|Year : 2018 | Volume
| Issue : 3 | Page : 116-121
Medial thigh flap: An eminent method of reconstruction of scrotal defect following fournier's gangrene
Imran Ahmad, Rajesh Kumar Maurya, Ali Adil Mahmud, Brajesh Pathak, Sudheer Kumar Maurya, Agrawal Lalit Harswarup
Department of Plastic and Reconstructive Surgery, JNMCH, Aligarh, Uttar Pradesh, India
|Date of Web Publication||2-Jul-2018|
Rajesh Kumar Maurya
Flat No. 301, Ohad Homes Welfare Society Apartment, Medical Road, Zakaria Market, Aligarh 202 001, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background and Objectives: Fournier's gangrene is a rare, rapidly progressive, fulminant form of necrotizing fasciitis of the genital, perianal, and perineal regions. It is characterized by progressive spread of necrosis in the skin and subcutaneous tissue which results in defects of various sizes in perineal region. Various techniques have been described for the reconstruction of these defects such as split thickness skin grafts, muscle flaps (e.g., Gracilis flap), and fasciocutaneous flaps (e.g., pudendal flap), perineal flap, anterolateral thigh flap, deep inferior epigastric perforator flap, and anteromedial thigh flap. We intend to study the results of medial thigh flap procedure in patients with scrotal defect following Fournier's gangrene. Materials and Methods: Medial thigh flap was performed in eight patients with Fournier's gangrene. The patients were selected consecutively from December 2016 to December 2017. All patients were followed for 3-6 months postoperatively. Results: All flaps survived well. However, in two cases, there was partial distal necrosis. Both cases were managed conservatively. In all cases, donor site healed well except for one case in which infection of the donor site suture line occurred. It was managed by frequent dressing. Interpretation and Conclusions: The medial thigh flap is a reliable fasciocutaneous flap which can be done in reasonably short operative time to cover difficult defects with excellent results.
Keywords: Fasciocutaneous flap, Fournier′s gangrene, medial thigh flap
|How to cite this article:|
Ahmad I, Maurya RK, Mahmud AA, Pathak B, Maurya SK, Harswarup AL. Medial thigh flap: An eminent method of reconstruction of scrotal defect following fournier's gangrene. Turk J Plast Surg 2018;26:116-21
|How to cite this URL:|
Ahmad I, Maurya RK, Mahmud AA, Pathak B, Maurya SK, Harswarup AL. Medial thigh flap: An eminent method of reconstruction of scrotal defect following fournier's gangrene. Turk J Plast Surg [serial online] 2018 [cited 2019 Mar 20];26:116-21. Available from: http://www.turkjplastsurg.org/text.asp?2018/26/3/116/235788
| Introduction|| |
Fournier's gangrene is a fulminant form of necrotizing fasciitis of the genital, perianal, and perineal regions. It is characterized by progressive spread of necrosis in the skin and subcutaneous tissue along with polymicrobial infection caused by both aerobic and anaerobic bacteria.  Any trauma in the perineal region or infection in the urinary tract forms the initial focus of disease. 
Fournier's gangrene is seen generally in immunocompromised patients such as diabetic, HIV seropositive, alcoholic, elderly, and malnourished.
Various techniques that have been described for the reconstruction of these defects are split-thickness skin grafts,  muscle flaps (e.g., Gracilis flap),  fasciocutaneous flaps (e.g., pudendal flap),  perineal flap,  anterolateral thigh flap,  deep inferior epigastric perforator flap,  and anteromedial thigh flap. 
| Materials and Methods|| |
Medial thigh flap was performed in eight patients with Fournier's gangrene admitted in Plastic and Reconstructive Surgery Department of JNMCH, Aligarh, which is a tertiary care center in Northern India. The patients were selected consecutively from December 2016 to December 2017. Mean age of patients was 50 years (range 33-65 years). After extensive debridement of Fournier's gangrene, all patients presented with soft-tissue defects of scrotal and perineal areas [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] and [Figure 6]. Unilateral medial thigh flap coverage was done in all patients. All patients were followed for 3-6 months postoperatively.
|Figure 1: Case 1: Scrotal defect following debridement of Fournier's gangrene|
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|Figure 6: Case 2: Scrotal defect following debridement of Fournier's gangrene|
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All patients were subjected to the following:
- Personal information such as age and gender
- History of presenting complaints including onset of symptoms, course of disease, and duration of symptoms
- Past medical and surgical history, to rule out diabetes mellitus, alcoholism, and any previous trauma or surgery
- Routine preoperative investigations.
Anatomical basis of the flap
The medial thigh flap is based on septocutaneous branch of femoral artery. The axis of the flap is a line joining the apex of the femoral triangle and the medial femoral condyle. The skin territory of the flap extends from the inferior aspect of the femoral triangle to the junction of the middle and distal thirds of the medial thigh. The lateral edge of adductor longus and the medial edge of rectus femoris muscle make the lateral border of flap. 
All patients were operated under general anesthesia. The axis of the flap was a line joining apex of femoral triangle to the medial femoral condyle [Figure 11]. The dominant pedicle was located at the apex of the femoral triangle around 6-8 cm below the inguinal ligament and it was detected preoperatively by Doppler examination. The width of the flap ranged from 7 to 11 cm, whereas the length ranged from 15 to 25 cm [Figure 2] and [Figure 7]. Dissection was done distally to proximal in the subfascial distal plane over the muscle [Figure 3] and [Figure 8]. After harvesting, flap was rotated to cover the testicular and perineal area and creating a scrotum with tension-free inset [Figure 4] and [Figure 9].
The donor sites were managed by either directly closing them (6 patients) or by doing a split-thickness skin graft (2 patients).
All patients had to restrict their movements in bed for 1 week. Antibiotics were continued for 10 days postoperatively. Stitches were removed after 10 days and the patients were kept under follow-up for 3-6 months [Figure 5] and [Figure 10].
| Results|| |
The age range of patients was 33-65 years with a mean age of 50 years. All of the patients had involvement of scrotum only except one patient whose perineum was also involved [Table 1].
All flaps survived well in the postoperative period. However, in two cases, there was partial distal necrosis. Both cases were managed conservatively. Transient loss of sensation over anterior part of thigh was seen in one patient and bulky flap in another patient [Table 2].
Wound dehiscence of about 2 cm was seen in two patients at donor sites which was treated by direct closure. In all cases, donor site healed well except for one case in which infection of the donor site suture line occurred. It was managed by frequent dressing [Table 3].
| Discussion|| |
Fournier's gangrene is an acute idiopathic necrotizing fasciitis of scrotum and perineum having high mortality and morbidity. Those patients who have diabetes, liver cirrhosis, alcoholism, uremia, and malignancy are high-risk candidates for this disease.  Common organisms which have been found in Fournier's gangrene are streptococcus, staphylococcus, Escherichia More Details Coli, and anaerobes. 
In patients with Fournier's gangrene, reconstruction of scrotum is a major challenge because of functional, psychological, and cosmetic reasons.  Several procedures have been described for the reconstruction of scrotal defect. The appropriate method of reconstruction is decided after taking into account patient's general condition, the extent of soft tissue defect, and viability of surrounding skin. 
Balakrishnan was the first one to use a skin graft to manage scrotal defect.  The presence of healthy granulation tissue and intact tunica vaginalis increase the success rate of above-mentioned procedure.  Despite having a good cosmetic result, the problems that beset this method are contractions, less mobility, and poor protection of the underlying testicles. 
Wolach et al.  mobilized the testes to medial thigh subcutaneous pouches in 40% of his patients. This method has a high success rate  and requires less surgical skill with lesser morbidity. However, disadvantages such as unsuitable environment for testicular function which can cause possible atrophy, feminine appearance, pain, tension, and fullness sensation again rule out this as the procedure of choice. 
Flap coverage has reliable vascularity, durability, functional expendability, and proximity to the perineum and is clearly superior to the use of skin grafts or local flaps of limited dimensions under similar circumstances.  Features for ideal reconstructive procedure are a single-stage procedure, good flap reliability, and appropriate flap sensation. 
The fasciocutaneous flap of inner thighs has excellent vascularization because of the presence of branches of the femoral artery (internal and circumflex pudendal), making the flap very reliable in diabetic and patients with ischemic disease.  Furthermore, it can be done in short operative time to cover difficult defects. Hallock  reported the same flap for scrotal reconstruction following Fournier's gangrene.
In this study, we used medial thigh flap coverage in eight patients with scrotal soft-tissue loss. All flaps survived well except for minor complications such as partial distal necrosis in only two patients. Both cases were managed conservatively. The flaps showed good sensation except for the transient loss of sensation over anterior part of thigh in one patient which he regained in the follow-up period. These advantages were comparable to that reported by Ferreira et al.  in their review of the management of 43 patients with Fournier's gangrene.
Donor site complications such as wound dehiscence and infection of the donor site suture line were seen in two patients and one patient, respectively. The direct closure was done for wound dehiscence, and infection was managed by frequent dressing. These minor complications were comparable to that reported by Ferreira et al.  and other flap techniques. 
Gracilis musculocutaneous flap and medial thigh fasciocutaneous flap have the same cutaneous territory and the donor site defect; however, the later has the advantage of being easier and faster to raise, less bulky, easier to transpose, and provides thin pliable skin.  Other pedicled thigh fasciocutaneous flaps have been described such as laterally based superomedial thigh flap, which is raised on the proximal medial thigh. However, they appear less versatile than the medial thigh flap.  Hayashi and Maruyama  used an anteromedial thigh fasciocutaneous flap for the reconstruction of the groin and lower abdominal wall. Hupkens et al.  classified the anteromedial thigh perforators anatomically. Song et al.  have previously described its use as a free flap for the reconstruction of the neck and forearm. Yu et al.  used the anterolateral thigh fasciocutaneous island flap in perineoscrotal reconstruction. This is not only more difficult to dissect but also more bulky and far from the defect.
| Conclusions|| |
The medial thigh fasciocutaneous flap provides durable and protective cover for perineoscrotal defects. This flap offers single stage, stable, and well-vascularized soft tissue coverage in scrotal defect cases without significant major complication.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nomikos IN. Necrotizing perineal infections (Fournier's disease): Old remedies for an old disease. Int J Colorectal Dis 1998;13:48-51.
Bhatnagar AM, Mohite PN, Suthar M. Fournier's ganagrene: A review of 110 cases for aetiology, predisposing conditions, microorganisms, and modality for coverage of necrosed scrotum with bare testes. N Z Med J 2008;121:46-56.
Maguiña P, Palmieri TL, Greenhalgh DG. Split thickness skin grafting for recreation of the scrotum following Fournier's gangrene. Burns 2003;29:857-62.
Ioannovich J, Kepenekidis A, Stamatopoulas K, Matar N. Use of gracilis musculocutaneous flap in tissue loss caused by Fournier's gangrene. A propos of 4 cases. Ann Chir Plast Esthet 1998;43:58-63.
Coruh A, Akcali Y, Ozcan N, Ekmekcioglu O. Modified pudendal thigh flap for perineoscrotal reconstruction: A case of Leriche syndrome with rapidly progressing Fournier's gangrene. Urology 2004;64:1030.
Core GB, Bite U, Pemberton JH, Petty PM. Sliding V-Y perineal island flaps for large perianal defects. Ann Plast Surg 1994;32:328-31.
Yu P, Sanger JR, Matloub HS, Gosain A, Larson D. Anterolateral thigh fasciocutaneous island flaps in perineoscrotal reconstruction. Plast Reconstr Surg 2002;109:610-6.
Zeng A, Xu J, Yan X, You L, Yang H. Pedicled deep inferior epigastric perforator flap: An alternative method to repair groin and scrotal defects. Ann Plast Surg 2006;57:285-8.
El-Majeed MA. Evaluation of anteromedial thigh fasciocutaneous flap for scrotal reconstruction. Egypt J Plast 2007;31:149-55.
Ayad WM, Al-Shahat OA, Zaied E, Albanooby T, Taman E. The versatility of medial thigh flap for reconstruction of post-Fournier's gangrene complex perineoscrotal defects. J Plast Reconstr Surg 2011;35:129-32.
Karian LS, Chung SY, Lee ES. Reconstruction of defects after fournier gangrene: A systematic review. Eplasty 2015;15:e18.
Singh A, Ahmed K, Aydin A, Khan MS, Dasgupta P. Fournier's gangrene. A clinical review. Arch Ital Urol Androl 2016;88:157-64.
Kim KS, Noh BK, Kim DY, Lee SY, Cho BH. Thin paraumbilical perforator-based cutaneous island flap for scrotal resurfacing. Plast Reconstr Surg 2001;108:447-51.
Balakrishnan C. Scrotal avulsion: A new technique of reconstruction by split-skin graft. Br J Plast Surg 1956;9:38-42.
Finical SJ, Arnold PG. Care of the degloved penis and scrotum: A 25-year experience. Plast Reconstr Surg 1999;104:2074-8.
Wolach MD, MacDermott JP, Stone AR, deVere White RW. Treatment and complications of Fournier's gangrene. Br J Urol 1989;64:310-4.
Selvan SS, Alagu GS, Gunasekaran R. Use of a hypogastric flap and split-thickness skin grafting for a degloving injury of the penis and scrotum: A different approach. Indian J Plast Surg 2009;42:258-60.
] [Full text]
Tiwari IN, Seth HP, Mehdiratta KS. Reconstruction of the scrotum by thigh flaps. Plast Reconstr Surg 1980;66:605-7.
Wee JT, Joseph VT. A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps: A preliminary report. Plast Reconstr Surg 1989;83:701-9.
Monteiro E, Carvalho P, Costa P, Ferraro A. "Inner thigh lift flap" for Fournier gangrene of the scrotum. Plast Reconstr Surg 2002;110:1372-3.
Hallock GG. Scrotal reconstruction following Fournier's gangrene using the medial thigh fasciocutaneous flap. Ann Plast Surg 1990;24:86-90.
Ferreira PC, Reis JC, Amarante JM, Silva AC, Pinho CJ, Oliveira IC, et al.
Fournier's gangrene: A review of 43 reconstructive cases. Plast Reconstr Surg 2007;119:175-84.
Bostwick J 3 rd
, Hill HL, Nahai F. Repairs in the lower abdomen, groin, or perineum with myocutaneous or omental flaps. Plast Reconstr Surg 1979;63:186-94.
Har-Shai Y, Hirshowitz B, Marcovich A, Eliachar I, Peretz BA. Blood supply and innervation of the supermedial thigh flap employed in one-stage reconstruction of the scrotum and vulva - An anatomical study. Ann Plast Surg 1984;13:504-10.
Hayashi A, Maruyama Y. The use of anteromedial thigh fasciocutaneous flap in the reconstruction of the lower abdomen and inguinal region: Areport of two cases. Br J Plast Surg 1988;41:633-8.
Hupkens P, Van Loon B, Lauret GJ, Kooloos JG, Vehof JW, Hartman EH, et al.
Anteromedial thigh flaps: An anatomical study to localize and classify anteromedial thigh perforators. Microsurgery 2010;30:43-9.
Song YG, Chen GZ, Song YL. The free thigh flap: A new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984;37:149-59.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
[Table 1], [Table 2], [Table 3]