of major scrotal and perineal defects.
Anatomy for flap design and elevation:
Internal pudendal artery perforator “IPAP” flap
inset and design were based on anatomical studies
of the internal pudendal artery and its skin perforators
[22,23]. Internal pudendal artery originates
from the internal iliac artery deep to the sacrotuberous
ligament, reaching the ischial tuberosity
toward the ischiorectal fossa. Three to five skin
perforators emerge in the fossa and nourish the
perineal skin. The vascular territory including the
perforators is formed by the ischia tuberosity, the
apex of the coccyx, and the scrotum. The imaginary
line from the ischial tuberosity to the scrotum
denotes the posterior boundary of the urogenital
diaphragm. The imaginary line between the ischial
tuberosity and the apex of the coccyx denotes the
margin of the gluteus maximus muscle. The line
from the scrotum to the apex of the coccyx indicates
the anococcygeal ligament Fig. (1).
The superior medial thigh flap based deep
external pudendal artery “DEPA “located at the
groin crease, between the scrotum medially and
the medial thigh laterally reaching posteriorly to
the perineum. It is approximately 20cm in length
and 10cm in width. The DEPA originates from the
femoral artery and crosses from deep to superficial
reaching the subcutaneous layer. During the course
of the artery it pass through the adductor longus
muscle and giving off both abdominal and perineal
branches at 4-6cm from the pubic symphysis [24].
PATIENTS AND METHODS
This is a cohort retrospective comparative study,
data retrieved from medical records from August
2015 to December 2018 in El-Demerdash, Ain
Shams University Hospital, we included records
of patients with exposed testes and perennial defects
due to forneir gangrene with more than 80% of
scrotal skin is lost and need coverage by fasciocutanous
flaps rather than primary closure of residual
scrotal skin.
Reconstruction was done after the surgical
intervention is carried by the colorectal team and
the patients general and local condition improves.
Female patients were excluded from the study.
Other surgical modalities such as primary closure
skin grafts, free flaps were excluded from this
study. Informed consent was obtained for all patients
to be include in any study and for medical
photography documentation as well.
10 patients underwent reconstruction of the
scrotal and perennial region by medial thigh flap
(Group A) and 13 patients by internal pudendal
artery perforator flap “Type I” (Group B). Patients
were followed at 3, 6 and 12 months postoperatively
(range 3-22 months). Data were collected,
analyzed and compared for flap dimension,
168 Vol. 44, No. 1 / Comparative Study Using Internal Pudendal Artery Perforator Flap
intraoperative time, the need of 2ry procedure,
complication, post-operative hospital stay, aesthetic
patients satisfaction “Likert scale”, it is an overall
rating for the aesthetic outcome was given on a
scale of 1-10 for the reconstructed scrotal and
perineal defects. Patients were asked, “how would
they rate the reconstruction on this scale [25]
(Tables 1,2).
All patients were photographed, flap marked
and the use of hand held Doppler (Group B patients)
is done in the pre-operative examination room.
Recording the percentage of skin defect and tissue
loss after surgical debridement, spermatic cord and
testacies dissection. Before flap harvesting marking
and flap design was assessed Fig. (1).
• The preparation of the recipient site:
In Group (A) all patients is positioned in supine
position with abduction and partial flexion of the
hip joint and 10-20 degree flexion of the knee joint.
In Group (B) all patients is positioned in lithotomy
position. Patient's anesthetised by general or regional
anesthesia (spinal or epidural). Immediate
pre-operative broad spectrum antibiotic was administered,
fibrotic scars and excessive granulation
tissue was excised followed by caudal dissection
of the spermatic cord and the testacies reaching
their anatomical position Fig. (2).
• Group SMT flap:
Flap is dissected in the sub fascial plane from
lateral to medial and caudal to cranial direction,
deep to the epimysium of the adductors and deep
fascia of the pudendal region. The blood supply
to this flap is through septo-cutanous perforators
of the deep external pudendal artery DEPA, which
is located at the groin crease at the level of scrotal
neck approximately 4-6cm from the pubic symphysis
[15]. Flap transposition followed by closure
of the donor site. In bilateral cases sutures are
made between the two flaps to the midline in the
base of the penis and the perineum, the donor sites
are primary closed in all patients without the use
of suction drain.
• Group B IPAP flap Type I (Propeller):
The flap is elevated with sharp dissection from
lateral to medial toward the vascular pedicles in
the subfascial plane reaching deep the epimysium
of gluteus maximums muscle. The perforators in
the ischiorectal fossa originate from the internal
pudendal artery in its thick fatty layer. The flap is
rotated 90 degrees and skin incision is completed
around the pedicles and blunt dissection is completed
until the flap reaches the defect without any
tension Fig. (3).
Egypt, J. Plast. Reconstr. Surg., January 2020 169
RESULTS
Patient's age ranged from 9 to 67 years, with
mean age of 46.8±11.8. A total number of 45 flaps
included in the study. Twenty SMT thigh flaps
were used for coverage of scrotal and perineal
defects in 10 patients. Twenty five IPAP flaps were
used for coverage of scrotal and perineal defects
in 13 patients. Twenty two patients reconstructed
with bilateral flaps and one patients a unilateral
flap.
In Group A, 10 patients underwent reconstruction
of the scrotal and perennial region by medial
thigh flap with mean age (43.4±8.1 years), age
range (34-62 years) and time for reconstruction
(14.3±2.58 days).
In Group B, 13 patients underwent reconstruction
of the scrotal and perennial region by internal
pudendal artery perforator flap “Type I” with mean
age (49.3±13.8 years), and time for reconstruction
(13±1.65 days). Average intraoperative time was
(113±21.1 minutes) in Group A, while it was (143.8
±30.1 minutes) in Group B, see Diagram (1).
In Group A, flap dimensions were (10.6±0.69
cm) average length and (7.6±0.96cm) average
width. Average hospital stay in this group of patient
was (2.6±0.5 days) with average aesthetic patients
satisfaction Likert scale (6.8±1.03).
In Group B, flap dimensions were (15.9±2.43
cm) average length and (7±0.9 cm) average width.
Average hospital stay in this group of patient was
(3.4±0.97 days) with average aesthetic patient's
satisfaction Likert scale (7.5±1.1), see Diagram
(2).
Post-operative complications for both groups
were analyzed and tabulated in a period of 12
months, including flap loss, hematoma, wound
dehiscence, infection, need for secondary procedure
and scar contracture, see (Table 3) and Diagrame
(3). All patients followed in the outpatient clinic
and medical photography was taken in the pre and
post-operative period with a mean follow-up time
in Group A (9.2±5.8) and (10±5.4) months in Group
B. Fig. (4) till 12 shows some off our patients
clinical outcome.
Table (1): Patient's summary.
Gender
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
Age
62
54
9
50
46
47
52
51
42
51
56
67
54
34
42
48
62
45
44
48
38
38
36
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
No. HTN
Y
Y
N
Y
N
N
Y
Y
N
Y
N
N
Y
Y
N
Y
Y
Y
N
Y
N
N
Y
Y
Y
N
N
Y
Y
N
Y
N
N
Y
Y
N
Y
Y
Y
N
Y
N
Y
Y
Y
Y
Smoking
Flab
used
IP
IP
IP
IP
IP
IP
IP
IP
IP
IP
IP
IP
IP
MT
MT
MT
MT
MT
MT
MT
MT
MT
MT
14
16
11
18
13
14
19
19
18
17
17
16
15
10
11
11
10
10
11
12
11
10
10
Flap dimension
length x width (cm)
6
7
5
8
7
6
8
7
7
7
8
8
7
7
6
7
8
7
8
9
9
8
7
Y
Y
N
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
N
Y
N
N
Diabetes
14
13
10
12
16
12
14
13
12
15
14
14
11
14
15
15
16
17
18
10
15
12
11
Time of
surgery (day)
Debridement
sessions
2
2
1
3
2
2
3
2
1
2
1
3
2
4
3
2
2
4
1
1
3
2
1
OR time
(min)
140
180
170
90
150
170
150
160
150
180
100
110
120
90
100
100
130
140
120
150
90
110
100
170 Vol. 44, No. 1 / Comparative Study Using Internal Pudendal Artery Perforator Flap
Table (2): Surgical and aesthetic outcome.
Hospital
stay (day)
3
3
5
4
4
4
4
3
5
3
2
2
3
2
3
3
3
2
3
3
2
2
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
No. Infection
Y
Y
N
N
N
N
N
N
N
N
Y
N
N
Y
N
N
N
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Hematoma
Scar
contracture
N
N
N
N
N
N
N
N
N
N
Y
N
N
Y
N
N
N
Y
N
N
N
N
N
Y
N
N
N
N
N
N
N
N
N
N
N
N
Y
N
N
N
N
N
N
N
N
N
Flap
loss
Y
N
N
N
N
N
N
N
N
N
N
N
N
Y
N
N
N
Y
N
N
N
N
N
Dehiscence
2ry
procedure
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Y
N
N
N
N
N
N
N
N
N
7
8
7
8
7
8
9
9
8
8
6
7
9
8
7
7
6
6
8
7
6
5
8
Aesthetic score
(0-10)
Table (3): Post-operative complications.
Flab
loss
10%
7.7%
A
B
Group
0%
0%
Hematoma
Wound
Dehiscence
20%
7.7%
Infection
20%
23%
2ry
procedure
10%
15.4%
20%
7.7%
Contracture
Group B Group A
Diagram (1): Intraoperative time in Group A and B.
Diagram (2): Average flap dimension, hospital stay and patients
satisfaction in Group A and B.
Group A Group B
16
14
12
10
8
6
4
2
0
Average
flab
length
Average
flab
width
Average
hospital
stay
Average
Likert
scale
Diagram (3): Post-operative complications in Group A & B.
25
20
15
10
5
0
Flab loss
Hematoma
Dehiscence
Infection
2ry
procedure
Contracture
Group A Group B
Egypt, J. Plast. Reconstr. Surg., January 2020 171
Fig. (2): Preparation of the recipient site: Photos from right to left showing the steps and significance of the cord and testicle
dissection to reach its normal caudal orientation.
Fig. (3): IPAP flap harvesting: Photos in the upper raw from the right to the left showing the dissection from lateral to medial
reaching the base and 90 degree rotation of the flap. Lower raw is the same but in the other side and suturing both
together I the mid line to create the mid line raphe.
Fig. (1): Marking the flap: The upper two photos
showing the IPAP flap marking showing the gluteal
crease and the perforators situated between the triangles
shown. The lower photo shows the design of the
superior medial flap in a hatchet design.
172 Vol. 44, No. 1 / Comparative Study Using Internal Pudendal Artery Perforator Flap
Fig. (4): Case 1, pre and post-operative photos of scrotal and perineal defect reconstructed by SMT flap.
Fig. (5): Case 2, pre and post-operative photos of scrotal and perineal defect reconstructed by SMT flap.
Fig. (6): Case 3, pre and postoperative
photos of scrotal and perineal
defect reconstructed by SMT flap.
Egypt, J. Plast. Reconstr. Surg., January 2020 173
Fig. (7): Case 4, pre and post-operative photos of scrotal and perineal defect reconstructed by SMT flap. The remaining
scrotal skin was used to cover the penis and the whole scotum was reconstructed with SMT flap.
Fig. (8): Case 5, pre and post-operative photos of scrotal and perineal defect reconstructed by IPAP flap. The remaining
scrotal skin was used to cover the root of the penis and the whole scotum was reconstructed with IPAP flap.
Fig. (9): Case 5, pre and post-operative photos of scrotal and perineal defect reconstructed by IPAP flap.
174 Vol. 44, No. 1 / Comparative Study Using Internal Pudendal Artery Perforator Flap
Fig. (10): Case 6, pre and postoperative
photos of scrotal and perineal
defect reconstructed by IPAP
flap.
Fig. (11): Case 7, pre and
post-operative photos of
scrotal and perineal defect
reconstructed by IPAP flap.
Fig. (12): Case 8, pre and post-operative
photos of scrotal and perineal defect reconstructed
by IPAP flap.
Egypt, J. Plast. Reconstr. Surg., January 2020 175
DISCUSSION
Fournier's gangrene was described by Baurienne
and Hebler. Male idiopathic severe genital gangrene
was described by Fournier in 1883, and Wilson
1952 explained it as necrotizing fasciitis [25].
Wound preparation and debridement is of utmost
and using the vacuum assisted closure therapy is
an option till definitive reconstruction is done.
However it is difficult to apply the dressing foam
and the adhesive film to this moist, contaminated
and irregular perineal, inguinal and scrotal region
[27,28]. In our study debridement was carried by
the colorectal team as shown in (Table 1) with an
average (2.130434783), and patients were transferred
to our department after general and local
wound improvement.
Scrotal and perineal reconstruction is complex
and it's clear from the different techniques mentioned
in the literature. The decision of choosing
a way of reconstruction depend on multiple factors:
The patients general condition and preference, the
wound site, size, condition and the surgical team
experience [29,30]. Testicular pocketing in the medial
thigh subcutaneous tissue was mentioned as an
option for temporary protection, but it cause pain,
psychological negative impact and testicular atrophy
[31-35]. We did not adopt this procedure in any
of our patients.
Scrotal defects with less than 50% could be
reconstructed with the primary closure or with the
residual myo-cutaneous residual scrotal tissue. For
losses >50%, or presence of perineal defects, other
ways of reconstruction to be considered as: Skin
grafting, local, regional or distant flaps [29,30, 36-
38]. All the patients in our study was having more
than 80% of scrotal tissue loss plus perineal defects.
Meshed split thickness skin graft is a good
option for reconstruction, however fixing the graft
to avoid shearing movements is very difficult,
presence of healthy tunica vaginalis is a must for
the graft take and the limited testicular mobility
after the graft 2ry contracture leading to chronic
pain. We used sheet grafts to cover defects over
the shaft of the penis and it is excluded from the
study [34,35,39].
Myo-cutaneous flaps as: The adductor minimums
myocutaneous flap [39], the gracilis myocutaneous
flap [41], the rectus abdominis flap [42],
and omental pedicle flaps [43], are very useful and
reliable, however their main disadvantage are the
donor site morbidity, bulky reconstruction, and
technically demanding [44].
Perforator flaps is an excellent tool in scrotal
reconstruction, including the thigh fasciocutanous
flaps as: Medial, superior and lateral, superomedial
and anterolateral thigh flap [45-52]. These flap are
technically not demanding with minimal donor site
morbidity however, they are claimed to be thick
and obliterate the perineoscrotal angle. Ferreira
[25] and Maguina 53 mentioned the advantage of
[30] using the SMT flap as a single stage reconstruction
with no change in the patient's position
on the surgical table. Mauro [54] showed low percentage
of ischemia and excellent esthetic outcome.
Elshahat mentioned the versatility of using the
hatchet flap in soft tissue reconstruction so we
utilized this concept in all our flaps [55]. As a
disadvantage, he considered the limitation of the
thigh diameter and the skin elasticity.
While utilizing the SMT flap we didn't change
the patient operative position. The average operative
time was (113±21.1 minutes) less than the IPAP
flap (143.8±30.1 minutes) and the average hospital
stay (2.6±0.5 days) were less than the IPAP flap
(3.4±0.97 days). Complications occurred in high
risk patients with diabetes hypertension and smokers.
Only one patient had partial flap loss which
required debridement and 2ry sutures. Infection
and dehiscence occurred in two patients which is
managed with daily dressings and unfortunately
resulted in 2ry contracture.
Internal pudendal artery perforator flap is close
to the perineal and scrotal regions so it doesn't
require tunneling, close the donor site primarily
in a hidden region [11]. Hong et al., [56] showed no
flap loss in in patients with perineal defects. Hashimato
et al., used the flap for vaginal and perineal
reconstruction with partial flap loss in 3 cases [22].
Lee et al., used the flap in 7 patients for scrotal
176 Vol. 44, No. 1 / Comparative Study Using Internal Pudendal Artery Perforator Flap
reconstruction, showing partial necrosis in one
patient [57].
IPAP flap entails the use of the lithotomy position,
which might explain the longer operative time
if compared to the SMT flap. The flap surface area
is larger in dimensions if compared to the SMT
flap (10.6±0.69cm) average length and (7.6±0.96
cm) average width comparing to the SMT flap
(15.9±2.43cm) average length and (7±0.9cm) average
width. See (Table 1) and Diagram (2).
Debulking of the flap was done in one patient
however it atrophy greatly after 3 to 6 months.
The aesthetic outcome with average aesthetic patient's
satisfaction is superior using the IPAP which
is (6.8±1.03) compared to the SMT (7.5±1.1), flap
Likert scale. One patient with diabetes, hypertension
and smoker had partial flap loss which required
debridement and 2ry sutures. Infection and dehiscence
occurred in two patients which is managed
with daily dressings and unfortunately resulted in
2ry contracture in one patient.
Conclusion:
We can conclude that both SMT flap and IPAP
flap are reliable and versatile option for the reconstruction
of huge scrotal and perineal region, showing
adequate functional and esthetic results. They
are easy to harvest, adequate with minimal morbidity.
The MTF is having the benefits of simple flap
design, no change in the patient's operative position,
less operative time and hospital stay but with
limited surface area to cover large defects of the
premium and less aesthetic outcome. While the
IPAP flap harvesting is more technically demanding,
patients prepared in lithotomy position, need
more operative time and hospital stay, however
they could cover extensive surface area of tissue
loss and more aesthetically pleasing to the patients.
Acknowledgments:
We would like to thank the residents and nursing
staff for their pre-operative, operative assistance
and post-operative care of the patients included in
the study at the Department of Plastic and Reconstructive
Surgery Ain Shams University El-
Demerdash Hospital.
