Scrotal raw areas are a source of morbidity and of great concern to the patients inflicted with this problem. These patient are commonly referred to the Plastic Surgery service for definitive treatment and coverage of the defect. Most of the cases of scrotal
raw area are seen as a result of diabetic patients who develop Fournier's gangrene and require radical debridement. Fournier's gangrene is usually a consequence of a polymicrobial infection with E.coli (aerobic), bacteriods (anaerobic) and streptococci (aerobic and anaerobic) [1,2].
It can be fatal if not treated aggressively with wide radical debridement of the affected tissue and administration of intravenous antibiotic targeting both aerobes and anaerobes.
Once the initial wound debridement has been completed and the infection has been eradicated; the testicles are usually exposed between the medial aspects of the thighs. This mandates proper coverage of the defect and reconstruction of the scrotum . The objective of this case series is to present the results of scrotal reconstruction, in 11 cases of near total to total scrotal defects, using bilateral Singapore flaps.
A total of 11 patients were included in this study. All patients were male, with total or near total scrotal defects following debridement of Fournier's gangrene. The patient's ages ranged from 39 to 62 years old. Ten out of the eleven patients were known diabetics. Seven patients had near total scrotal defects and four patients had total scrotal defects (Table 1).
The same surgical protocol was followed in all cases:
- Wide surgical debridement of all infected tissues
- A wound swab was sent for culture and sensitivity
- Twice daily povidone iodine based wound dressing was done after the application of 1% acetic acid soaked gauze for 5 minutes
- All patients received intravenous clindamycin, which was then changed in some cases based on the sensitivity results
- Surgical planning was deferred until the wound was clinically clean and the repeated wound swab did not show any bacterial growth
• All cases were managed with bilateral Singapore flap (Pudendal thigh flap) which is based on the posterior scrotal artery from internal pudendal artery and innervated by the pudendal nerve and cutaneous branches from the posterior cutaneous nerve of the thigh [4,5].
The perforator of the flap was marked preoperatively using a hand held Doppler. It was consistently found to be located in the vicinity of the ischial tuberosity. The flap was designed in an inverted 'U' shape with length up to 15 cm and width 6-8 cm; in order to aid in the primary closure of the donor site defect (Figure 1).
The patients were put in lithotomy position, following the preoperative marking (Figure 2).
(Figure 1). Abstract drawing demonstrating the position of the patient, the defect area (shown in red), and the position of the flaps on either side.
In each case, lidocaine with adrenaline solution was used for infiltration along the incision lines. The incision was made laterally and deepened to the fascia without incising it. Prior to incision of the fascia, 5 cm of dissection was performed, and then the fascia was incised and included in the flap. This was done to avoid bulkiness in the distal part of the flap.
The donor area was closed primarily in 2 layers once the flap was raised. The flap was then inset to the defect and secured in place by suturing in layers. Two closed suction drains were placed in the donor area in all cases. On average, the drains were removed after 48 hours (Figure 2).
All patients received postoperative prophylactic antibiotics in the form of intravenous cefazolin for 48 hours, followed by oral cephalexin for one week. Patients were discharged on the second or third postoperative day, and they all had their first postoperative visit in the outpatient clinic one week later. Patient had follow up appointments at 1 and 6 months postoperatively
Results and Discussion
Surgical reconstruction of near total or total scrotal defects using the Singapore flap was done for 11 patients who underwent debridement as a treatment for Fournier's gangrene. The flap survival rate was found to be 100% in all cases and none of the postoperative patients required revision of the flap. At the one month postoperative visit, all patients presented with stable, viable flaps. All flaps proved to be exceptional color matches to the surrounding tissue (Figures 3 and 4) and demonstrated excellent pain and light touch sensation. All patients reported high levels of satisfaction in regards to the esthetic appearance as well as the functionality and sensation of their new scrotum (Table 1).
The pudendal thigh flap which is also known as the Singapore flap, is an excellent choice for reconstruction of major scrotal defects. It restores the scrotum with like tissue and provides excellent sensation to the neo-scrotum.
Singapore flap reconstruction is a very versatile technique and can be achieved as a single stage procedure. It allows for exceptional color match and excellent sensation for both pain and light touch in the new scrotum. The patients in this study have attested to a high level of satisfaction in regards to esthetics and functionality of the new scrotum, and therefore, we have concluded that the Singapore flap is a superior choice in scrotal defect coverage and reconstruction.