Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 15  |  Issue : 1  |  Page : 9-13

Split-thickness skin grafting: A modest technique for scrotal reconstruction in patients of Fournier’s gangrene


Department of Plastic and Reconstructive Surgery, JNMC, Aligarh, Aligarh, Uttar Pradesh, India

Date of Web Publication26-Aug-2019

Correspondence Address:
Dr. Rajesh K Maurya
Flat No 301, Ohad Homes Welfare Society Apartment, Medical Road, Zakaria Market, Aligarh 202001, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njps.njps_11_18

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  Abstract 


Background and Objectives: Fournier’s gangrene is rapidly progressive fulminating gangrene of the genitals and the perineum. The resulting skin loss can be covered by various techniques. Split thickness skin grafting (STSG) is a surgical technique which gives good functional and cosmetic outcome and is relatively easier to perform. We intend to study the results of split-thickness skin grafting in patients with scrotal defect following Fournier’s gangrene. Materials and Methods: Split-thickness skin graft was performed in seven patients with Fournier’s gangrene. The patients were selected consecutively from December 2016 to April 2018. All patients were followed for 3 to 6 months postoperatively. Results: All patients had good uptake of graft with no complications except two patients, one had infection at the graft site and in the other one there was a gap devoid of skin at the junction of perineum and base of scrotum. The first patient was managed conservatively with antibiotics and the gap in second patient was repaired by suturing. The donor site in all patients had healed well without any complications. Conclusion and Interpretations: STSG is safe, simple technique for scrotal reconstruction which is both cosmetically and physiologically compliant to the patient.

Keywords: Fournier’s gangrene, scrotal reconstruction, STSG


How to cite this article:
Ahmad I, Maurya RK, Khurram MF, Pathak B, Mahmud AA, Maurya SK. Split-thickness skin grafting: A modest technique for scrotal reconstruction in patients of Fournier’s gangrene. Nigerian J Plast Surg 2019;15:9-13

How to cite this URL:
Ahmad I, Maurya RK, Khurram MF, Pathak B, Mahmud AA, Maurya SK. Split-thickness skin grafting: A modest technique for scrotal reconstruction in patients of Fournier’s gangrene. Nigerian J Plast Surg [serial online] 2019 [cited 2019 Sep 16];15:9-13. Available from: http://www.njps.org/text.asp?2019/15/1/9/265403




  Introduction Top


Fournier’s gangrene is rapidly progressive fulminating gangrene of the genitals and the perineum.[1] It is caused by polymicrobial infection of both anaerobic and aerobic nature. Treatment of the condition requires broad spectrum antibiotics and aggressive surgical debridement which may lead to significant scrotal soft tissue defect.[1] The resulting skin loss can be covered by various techniques described earlier such as primary closure in case of limited defect, full-thickness skin grafts, split-thickness skin grafts, and local tissue flaps. Split thickness skin grafting (STSG) is a surgical technique which gives good functional and cosmetic outcome and is relatively easier to perform.[2] Balakrishnan[3] introduced the use of split skin in reconstruction of scrotum, and Tanner et al.[4] were the first to describe meshed STSG to expand the graft.

We present a study of seven cases of scrotal defect following Fournier’s gangrene reconstructed successfully with STSG.


  Materials and methods Top


Split-thickness skin graft was performed in seven patients with Fournier’s gangrene admitted in Plastic and Reconstructive Surgery Department of JNMCH, Aligarh, which is a tertiary care center in northern India. An ethical clearance was obtained for the study. The patients were selected consecutively from December 2016 to April 2018. Mean age of patients was 47 years (range 25–65 years). After extensive debridement of Fournier’s gangrene, all patients presented with loss of scrotal and/or perineal skin [Figure 1]. Split-thickness skin graft was performed in all patients. All patients were followed for 3 to 6 months postoperatively.
Figure 1 Scrotal defect following debridement of Fournier’s gangrene

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All patients were subjected to the following:

Preoperative evaluation

  1. Personal information such as age and gender
  2. History of presenting complaints including onset of symptoms, course of disease, and duration of symptoms
  3. Past medical and surgical history
  4. Routine preoperative investigations


Surgical technique

After cleaning the donor area (lateral surface of right thigh), partial thickness skin graft was taken with the help of Humby knife running it in a back and forth motion and keeping it at an angle of 45° to the taught skin surface. After harvesting, the graft was meshed by making cuts in it with knife. This prevents blood and serum from accumulating under the graft, increases the surface area, and resembles scrotal rugosity. Then it was placed on the cleaned recipient site with dermis side down and sutured at margins with absorbable sutures [Figure 2]. Paraffin gauze dressing was then applied. On the 5th day, the dressing was opened, and the graft was found to be healthy. Dressing was continued, and after 2 weeks, the graft was adherent to wound [Figure 3]. Thereafter dressing was stopped, and the patient was asked to apply bland emollients only.
Figure 2 Immediate postoperative period after split-thickness skin grafting

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Figure 3 Graft condition after 2 weeks

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After harvesting, the graft donor site was covered with paraffin and antibiotic-soaked gauze. Dressing was opened after 3 weeks, and the donor area [Figure 4] had healed well. The patients were followed up for 3 to 6 months [Figure 5] and [Figure 6].
Figure 4 Donor site after 3 weeks

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[Figure 5]
Figure 6 Follow-up after 6 months

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  Results Top


The age range of the patients was 25 to 65 years with mean age of 47 years. All of the patients had involvement of scrotum only except one patient whose perineum was also involved [Table 1].
Table 1 Details of patients

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All patients had good uptake of graft with no complications except one patient who had infection at the graft site. Pus culture and sensitivity was sent, and antibiotics were given accordingly to which he responded well and the graft uptake was adequate. However, there was mild contracture of graft when followed up after a period of 3 months. Another patient in whom both scrotum and perineum was involved, there was a gap devoid of skin at the junction of perineum and base of scrotum. However, the gap was repaired by suturing [Table 2].
Table 2 Complications at recipient site

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The donor site in all patients had healed well without any complications.


  Discussion Top


Fournier’s gangrene is a rapidly progressing necrotizing fascitis of perineum and external genitalia which spreads along adjacent fascia. Those patients who have diabetes, liver cirrhosis, alcoholism, uremia, malignancy are often predisposed to this disease.[5] Because of accompanying comorbidities, a simple technique for reconstruction of scrotal defect following Fournier’s gangrene is required. Common organisms which have been found in Fournier’s gangrene are Streptococcus, Staphylococcus,  Escherichia More Details coli, and anaerobes.[6]

Management of Fournier’s gangrene requires aggressive debridement along with antibiotics to get rid of infection. Reconstruction of the scrotum and perineal areas has to be performed to give adequate protective coverage for testes to carry out its normal physiologic function. The reconstructed scrotum should mimic the original one in being sac-like, thin, flexible, not adherent to the body with underlying testes being slightly mobile.[7] Primary closure can only be performed when the defect is minimal.

STSG is a safe, cost-effective method of reconstruction which 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 testes cooler than the normal body temperature. However, the newly constructed scrotum lacks the redundant skin. In addition, testicles keep lying in a low position due to loss of cremasteric function.[8] Hesselfeld-Nielsen et al.[9] had reported three such cases of scrotal reconstruction with STSG with excellent results except for the lack of cremasteric suspensory function which was taken care of easily by ordinary tight underpants. Other complications which can occur are graft loss due to bleeding, graft contracture, or infection.[10] Weight of the testes prevents graft contracture in most of the cases.[11] Only one of our patients developed infection which was treated by antibiotic coverage of causative organisms.

Patients of Fournier’s gangrene are mostly elderly with a number of preexisting medical problems, such as diabetes, alcoholism, and low immunological defense with reduced healing capacity. This should be taken into consideration while choosing the reconstructive procedure as it should be less disabling to the patient, easy to perform, and of low cost.[12] Lesser duration of hospital stay and faster healing are added advantages of STSG procedure.

Several authors have reported the use of STSG for scrotal reconstruction following Fournier’s gangrene. Parkash and Gajendran[13] reported 43 cases of scrotal reconstruction following Fournier’s gangrene. Altcheck and Hoffman[14] in 1979 published a report of scrotal reconstruction in two patients using meshed STSG without any complications. Gonzalez et al.[15] managed scrotal defect following Fournier’s gangrene using various reconstruction modalities such as STSG, myocutaneous flaps, and placement of testis in subcutaneous thigh and abdominal wall pockets and concluded that the modality of choice for scrotal reconstruction should be STSG. Tan et al.[7] reported successful treatment of 27 patients of scrotal defect following Fournier’s gangrene by creating a neoscrotum by testicular apposition and wrap-around grafting. Only one of his patients had recurrent infection resulting in scarred scrotum. Similarly, in our case series also, there was a patient with infection who was treated by antibiotics. However, at 3-month follow-up, there was mild graft contracture.

A number of flaps have been reported in literature for scrotal reconstruction; however, the flaps are bulky unlike normal scrotal sac skin. Besides, excessive fat content of muscle and thick fasciocutaneous flaps can increase the temperature around testes, resulting in inhibition of spermatogenesis.[7] Owing to complex techniques or multistage operations in some cases, the hospital stay is also prolonged adding to the monetary burden of patient. Boukind et al.[8] mentioned that hospital stay following reconstruction with flaps was up to 45 days, with a mean of 15 days. In our case series, the patients were discharged within 10 days postreconstruction. 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, which is the chief advantage of using flaps for scrotal reconstruction.[7]


  Conclusion Top


We believe that STSG is safe, simple technique for scrotal reconstruction in elderly and already debilitated patients without cost overburden to the patients. The testes are covered with thin, rugose, pliant skin, and hangs loosely in the newly constructed scrotal sac. This is both cosmetically and physiologically compliant to the patient.

Authors’ contribution

  1. Imran Ahmad: Concept, definition of intellectual content, manuscript editing, and review.
  2. Rajesh K. Maurya: Concept, design, literature search, data analysis, manuscript preparation.
  3. Mohammed F. Khurram: Concept, literature search, data analysis.
  4. Brajesh Pathak: Data analysis.
  5. Ali A. Mahmud: Manuscript editing.
  6. Sudheer K. Maurya: Manuscript editing.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/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

1.
Fournier JA. Overwhelming gangrene. Semaine Med 1883;3:345.  Back to cited text no. 1
    
2.
Black PC, Friedrich JB, Engrav LH, Wessels H. Meshed unexpanded split thickness skin grafting for reconstruction of penile skin loss. J Urol 2004;172:976-9.  Back to cited text no. 2
    
3.
Balakrishnan C. Scrotal avulsion: A new technique of reconstruction by split-skin graft. Br J Plast Surg 1956;8:38.  Back to cited text no. 3
    
4.
Tanner JC, Vandeput J, Olley JF. The mesh skin graft. Plast Reconstr Surg 1964;34:287-92.  Back to cited text no. 4
    
5.
Karian LS, Chung SY, Lee ES. Reconstruction of defects after Fournier gangrene: A systematic review. Eplasty 2015;15:155-69.  Back to cited text no. 5
    
6.
Singh A, Ahmed K, Aydin A, Khan MS, Dasgupta P. Fournier’s gangrene: A clinical review. Arch Ital Urol Androl 2016;88:155-64.  Back to cited text no. 6
    
7.
Tan BK, Rasheed MZ, Wu WTL. Scrotal reconstruction by testicular apposition and wrap-around skin grafting. J Plast Reconstr Aesthet Surg 2011;64:944-8.  Back to cited text no. 7
    
8.
Boukind H, Ezzoubi M, Chafiki N, Alibou F, Chlihi A, Bahechar N et al. The scrotal reconstruction after necrotizing cellulitis of perineum and external genitalia. Ann Urol 1995;29:308-12.  Back to cited text no. 8
    
9.
Hesselfeld-Nielsen J, Bang-Jensen E, Riegels-Nielsen P. Scrotal reconstruction after Fournier’s gangrene. Ann Plast Surg 1986;17:310.  Back to cited text no. 9
    
10.
Maguina 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. 10
    
11.
Schaller P, Akcetin Z, Kuhn R, Radu C, Geldmacher J. Scrotal reconstruction after Fournier’s gangrene with simple skin grafting. Eur J Plast Surg 1994;17:261-3.  Back to cited text no. 11
    
12.
Norton K, Johnson L, Perry T, Perry K, Sehon J, Zibari G. Management of Fournier’s gangrene: An 11-year retrospective analysis of early recognition, diagnosis and treatment. Am Surg 2002;68:709-13.  Back to cited text no. 12
    
13.
Parkash S, Gajendran V. Surgical reconstruction of the sequelae of penile and scrotal gangrene: A plea for simplicity. Br J Plast Surg 1984;37:354-7.  Back to cited text no. 13
    
14.
Altcheck E, Hoffman S. Scrotal reconstruction in Fournier syndrome. Ann Plast Surg 1979;3:523-8.  Back to cited text no. 14
    
15.
Gonzalez J, Rivas M, Martin C, Nogueira A, Alvarez R, Martinez M. Etiology and treatment of cutaneous penoscrotal losses. Arch Esp Urol 1999;52:1033-42.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2]



 

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