|Ahead of print
|Perineoscrotal reconstruction following fournier's gangrene using the upper medial thigh perforator flap
Fatih Irmak1, Selami Serhat Sirvan1, Mert Sizmaz1, Sevgi Kurt Yazar2, Arzu Akcal3, Semra Karsidag1
1 Department of Plastic, Reconstructive and Aesthetic Surgery, Health Sciences University, Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
2 Department of Plastic, Reconstructive and Aesthetic Surgery, Health Sciences University, Istanbul Training and Research Hospital, Istanbul, Turkey
3 Private Yaşam Hospitals, Antalya, Turkey
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Background: Fournier's gangrene (FG) is a synergistic necrotizing fasciitis that involves the genitalia, perineum, or anal region and can be life threatening and generally necessitates urgent surgical intervention. It often causes scrotal defects that require reconstruction after surgical debridement. The reconstruction of these serious scrotal defects poses certain challenges for surgeons. In this study, reconstruction of scrotal defects caused by FG with medial circumflex femoral artery perforator (MCFAP) flap evaluated. Patients and Methods: Seventeen patients with FG reconstructed using a MCFAP flap, admitted to our hospital between February 2003 and March 2017, are included in this study. Reconstruction with MCFAP flap results, mean debridement number, comorbid diseases, and length of hospital stay are analyzed together. Patients with FG reconstructed using techniques other than MCFAP were not included in this study. Results: Eighteen MCFAP flaps were performed in 17 patients. The mean duration of operation was 2 h 55 min. Diabetes mellitus was the most common comorbid disease. The mean days of hospital stay were 19.9. Total flap loss was not seen in 17 patients. Donor area of the flap is closed primarily, by V-Y advancement flaps or by split-thickness skin grafts. Acceptable cosmetic results and scrotal contours were obtained in all patients. No major complications were observed. Conclusions: Using a MCFAP flap, a method that has minimal donor site morbidity, requires single session surgery, provides good skin quality and color similar to the scrotum, is an easy-to-perform process, proving to be a reliable flap for scrotal reconstruction.
Keywords: Fournier's gangrene, medial circumflex femoral artery, perforator flap, reconstruction
|How to cite this URL:|
Irmak F, Sirvan SS, Sizmaz M, Yazar SK, Akcal A, Karsidag S. Perineoscrotal reconstruction following fournier's gangrene using the upper medial thigh perforator flap. Turk J Plast Surg [Epub ahead of print] [cited 2019 Apr 22]. Available from: http://www.turkjplastsurg.org/preprintarticle.asp?id=250623
| Introduction|| |
Fournier's gangrene (FG) is a synergistic necrotizing fasciitis that involves the genitalia, perineum, or anal region. This gangrene is generally caused by a mixture of aerobic and anaerobic microorganisms. The disease displays an insidious onset, progresses rapidly, and becomes fulminant. It may give rise to a serious defect sequel, even resulting in death, and is, therefore, considered a surgical emergency. As the testes are nourished by testicular arteries that are branches of the abdominal aorta, their blood supply is contained despite extended debridments. In the reconstruction of FG, covering the testes and preserving their function are essential. Reconstruction options are evaluated after the infection in the scrotal area is alleviated by serial debridement and IV broad-spectrum antibiotics. Negative pressure wound therapy, the closure of the wound by skin grafts, as well as fasciocutaneous and myocutaneous flaps are among first tier options. Hallock described how to use the medial circumflex femoral artery perforator (MCFAP) flap, nourished by perforator vessels passing through the gracilis muscle, for the reconstruction of major scrotal defects. Using a MCFAP flap is a single staged, functional, and muscle sparing (including the gracilis muscle) method that can be readliy applied for covarege of scrotal defects. This flap has minimal donor area morbidity.
In this retrospective study, patients with large scrotal and perineal defects reconstructed using MCFAP flaps are evaluated according to age, predisposing factors, time to surgical debridement, isolated bacteria, and the number of surgical debridements before reconstruction.
The fascial plexus holds an important place in the blood supply of the medial thigh area. Whetzel et al. found that adding fascia to the flap increases skin survival. This fascial plexus is fed by vessels extending in three rows, as anterior, medial, and posterior, along the extremity. The front (anterior) row is fed by the femoral artery through segmental arteries. The middle row is composed of musculocutaneous perforators originating from the gracilis and adductor longus muscles (profunda femoris). The back row is formed by musculocutaneous perforators from the adductor magnus muscle and arterial profunda femoris, as well as perforators passing between the gracilis and adductor magnus muscles. The MCFA, which arises from the deep femoral artery, enters the gracilis muscle 10 ± 2 cm below the pubic tubercle. It has been shown that perforators are present in a 6 cm × 6 cm area where the artery enters the muscle. In the injection studies of the MCFA, it has been shown that the skin area fed by it extends in parallel to the thigh creases instead of along the vertical axis as would be expected. Venous flow is usually provided by concomitant veins. Adding saphenous vein into the flap shall be effective in preventing venous congestion.
| Patients and Methods|| |
The principles of the Declaration of Helsinki were followed in this study. Patients whose scrotal defects were reconstructed with MCFAP flap between February 2003 and March 2017 years were evaluated. The inclusion criteria were defined as follows: having FG, having a defect that needs reconstruction, a minimum follow-up of 6 months for each subject, and patients with postoperative photographs. Patients who did not come to follow-up visits were excluded from the study. Patients with FG reconstructed using techniques other than a MCFAP flap were not included in this study. Age, sex, bacterial colonization, comorbid diseases, and the length of stay in the hospital were the factors analyzed.
The SPSS 15.0 (SPSS Inc, Chicago, IL, USA) for Windows program was used for statistical analyses. Descriptive statistics were listed as number and percentage for categorical variables and as mean, standard deviation, minimum and maximum for numeric variables. Two independent group comparisons of numeric variables were performed through the Mann–Whitney U-test since the normal distribution condition could not be provided. The statistical significance level was accepted as P < 0.05.
Prior to scrotal reconstruction, infection as the wound has to bve eliminated. The patient must be situated in the lithotomy position on the surgical table. This position allows for easy surgical intervention into the medial and posterior thigh region, also aids adductor longus muscle to be palpated in thin patients. A Foley catheter is inserted while the patient is draped. Gracilis musculocutaneous perforators are located 10 cm below the pubic tubercle, posterior to the adductor longus muscle, using a handheld audible Doppler. The flap is designed according to location of perforators and size of the defect. If the flap width is >8 cm, the donor area cannot be closed primarily. The incision is made from the posteroinferior margin of the designed flap. The gracilis muscle is detected by incising through the deep fascia. The posterior part of the flap is harvested, continuing until the posterior margin of the muscle is reached. The perforators are then exposed with a meticulous dissection of the gracilis muscle. Perforators which have sufficient calibration and pulsation are selected. Following this perforator selection, the remainder of the flap is harvested in the subfascial plane. Perforators are dissected up to the vascular hilum. The skin island between the flap and the testicular defect is incised. The flap is adapted to its new location by being rotated 180° on its pedicle. To decrease tension, the ipsilateral thigh should always be kept in adduction. Abduction of the thigh should be limited, until satisfactory healing is achieved.
| Results|| |
In this study, 17 patients with FG reconstructed with 18 MCFAP flap [Table 1]. The mean age of patients was 57.2 ± 23.6 (24–76). All patients were male. Escherichia More Details coli was mostly detected in tissue cultures that were taken during the first debridement procedure. The second most common organism detected in tissue cultures was Acinetobacter. The mean length of stay in hospital was 19.9 ± 10.3 days (6–50). The most common systemic disease accompanying FG in this group of patients was observed to be diabetes mellitus (DM). Eight of the 17 patients had DM. One of these patients with DM also had hypertension. Among this group of patients, one had chronic obstructive pulmonary disease, one had tuberculosis and simultaneous lymphoma, and one had acquired immune deficiency syndrome.
|Table 1: Perineoscrotal reconstruction patients using a medial circumflex femoral artery perforator flap|
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The median value of time that elapsed between the onset of the initial symptoms of FG and the first surgical debridement was 9 days (3–15). The average number of debridement for one patient was 2.1 (1–4). It is stated that the number of surgical debridements per patient increases when a comorbid disease is present (especially DM). The mean amount of time between the last surgical debridement and the reconstruction using a MCFAP flap was 7.6 days (4–12), and mean follow-up period was 19 months (6–34).
All of the perforators were musculocutaneous. The average defect size was 10.5 cm × 6.9 cm. The perforator found in one patient during the process of dissection was assessed as unreliable (low caliber, low pulsation, and small vessel diameter) and distally located. In this patient, the skin island at the posterior part of the flap was incised. This was used as a posterior-based transposition flap to cover the defect. This patient is excluded from the study [Figure 1]. The mean duration of operation was 2 h 55 min (2:15–4:20). In 14 of the 17 patients, the donor area was closed primarily. In two of these patients, the donor area was closed by designing a V-Y advancement flap to facilitate primary closure. The other patient's donor area was closed by split-thickness skin graft.
|Figure 1: (a) Fully exposed testes of a patient with Fournier's gangrene. (b) Distally located and unreliable perforator of the medial circumflex femoral artery which is not a suitable pedicle for the flap. (c) Preservation of the skin pedicle at the posterior part of the flap and rotation of the flap toward the defect. (d) Appearance of the adapted flap in the early postoperative period|
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In our group of patients, all of the flaps survived postoperatively. Leech therapy was applied to one flap, which showed signs of venous insufficiency. A complete resolution of symptoms was observed after this leech therapy. Marginal necrosis of the medial suture line was observed in two of the patients, and surgical site infection occurred in one patient. After the demarcation line of the necrosis was established in 4–5 weeks postoperatively, surgical debridement and secondary suturing were applied to the patients manifesting marginal necrosis. Full recovery through medical treatment was achieved in the patient with surgical site infection. None of the patients displayed lymphedema during the follow-up period. Satisfying esthetic and functional outcomes were achieved in all of the patients [Figure 2] and [Figure 3].
|Figure 2: (a) Fully exposed testes of a patient with Fournier's gangrene after serial debridement. (b) Perioperative view of the flap. (c) Complete recovery of the scrotal defect using a medial circumflex femoral artery perforator flap, primary closure of donor area, and neo-scrotum at 6 months postoperatively|
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|Figure 3: (a) Fully exposed testes of a patient with Fournier's gangrene after debridement of scrotal area. (b) View of the patient after reconstruction with medial circumflex femoral artery perforator flap, postoperative 2nd month results|
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| Discussion|| |
FG is an acute necrotizing infection that begins with scrotal (in male patients) or vulvar (in female patients) pain and hyperemia. The disease progresses rapidly and may cause gangrene in the genital region.
FG is not specific to male patients alone. For instance, Norton et al. presented a study that included 7 female cases among 33 patients (21%). In Eke's review of 1726 cases of FG, it was reported that the male-to-female ratio in FG was approximately 10:1. The reason for the low incidence of the disease in females is probably the increased regional drainage provided by vaginal secretions. All of the patients in our study were male. When the condition was first described by Jean Alfred Fournier, its etiology was unknown. Through numerous studies performed many risk factors associated with FG have been described. These are DM, local trauma, alcoholism, paraphimosis, perirectal or perianal infections, and previous surgeries. In fact, the mechanism resulting in the disease is thrombosis and the infection of small subcutaneous vessels, leading to skin necrosis.
In a study by Nisbet and Thompson, it was demonstrated that DM presence did not influence the length of hospital stay or the number of surgical debridements in cases of FG. In their sample group, 76.9% of the patients were found to suffer from DM.
In our study, the length of hospital stay and number of surgical debridements in patients with DM proved higher than patients without DM. This suggestion is statically significant (P = 0.001 and P = 0.003) [Table 2].
|Table 2: The effect of diabetes mellitus on the duration of hospital stay and number of debridements|
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Hyperbaric oxygen therapy involves intermittent inhalation of 100% oxygen under a pressure >1 atm. Despite its widespread use in FG, hyperbaric oxygen remains a controversial therapy. Our treatment approach in FG, on the other hand, is appropriate fluid resuscitation, antibiotics, and surgical debridement. In this study, all patients underwent adequate successive surgical debridements under optimal anesthesia in operation room conditions. Following the termination of the acute phase through adequate debridement, fluid resuscitation, and antibiotics, appropriate reconstruction options must be evaluated. In our study, reconstruction options were planned after the wound bed was prepared with the resolution of the infection and relief of symptoms. The optimum time of reconstruction remains an arguable matter. We preferred to perform the reconstruction as soon as the wound bed was in a suitable state. In a study by Kiliç et al., however, delayed reconstruction was preferred, with the operation being conducted 2–3 months after the completion of the last surgical debridement; and fair results were obtained.
When the testicles are exposed, Leydig cells cannot secrete hormones affecting spermatogenesis. Hence, an early reconstruction of the defect increases the patient's comfort, provides fast recovery, and moreover, yields functional testicles. In our group of patients, we did not observe any complications due to early reconstruction. It is obvious that covering testicles with a flap increases its temperature. Increased testicular temperature may disrupt spermatogenesis. This problem can be neglected in very elderly patients. However, young patients should be informed about negative effects of scrotal reconstruction with a flap on spermatogenesis and reproduction. The scrotum is a special tissue due to its unique thickness, color, and texture. It is not easy to obtain natural results in reconstructions using tissues that have similar qualities. Various treatment methods are described for defect reconstruction in cases of FG. These include skin grafts, muscle-skin flaps, scrotal advancement flaps, and healing by secondary intention.
Skin grafts cannot be used when the testicular tissue is exposed or tunica vaginalis is not intact. This procedure entails a long healing process and is difficult to adapt when the recipient area has irregular contours. Contraction is frequent in skin grafts.
Muscle and muscle-skin flaps are voluminous and therefore not suitable for scrotal reconstruction. Besides, they manifest high donor area morbidity.
Scrotal advancement flaps make for a good option when the defect is smaller in size than 50% of the scrotal skin.
Defects should be very small if they are to be left to heal by secondary intention.
In addition, none of the above-discussed flaps are as suitable as a MCFAP flap in terms of color and texture, and the MCFAP flap is not affected by any of the limiting factors as listed above. Its only handicap is that it does not allow for flap adaptation because perforators are sometimes unreliable or localized distant to the defect. For instance, in one patient in our study, it was not possible to move the perforator to the area of the defect because of its unreliable diameter and its penetration from the distal end of the flap. If the posterior skin is left intact during the flap planning and incision, it can be used as a pedunculated fasciocutaneous flap, giving us an option for plan B. Therefore, we also performed a posterior-based fasciocutaneous transposition flap in this patient. Another drawback in using this flap is that the learning curve is steep and that it requires technical flap elevation experience.
Moreover, the use of MCFAP flaps in obese patients will result in a very thick scrotum and thus should not be preferred.
As the MCFAP flap is harvested and adapted through the perforator, problems such as tension at the suture lines are not encountered. In addition, donor site morbidity is minimal; and in comparison with classical myocutaneous flaps, perforator flaps provide more subtle and favorable results.
| Conclusion|| |
Using a MCFAP flap, which has minimal donor site morbidity, requires single session surgery, provides good skin quality and color similar to the scrotum, is an easy-to-perform process, proving to be a reliable fl ap for scrotal reconstruction. It has perfect esthetic results in closing wide scrotal and perineal defects, especially when designed bilaterally.
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Conflicts of interest
There are no conflicts of interest.
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Department of Plastic Reconstructive and Aesthetic Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Halaskargazi Cad, Etfal Sk, 34371, Şişli, Istanbul
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]
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