Scrotal Reconstruction Using Gracilis Muscle Flap in Fournier’s Gangrene

Sug Won Kim, MD, Bom Jin Kim, MD and Chul Hwan Seul, MD

INTRODUCTION: Fournier’s gangrene is a rare but fatal form of acute necrotizing fasciitis in the perineum and external genitalia in men. In some cases, it is characterized by the rapid clinical progression from an infection by a combination of both aerobic and anaerobic bacteria. Although the early symptoms are similar to those of acute testicular disease, active early intervention such as extensive debridement, drug therapy using broad-spectrum antibiotics and hyperbaric oxygen therapy, are needed to stop the necrosis initially because the infection spreads quickly once the gangrene develops. Many authors reported the use of a skin graft, fascial flap transfer and muscle flap transfer in reconstructing soft tissue defects in the scrotum, perineum, and the anterior abdominal wall in severe cases.We reconstructed defects in the scrotum, perineum, and anterior abdominal wall due to Fournier’s gangrene using a gracilis muscle flap and a skin graft, and obtained cosmetically satisfactory results with an appropriate scrotal volume.

PATIENTS AND METHODS: We have experienced nine patients with Fournier’s gangrene who underwent a soft tissue reconstruction using a piece of unilateral or bilateral gracilis muscle flap from 1999 to 2005. Ages ranged from 23 to 75 years (mean age, 48.3 years), and the mean hospital stay was 69.5 days (range, 46 to 96 days).Extensive debridement was carried out in all patients at the early stage and additional debridement was performed when needed. In addition, eight out of nine patients underwent combined hyperbaric oxygen therapy and walking exercise in an attempt to promote wound healing and prevent flap atrophy. Hyperbaric oxygen therapy was given by placing the patient into a Hyperbaric Chamber Monoplace (Choongwae Machinery Corporation, Seoul, Korea) for 90 min a day at 2 atmospheric pressures when the patient was relatively stable after the diagnosis or after the early debridement. The patients were asked to perform adduction motion of the thigh and to walk after training the patients and their guardians in how to perform these exercises. Hyperbaric oxygen therapy and exercise therapy were performed during the same period. The scrotal reconstruction was carried out after carefully performing extensive debridement in an attempt to correct the deformity due to spermatic cord contracture and to prevent damaging the testes and cord. At that time, the maximum removal of granulation tissue in the remaining internal spermatic fascia was done in order to obtain a natural testes drop. The gracilis muscle was elevated according to the conventional method. It was dissected from the origin to its insertion site to obtain the length of a flap sufficient to cover up to the penoscrotal junction through a subcutaneous tunnel (Figure 1). An attempt was made to prevent flap atrophy by not severing the obturator nerve distributing the gracilis muscle in the last seven patients who underwent the reconstruction.

RESULTS: The five patients had diabetes, and among these patients, one patient had liver cirrhosis also. Another patient had hypertension, whereas two had no special medical history (Table I). There was no necrosis extending to the tunica vaginalis in any of these patients. The defect area was covered with bilateral gracilis muscle flaps in the six patients who underwent extensive debridement in the scrotum, external genitalia and abdominal wall. A unilateral gracilis muscle flap was used in three patients who underwent debridement limited to one scrotum and partial inguinal or perianal area. Urinary diversion was performed in all patients, and fecal diversion was done in one patient. The average period of hospitalization was 69.5 days (range, 46 to 96 days). The average period of hyperbaric oxygen therapy and exercise was 13 days (range: 0 to 23 days). No recurrence and special complications were noted during the time of hospitalization. Cosmetically satisfactory results were observed in all patients.

TABLE I. Clinical evaluation of the Fournier’s gangrene patients

Case
No. / Age
(year) / Duration of symptoms
(day) / Cause / Associated condition / Surgical treatment / Days in hospital / Duration of hyperbaric and physical therapy(day)
1 / 39 / 2 / hemorrhoid / None / Debridement,
bilateral gracilis muscle flap transposition, and S.T.S.G. / 55 / 23
2 / 68 / 2 / hemorrhoid / DM / Debridement,
bilateral gracilis muscle flap transposition, and S.T.S.G. / 82 / 12
3 / 54 / 15 / undetermined / None / Debridement,
unilateral gracilis muscle flap transposition, and S.T.S.G. / 51 / 20
4 / 48 / 3 / undetermined / DM / Debridement,
bilateral gracilis muscle flap transposition, and S.T.S.G. / 82 / 0
5 / 43 / 14 / perianal
abscess / DM / Colostomy, debridement,
unilateral gracilis muscle flap transposition, and S.T.S.G. / 46 / 10
6 / 42 / 30 / perianal & scrotal / LC / Debridement,
unilateral gracilis muscle flap transposition, and S.T.S.G. / 65 / 0
7 / 43 / 30 / undetermined / DM, LC / Debridement,
bilateral gracilis muscle flap transposition, and S.T.S.G / 82 / 0
8 / 75 / 1 / undetermined / HTN / Debridement,
bilateral gracilis muscle flap transposition, and S.T.S.G. / 96 / 24
9 / 23 / 4 / Undetermined / DM / Debriidement,
bilateral gracilis muscle flap transposition, and S.T.S.G / 67 / 0

CONCLUSIONS: Fournier’s gangrene was actively treated by prompt extensive debridement, antibiotics therapy, and hyperbaric oxygen therapy. The soft tissue defect in the scrotum, perineum and anterior abdominal wall as a result of the debridement were reconstructed using gracilis muscle flap transfer and skin graft. Functionally and cosmetically satisfactory outcomes with appropriate scrotal volume were obtained.

Figure 1. Illustrations of the surgical sequence. (Left) The grailis muscle was elevated at both thighs. (Center) It was dissected from the origin to its insertion in order to obtain the length of a flap sufficient to cover up the penoscrotal junction through a subcutaneous tunnel. (Right) Donor site was repaired and a skin graft was performed on the gracilis muscle flap.

Figure2. A 39-year old man. (Left) Before reconstruction, the denuded testicles with granulation tissue was noted. (Right) Appearance one month after surgery.

Figure 3. A 68-year old man. (Left) The soft tissue defect was noted on the scrotum and lower abdomen before the reconstruction. (Right)Appearance one month after surgery.

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