Various Options for Scrotal Reconstruction: A Prospective Observational Study

Background Scrotal defects in developing countries are common challenges for the reconstructive surgeon and hence this work has been done with the aim to compare the outcome, advantages and disadvantages of different modalities of scrotal reconstruction. Methods The prospective observational hospital-based study of reconstruction of scrotal defects following trauma and Fournier’s gangrene was done over a period of three years. Scrotal defect reconstruction was done in 35 patients by scrotal advancement flap, split thickness skin grafting, medial thigh flap, anterolateral thigh flap and groin flap keeping in mind the various indication of different modalities. The reconstructed scrotums were observed for flap survival and skin graft intake for seven to 10 days in the hospital and then were followed for three months in a follow-up clinic. Results and observations The mean age of our patients was 48.57±5.01 years. Most of the soft tissue defects of the scrotum were post-traumatic (83%). Scrotal reconstruction was done often by flaps and more frequently used flap for reconstruction of scrotum was scrotal advancement flap. All flaps and grafts survived well. Mean hospitalization time was highest for groin flap cover whereas mean operative time was highest for anterolateral thigh flap cover. Conclusion Every case of scrotal defect needs an individual approach for scrotal reconstruction depending upon patient age, general condition of the patient, wound status, and the patient’s requirement.


Introduction
Trauma and Fournier's gangrene can cause significant soft tissue loss involving the scrotum, penis and thighs. The soft tissue coverage of scrotal defects and exposed testes is vital for the protection of testicular function and sparing the sexual wellbeing of the person. Reconstruction is also important for perineal cosmesis and the psychological wellbeing of a patient. Various reconstructive procedures are split thickness skin grafting and flaps.
Trauma is the leading cause of soft tissue loss of the scrotum worldwide, however in developing countries Fournier's gangrene is still contributing to a significant proportion of soft tissue loss of the scrotum.
Fournier's gangrene is a rapidly progressive, fatal, necrotizing fasciitis involving skin and soft tissue of the scrotum and perineum. Several terms that have been used alternatively for Fournier's gangrene are streptococcus gangrene, necrotizing fasciitis, periurethral phlegmon, phagedaena and synergistic necrotizing fasciitis [1].
Systemic conditions such as alcoholism, diabetes mellitus, paralysis or neurological deficit and immunosuppression are predisposing factors of Fournier's gangrene [2]. Men are most commonly involved and it can present in any age group. Fournier's gangrene may occur in children following insect bite and trauma [3].
It can cause significant soft tissue loss involving the scrotum, penis and thighs. Since the testes have an independent vascular supply, they survive but may have secondary function loss. After debridement and control of infection, skin coverage of scrotal defects and exposed testes is indispensable.
Scrotal defects in developing countries are a common challenge to the reconstructive surgeon and hence this work has been done with the aim to compare the outcome, advantages and disadvantages of different modalities of scrotal reconstruction.

Study design
The prospective observational hospital-based study of reconstruction of scrotal defects following trauma and Fournier's gangrene was done over a period of three years. The study was conducted at the first two author's previous institution after institutional ethical approval and is registered vide reference number 642/FM/17.

Study population and sample size
Patients with soft tissue defects of the scrotum following trauma (n=29) and Fournier's gangrene (n=6) who underwent reconstruction were included in the study and observed prospectively during the hospitalized period and then afterward for three months. The sample size calculation was performed using OpenEpi (OpenEpi, Version 3, open-source calculator-SS Cohort) online tool. Considering 80% power with 5% of significance and high effect size, the sample size calculated was 35. The study design and population are described in Figure 1.

FIGURE 1: Study design
Flow diagram depicting the number of cases recruited, excluded and included. It also show the number of cases in each mode of management and the overall study design from recruitment of cases to end of follow up.

Selection criteria for study participants
All patients from 16-59 years of age with scrotal soft tissue defects who underwent tissue coverage were included in the study. Children of less than 16 years and elderly of more than 59 years, hemodynamically unstable patients, immunocompromised patients, uncontrolled diabetes and critically ill patients not fit for anesthesia were excluded.
The scrotal defect coverage was done by various method chosen according to size of defect, age and comorbidities of the patient. In our study scrotal defect reconstruction was done in 35 patients with scrotal advancement flap, split thickness skin grafting, medial thigh flap , anterolateral thigh flap and groin flap, keeping in mind various indications for different modalities. Patients were observed for seven to 10 days in ward for skin graft take clinically and flap viability clinically and using hand held vascular doppler. After discharge from hospital the patients were followed weekly in a follow-up clinic for three months addressing size of scrotum, color and hair bearing skin of scrotum, scar appearance at scrotum and donor site morbidity.
The aesthetic outcome of operated patients was evaluated at two months of follow-up through Likert scale based on a questionnaire that included assessment of size of scrotum, shape and appearance, scrotum color and donor site scar by three independent plastic surgeons. The satisfaction score was calculated as per Table  1.  The parameters for satisfaction score used for aesthetic assessment after reconstruction by three independent Plastic Surgeons.

Data collection and statistical analysis
The data was recorded as per set Performa which was then tabulated in a Microsoft Excel spread sheet. The data has been analyzed using Statistical Package for Social Sciences (SPSS) version 26.0 (IBM Corp., Armonk, NY, USA). The results are expressed as mean ± standard deviation (SD) for discrete data and proportions for descriptive data.

Results
The mean age of our patients was 48.57±5.01 years. Most of the soft tissue defects of the scrotum were posttraumatic (83%) and Fournier's gangrene contributed to 17%. The soft tissue defects after Fournier's gangrene often required wound optimization before tissue coverage. The scrotal defect coverage was done with various methods chosen according to size of defect and age and comorbidities of patient. In our study scrotal defect reconstruction was done in 35 patients by scrotal advancement flap, split thickness skin grafting ( Figure   The scrotal reconstruction was done often by flaps and the most frequently used flap for reconstruction of the scrotum was scrotal advancement flap. All flaps and grafts survived well. Mean hospitalization time was highest for groin flap cover whereas mean operative time was highest for anterolateral thigh flap cover. Various complications seen in patients treated with different reconstructive techniques are mentioned in Table 2.

Total number of patients (n=35)
Mean Hospitalization time ± SD (in days)   The aesthetic outcomes were evaluated through Likert scale based on a questionnaire that included assessment of the size of the scrotum, shape and appearance, scrotum color and donor site scar by three independent plastic surgeons. The aesthetic outcome was highly satisfactory after scrotal advancement flaps with mean ± SD score of 11.5 ± 1.61 followed by anterolateral thigh flap 11.4 ± 1.98 and least after skin grafting 9.7 ± 1.99. A summary of aesthetic results is given in Table 3.  The table shows aesthetic outcome was highly satisfactory after scrotal advancement flaps followed by anterolateral thigh flap and least after skin grafting.

Mean operative time ± SD (in minutes) Complications
After the completion of our study, we were able to derive the following advantages and disadvantages of various modalities of scrotal reconstruction, which are tabulated below in Table 4. Consideration of the listed advantages and disadvantages of these different flaps and STSG in Table 4 can help in decision making of the type of flap required in different cases of scrotal soft tissue defects in different clinical scenarios.

Discussion
Reconstruction of a scrotal defect poses a challenge after surgical debridement. The "replace like with like" principle has an important role in functional and aesthetic reconstruction of scrotal defects, which is difficult because of its unique texture, color and contour.
According to Chen et al. [10], when the scrotal defect area is less than half the scrotal surface area, scrotal advancement flap can be performed. Closure of scrotal defect with remnant scrotal tissue has an advantage of the testes being covered with native tissue so appearance is similar to the original scrotum. Since testes are covered with native tissue, spermatogenesis is affected minimally, in contrast to fascio-cutaneous flaps.
There is no donor site morbidity. The procedure is safe and simple without the risk of any complications besides reducing the hospital stay and hence, cost as well. Chen et al. [11] reported successful scrotal defect reconstruction in 11 patients using the scrotal advancement flap. All patients had scrotal defects less than half the surface area of scrotum. Partial flap loss was seen in one patient and wound edge necrosis was seen in two patients in their study. We have also done scrotal defect resurfacing by scrotal advancement flap in 10 patients having scrotal defect less than 50% of scrotal surface area and all flaps survived well without any complications.
Balakrishnan was the first to use skin grafts to manage scrotal defects [12]. Split thickness skin grafting is a safe, cost-effective method of scrotal defect reconstruction that is technically easy to perform. The reconstructed scrotum is identical in color and shape to the original scrotum, besides, having thin skin which keeps the testis cooler than the normal body temperature. However, the newly constructed scrotum lacks the redundant skin. Also, testicles keep lying in a low position due to loss of cremasteric function [13]. Hesselfeldt-Nielsen and co-workers had reported three such cases of scrotal defect reconstruction with split thickness skin grafting with excellent results except for the lack of cremasteric suspensory function which was taken care of easily by using ordinary tight underpants [14]. Several authors have reported the use of split thickness skin grafting for scrotal reconstruction following Fournier's gangrene. Parkash and Gajendran reported 43 cases of scrotal reconstruction following Fournier's gangrene [15]. Altcheck and Hoffman [16] managed scrotal defect following Fournier's gangrene using various reconstruction modalities such as split thickness skin grafting, myo-cutaneous flaps and placement of testis in subcutaneous thigh and abdominal wall pockets and concluded that the modality of choice for scrotal reconstruction should be split thickness skin grafting. We have also resurfaced scrotal defects in seven patients with split thickness skin grafting with acceptable aesthetic results.
A number of flaps have been reported in literature for scrotal reconstruction, however these flaps are bulky unlike normal scrotal skin. Besides, excessive fat content of thick fascio-cutaneous flaps can increase the temperature around testes resulting in inhibition of spermatogenesis. Due to complex techniques or multistage operations in some cases, the hospital stay is also prolonged adding to the monetary burden of patient. The only absolute indication for flap reconstruction is when vital structures such as the tunica, corpora and urethra are breached. Flaps, however, provide hair-bearing skin and more durable soft tissue than skin graft which is the chief advantage of using flaps for scrotal reconstruction. Flap coverage has reliable vascularity, durability, functional expendability. The fascio-cutaneous 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 [17]. Also, it can be done in short operative time to cover difficult defects. Hallock [18] reported the same flap for scrotal reconstruction following Fournier's gangrene.
We have seen minor complications such as margin necrosis in two patients of medial thigh flap coverage however, both cases were managed conservatively and the flaps showed good sensation except for transient loss of sensation over anterior part of thigh which regained in the follow-up period. These advantages and disadvantages were comparable to that reported by Ferreira et al. [19] in their review of management of 43 patients of 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. 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. [19].
Anterolateral thigh flap is another option for reconstruction of scrotal defect of Fournier's gangrene. Anterolateral thigh flap is away from the zone of infection in cases of Fournier's gangrene and bring healthy vascularized tissue into the defect. These flaps can cover defect up to 35×25 cm [20]. Anterolateral thigh flap can be harvested as fascio-cutaneous or musculocutaneous flaps with part of vastus lateralis or as neurocutaneous flap with anterior lateral cutaneous nerve of thigh. Anterolateral thigh flap has some limitations. In obese patients, anterolateral thigh flap would be thick so cannot be used for scrotal reconstruction. Chen et al. [11] reported reconstruction of three scrotal defects with pedicled anterolateral thigh flap cover with good outcome and survival. Spyropoulou et al. [21] used a pedicled ALT flap in nine patients with penoscrotal defect. According to the author, flap appeared bulky in initial postoperative period but oedema subsided during the course of time, leaving a more natural-looking scrotum. In, our study we used ALT flap in seven patients to reconstruct scrotal defect and all flaps survived well with good aesthetic outcome. However, the bulkiness of ALT flap remains its disadvantage.
Groin flap technique is simple and flap advances easily to cover scrotal defects. Groin flap has functional expandability and achieves reasonable aesthetic results. In our cases results were also acceptable. The flap is thin and pliable as compared to other fascio-cutaneous flaps. This flap remains the choice when pliable tissue is required.
The choice of reconstruction technique of scrotal depends upon the site of defect, extent of scrotal involvement, age of patient, comorbidities and surgeon's preference. Both delayed primary closure and STSG are safe, easy and single-stage procedures with shorter hospital stay. However, delayed primary closure is only possible for scrotal defect involving less than 50% of scrotal surface area and STSG cannot be done when tunica vaginalis is stripped off, although thin skin in STSG resembles a normal scrotum which preserves testicular function. Fascio-cutaneous flaps offer single staged, well-vascularized soft tissue coverage in scrotal defects. Medial thigh flaps can be used for coverage even in diabetic and vasculopathy patients. Anterolateral thigh flaps provide large, hair-bearing cutaneous pedicles that are out of zone of infection and can be harvested as musculocutaneous flaps to obliterate dead space in perineum whereas groin flaps offer thin expandable coverage.
Every modality used to cover scrotal defect has its own pros and cons, so every case needs an individual approach for scrotal reconstruction depending upon patient's condition, patient's requirement and surgeon's expertise to achieve reasonable functional and aesthetic outcome without any major complication and donor site morbidity.
The limitation of our study is a small sample size and lack of standardization, hence it is recommended to conduct randomized controlled trials to evaluate the different methods for soft tissue reconstruction of the scrotum.

Conclusions
Each case of scrotal defect needs an individualized approach for tailoring the scrotal reconstruction depending upon patient's age, general condition of patient, wound status, comorbidities, patient's requirement and the advantages and disadvantages of the different management modalities will definitely help in decision-making for soft tissue reconstruction of the scrotum under optimal conditions.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Faculty of Medicine, Aligarh Muslim University issued approval 642/FM/17. The study has been approved by the institutional ethical committee. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.