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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 27  |  Issue : 3  |  Page : 132-136

Reconstruction after Fournier gangrene: Our approaches and outcomes


Department of Plastic, Reconstructive and Aesthetic Surgery, Balikesir Atatürk City Hospital, Balikesir, Turkey

Date of Web Publication4-Jul-2019

Correspondence Address:
Dr. Bilgen Can
Department of Plastic, Reconstructive and Aesthetic Surgery, Balikesir Atatürk City Hospital, Clinic 6 Eylül, Balikesir
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_77_18

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  Abstract 


Context: Fournier's gangrene is a necrotizing infection of the perianal region and scrotum. It progresses quite quickly and is fatal. Treatment involves debridement of the necrotized tissues, broad-spectrum antibiotherapy, and fluid replacement therapy. Delayed reconstruction can be planned after clinical stabilization. While there is a wide range of reconstruction options, no ideal method is applicable to all patients. Aims: By presenting our results for Fournier's gangrene reconstruction surgery at our center, we aim to discuss surgical approaches for the condition, and their pros and cons. Settings and Design: Retrospective analysis. Subjects and Methods: Sixteen patients who underwent Fournier's gangrene reconstruction in 2014–2018 at Balıkesir Atatürk City Hospital were analyzed retrospectively. The mean age, defect size and location, concomitant diseases, mean time to reconstruction, reconstruction method, hospital stay after reconstruction, and complication rates were reported. Results: All patients were male. The most common comorbidity was diabetes mellitus (75%). The mean time to reconstruction was 48.4 days. Scrotal flap alone was the most common reconstruction method (56.25%). Bilateral superomedial thigh flap was used in four patients with total scrotal defect (25%). Gracilis musculocutaneous flap was combined with scrotal flap for three patients (18.75%), with defect extending to the perianal region. The mean hospital stay after reconstruction was 8.6 days. Two patients (12.5%) developed wound dehiscence. Conclusions: No ideal method is applicable to all patients. Rather, the patient age, expectations, and general condition; defect characteristics; and the surgeon's experience determine the ideal method.

Keywords: Flap, Fournier, reconstruction


How to cite this article:
Can B. Reconstruction after Fournier gangrene: Our approaches and outcomes. Turk J Plast Surg 2019;27:132-6

How to cite this URL:
Can B. Reconstruction after Fournier gangrene: Our approaches and outcomes. Turk J Plast Surg [serial online] 2019 [cited 2019 Oct 21];27:132-6. Available from: http://www.turkjplastsurg.org/text.asp?2019/27/3/132/262132




  Introduction Top


Fournier's gangrene is a necrotizing fasciitis of the scrotal, perianal, and genital areas. It is fulminant and progresses very rapidly. The majority of patients are male and the area most commonly affected is the scrotum.[1] The disease is caused by the combination of polymicrobial infection and subcutaneous arteriolar microthrombosis. Often, a comorbidity that causes immunosuppression is present.

Treatment is a true emergency because the disease progresses very quickly. Early debridement of the affected tissues, broad-spectrum intravenous antibiotic therapy, and fluid resuscitation constitute the three main legs of the treatment plan.

After primary treatment, there is a need to reconstruct the large tissue defects in the scrotal and perianal regions. Reconstruction can be planned after clinical stabilization of the disease and eradication of infection. For reconstruction, repair with skin grafts[2] using residual scrotal tissue,[3] temporary or permanent adaptation of the testes into the medial thigh,[4] local fasciocutaneous flaps,[5] musculocutaneous flaps,[6] or even free flaps[7] can be used.

Despite the wide range of options available for reconstruction, no single method is ideal and applicable for all cases. In the present study, we present cases at our center who underwent reconstruction surgery after Fournier's gangrene and discuss the reconstruction methods reported in the literature.


  Subjects and Methods Top


Sixteen patients who underwent reconstruction after debridement of Fournier's gangrene in 2014–2018 at Balıkesir Atatürk City Hospital were analyzed retrospectively. The mean age, defect size and location, concomitant diseases, mean time to reconstruction, reconstruction method, mean hospital stay after reconstruction, and complication rates were evaluated. Informed consent was obtained from all patients.


  Results Top


The mean age of the 16 male patients was 57.25 (range, 37–72) years [Table 1]. The defect most commonly involved the scrotum. On an average, 62.5% of scrotal skin was lost (30%–100%). Three patients had gluteal region involvement. Comorbidity was present in 87% of patients, of which 75% was diabetes mellitus. The mean time to reconstruction was 48.4 days (25–67 days). The most commonly used reconstruction method was scrotal flap alone (56.25%) [Figure 1]a and [Figure 1]b. Bilateral superomedial thigh flap (SMTF) was used for four patients with total scrotal defect (25%) [Figure 2]a and [Figure 2]b. Gracilis musculocutaneous flap was used with scrotal flap for three patients (18.75%) who had defect extending to the gluteal region [Figure 3]a and [Figure 3]b. The mean hospital stay after reconstruction was 8.6 days. Two patients (12.5%) developed wound dehiscence and were treated with a conservative approach.
Table 1: Patient details

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Figure 1: (a) Scrotal defect after Fournier gangrene. (b) After reconstruction with scrotal flap

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Figure 2: (a) Total scrotal defect. (b) After reconstruction with superomedial tigh flap

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Figure 3: (a) Scrotal and perianal defect. (b) After reconstruction with scrotal flap and gracilis musculocutaneous flap

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  Discussion Top


Fournier's gangrene is a necrotizing fasciitis of the scrotal, perianal, and genital areas. It is frequently seen in men but can also occur in women. Together with subcutaneous arteriolar microthrombosis, polymicrobial infection caused by anaerobic and aerobic bacteria leads to gangrene in the affected tissues. Necrosis progresses quite rapidly, and there is 3%–67% mortality.[8]

Although it was described by Fournier in 1883 as a necrotizing infection in a healthy male patient without any cause,[9] the current definition of the disease is quite different, i.e., a necrotizing infection due to a specific cause in an old patient with a comorbidity.[10] In most patients, an initiating cause such as colorectal disease, perianal skin infection, or urinary infection is seen. Again, diabetes mellitus is the most common comorbidity.[5],[8] In the present study, diabetes mellitus was the most common comorbidity, which is in accordance with the literature.

As the disease progresses rapidly, treatment includes debridement of the necrotized tissues, broad-spectrum antibiotherapy, and fluid replacement therapy. After clinical stabilization of the disease and eradication of the infection, the scrotal and perianal defects warrant reconstruction surgery. The mean time from disease occurrence to defect reconstruction is 33–35 days.[5],[8] In the present study, the mean time to reconstruction was 48.4 days. This period involves clinical stabilization of the disease and preparation of the wound for reconstruction. At our center, the urology department monitored our patients during the period until reconstruction, and daily wound care was provided with conventional dressing methods. Vacuum-assisted closure (VAC) therapy following debridement has increased over the years.[11],[12],[13],[14] The literature shows that, with VAC, costs are decreased due to decreased wound-dressing changes, and patients have decreased need for pain killers; more importantly, the duration of hospital stay is decreased.[11],[12] In the present study, the average hospital stay following reconstruction is 8.6 days. For patients, most hospital stays involve clinical stabilization of the disease and preparation for reconstruction. Compared with the literature, the duration of stay at our hospital was longer. Therefore, more frequent coordination with the urology department prior to reconstruction and further research focusing on the application of VAC therapy would be beneficial.

Hyperbaric oxygen therapy is used as an adjuvant treatment in Fournier's gangrene. It increases optimal tissue oxygenation, and thus it is emphasized that it has a bactericidal effect on the anaerobic bacteria in the tissues affected by anaerobic and aerobic bacteria in Fournier's gangrene.[15] Midrup et al. compared patients who received hyperbaric oxygen therapy with those who did not after Fournier's gangrene.[16] They showed increased mortality and morbidity in patients who received hyperbaric oxygen therapy; thus, it is suggested that hyperbaric oxygen therapy should not be routinely used in Fournier's gangrene.

The most common site of Fournier's gangrene is the scrotum.[8] Therefore, reconstruction after Fournier's gangrene is performed mainly in the scrotum, and if necessary, in the perianal region. As the testis and spermatic cord blood supply are different from the skin circulation, the testes are not affected by the necrotic infection and are exposed after debridement of the scrotal skin. Covering the testes is another challenge for the plastic surgeon.

Due to its unique flexible structure, losses of up to 50% of scrotal skin can be repaired with scrotal musculocutaneous flaps.[17],[18] This is the most cosmetic and functional reconstruction. However, no specific reconstruction method is applicable to all patients, with >50% scrotal skin loss.

Skin grafts can be used in cases where the tunica vaginalis is protected. However, the difficulty in its adaptation to the base is a disadvantage for graft intake. Moreover, skin grafts are not widely used currently because their coverage is fragile and nonsensitive, as trauma and pain cause dyspnea in the testes because of the development of graft contracture, and are cosmetically unsatisfactory. Nevertheless, Tan et al. asserted that the graft softens within 6 months and even allows for testicular movement, and is also recommended particularly in elderly and comorbid patients because reconstruction with grafts can be easily applied and the duration of the operation is relatively short.[19]

It should be noted that the testes have such functions as secreting testosterone and ensuring spermatogenesis. To perform such functions, the testes must be at a lower temperature than the body. While no reconstruction method available can mimic the special environment provided by the scrotum, Demir et al. show in their experimental study that reconstruction with skin flap does not reduce spermatogenesis, whereas reconstruction with grafts leads to significantly decreased testicular volume and spermatogenesis, and they recommend reconstruction with skin flap.[20]

Another reconstruction method is the temporal or permanent adaptation of the testes into the medial thigh. In a study of 12 patients, Okwudili reported that the testes adapted to the medial thigh, passing down into the residual scrotal sac within 6 months through testicular massage.[4] Emphasizing that reconstruction shortens the length of hospital stay because it is a simple operation, the author also reported that testis volume is not decreased, based on ultrasonographic measurement of the postoperative testicular volume. However, the author did not report how spermatogenesis is affected. Similarly, residual infection in the testes leads to medial thigh pouch infection.[21] Considering that the literature states that it adversely affects spermatogenesis and has adverse cosmetic and psychosocial effects, we did not use this method for any of our patients.

In the present study, scrotal defect involved an average 62.5% of the scrotal skin. Only four patients had near-total scrotal defect. Thus, we ensured ideal reconstruction with scrotal flap alone in most of our patients (56.25%). We used SMTF for three patients with near-total skin defect. We encountered no complications. In the literature, the ideal method for scrotum reconstruction is described as one that is pliable, sensitive, trauma resistant, esthetically acceptable, and that would not lead to bulky formation, and local/locoregional fasciocutaneous flaps are recommended as the reconstruction option closest to the ideal.[22] Among these, functions such as the ease of surgical technique with SMTF stand out, ensuring single-stage reconstruction, reliable vascular feeding, and requiring no position change of the patient on the Surgical table.[5],[23] Our first choice for total and near-total scrotal skin defects is also SMTF.

The development of microsurgical techniques and angiosome mapping has enabled the use of perforating flaps in scrotum reconstruction. Coşkunfırat et al. did not encounter flap necrosis in seven patients who underwent surgery with medial circumflex femoral artery perforator flap.[24] The authors preferred this flap because it can be narrowed, and the flap is highly mobile when elevated over a single perforating artery and causes minimal morbidity at the donor site. However, it was not our first choice because it requires microsurgical experience and could take a long time in our patient group, especially those with serious comorbidities.

Other perforator flaps include the pudendal artery perforator flap[25] and inferior epigastric artery perforator flap.[26]

The medial thigh flap has been used successfully in cases where the defect extends to the perineum.[27],[28] We preferred using the gracilis musculocutaneous flap for defects extending to the perianal region. Among its advantages are the fact that muscle tissue is resistant to infection, as well as its cavity-filling effect. The fact that feeding of the skin island is suspicious, particularly in the distal one-third, is an important detail in flap planning. Therefore, the skin island should be positioned proximally to the muscle.[6],[29] Skin graft can be applied onto the muscle flap.[29]

In addition to these major methods, anterolateral artery thigh flap,[30] rectus abdominis muscle flap,[31] and omentum-free flap[7] are also used in scrotum reconstruction. In addition, Kwoni showed that scrotal defects of up to 75% could be repaired in one session with intraoperative expansion.[32]

Given this wide range of reconstruction methods, the ideal one should differ for each patient. The ideal method should be identified individually for each patient, and take into account parameters such as defect location and size, cavitation status, general status, patient age and expectations, and surgeon experience. With scrotal defects of up to 60%, we used scrotal musculocutaneous flap; for defects greater than 60%, we used bilateral SMTF, and for defects extending to the perianal region, we used the gracilis musculocutaneous flap. We have achieved successful results with this algorithm.

A weakness of the study is that it is impossible to compare methods due to the limited number of patients and to compare the performance of conventional reconstruction options on the limited number of patients. However, we believe that we present an algorithm that can be used particularly in the public hospital setting in Fournier's gangrene reconstruction by presenting the successful results we have obtained.


  Conclusions Top


No ideal method is applicable to all patients. Rather, the patient age, expectations, and general condition; defect characteristics; and the surgeon's experience determine the ideal method.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Erol B, Tuncel A, Hanci V, Tokgoz H, Yildiz A, Akduman B, et al. Fournier's gangrene: Overview of prognostic factors and definition of new prognostic parameter. Urology 2010;75:1193-8.  Back to cited text no. 1
    
2.
Maguiña P, Palmieri TL, Greenhalgh DG. Split thickness skin grafting for recreation of the scrotum following Fournier's gangrene. Burns 2003;29:857-62.  Back to cited text no. 2
    
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Norton KS, Johnson LW, Perry T, Perry KH, Sehon JK, Zibari GB. Management of Fournier's gangrene: An eleven year retrospective analysis of early recognition, diagnosis, and treatment. Am Surg 2002;68:709-13.  Back to cited text no. 3
    
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Okwudili OA. Temporary relocation of the testes in anteromedial thigh pouches facilitates delayed primary scrotal wound closure in fournier gangrene with extensive loss of scrotal skin-experience with 12 cases. Ann Plast Surg 2016;76:323-6.  Back to cited text no. 4
    
5.
Mello DF, Helene Júnior A. Scrotal reconstruction with superomedial fasciocutaneous thigh flap. Rev Col Bras Cir 2018;45:e1389.  Back to cited text no. 5
    
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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;60:1055-9.  Back to cited text no. 6
    
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Ng D, Tang CB, Kadirkamanathan SS, Tare M. Scrotal reconstruction with a free greater omental flap: A case report. Microsurgery 2010;30:410-3.  Back to cited text no. 7
    
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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.  Back to cited text no. 8
    
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Fournier AJ. Overwhelming Gangrene. Sem Med 1883;3:345.  Back to cited text no. 9
    
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Kiliç A, Aksoy Y, Kiliç L. Fournier's gangrene: Etiology, treatment, and complications. Ann Plast Surg 2001;47:523-7.  Back to cited text no. 10
    
11.
Assenza M, Cozza V, Sacco E, Clementi I, Tarantino B, Passafiume F, et al. VAC (Vacuum assisted closure) treatment in Fournier's gangrene: Personal experience and literature review. Clin Ter 2011;162:e1-5.  Back to cited text no. 11
    
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Silberstein J, Grabowski J, Parsons JK. Use of a vacuum-assisted device for Fournier's gangrene: A new paradigm. Rev Urol 2008;10:76-80.  Back to cited text no. 12
    
13.
Ozturk E, Ozguc H, Yilmazlar T. The use of vacuum assisted closure therapy in the management of Fournier's gangrene. Am J Surg 2009;197:660-5.  Back to cited text no. 13
    
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Cuccia G, Mucciardi G, Morgia G, Stagno d'Alcontres F, Galì A, Cotrufo S, et al. Vacuum-assisted closure for the treatment of Fournier's gangrene. Urol Int 2009;82:426-31.  Back to cited text no. 14
    
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Pizzorno R, Bonini F, Donelli A, Stubinski R, Medica M, Carmignani G, et al. Hyperbaric oxygen therapy in the treatment of Fournier's disease in 11 male patients. J Urol 1997;158:837-40.  Back to cited text no. 15
    
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Mindrup SR, Kealey GP, Fallon B. Hyperbaric oxygen for the treatment of Fournier's gangrene. J Urol 2005;173:1975-7.  Back to cited text no. 16
    
17.
Por YC, Tan BK, Hong SW, Chia SJ, Cheng CW, Foo CL, et al. Use of the scrotal remnant as a tissue-expanding musculocutaneous flap for scrotal reconstruction in Paget's disease. Ann Plast Surg 2003;51:155-60.  Back to cited text no. 17
    
18.
Karian LS, Chung SY, Lee ES. Reconstruction of defects after fournier gangrene: A systematic review. Eplasty 2015;15:e18.  Back to cited text no. 18
    
19.
Tan BK, Rasheed MZ, Wu WT. Scrotal reconstruction by testicular apposition and wrap-around skin grafting. J Plast Reconstr Aesthet Surg 2011;64:944-8.  Back to cited text no. 19
    
20.
Demir Y, Aktepe F, Kandal S, Sancaktar N, Turhan-Haktanir N. The effect of scrotal reconstruction with skin flaps and skin grafts on testicular function. Ann Plast Surg 2012;68:308-13.  Back to cited text no. 20
    
21.
Choe JM, Battino BS, Benedict J, Bell TE. Myositis and myonecrosis of the thigh: An unusual complication of a testicular thigh pouch. J Urol 2001;165:1217.  Back to cited text no. 21
    
22.
Mopuri N, O'Connor EF, Iwuagwu FC. Scrotal reconstruction with modified pudendal thigh flaps. J Plast Reconstr Aesthet Surg 2016;69:278-83.  Back to cited text no. 22
    
23.
Hirshowitz B, Peretz BA. Bilateral superomedial thigh flaps for primary reconstruction of scrotum and vulva. Ann Plast Surg 1982;8:390-6.  Back to cited text no. 23
    
24.
Coskunfirat OK, Uslu A, Cinpolat A, Bektas G. Superiority of medial circumflex femoral artery perforator flap in scrotal reconstruction. Ann Plast Surg 2011;67:526-30.  Back to cited text no. 24
    
25.
Lee SH, Rah DK, Lee WJ. Penoscrotal reconstruction with gracilis muscle flap and internal pudendal artery perforator flap transposition. Urology 2012;79:1390-4.  Back to cited text no. 25
    
26.
Murakami M, Hyakusoku H, Matsuzawa I, Kondo Y, Akimoto M. Scrotal reconstruction with a thinned flap based on both inferior epigastric arteries. Case report. Scand J Plast Reconstr Surg Hand Surg 2001;35:99-101.  Back to cited text no. 26
    
27.
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  [Full text]  
28.
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29.
Katusabe LJ, Balumuka D, Hodges A. Scrotal reconstructıon wıth a pedıcled gracılıs muscle flap after debrıdement of Fournıer's gangrene: A case report. East Afr Med J 2013;90:375-8.  Back to cited text no. 29
    
30.
Yu P, Sanger JR, Hani S. Anterolateral thigh fasciocutaneous island flaps in perineoscrotal reconstruction. Plast Reconstr Surg 2002;109:610-6.  Back to cited text no. 30
    
31.
Young WA, Wright JK. Scrotal reconstruction with a rectus abdominis muscle flap. Br J Plast Surg 1988;41:190-3.  Back to cited text no. 31
    
32.
Kwon EO, Pareek G, Fracchia JA, Armenakas NA. Scrotal reconstruction using rapid intraoperative tissue expansion: A preliminary report. J Urol 2008;179:207-9.  Back to cited text no. 32
    


    Figures

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    Tables

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