A Novel Application for Repair of Skin Defects of the Penis: Anterior Scrotal Artery Flap

Abstract

Sir: Miscellaneous treatment alternatives have been described to repair skin defects of the penis. In all reconstruction modalities, the main purposes are to choose an option that has properties nearest to the repair site and to obtain acceptable cosmetic and functional results. We conclude that use of the scrotum can fulfill these reconstruction aims for repair of partial penile defects. The scrotum receives its blood supply from the following sources: (1) the perineal branch of the internal pudendal artery that forms the posterior scrotal arteries, (2) the external pudendal branches of the femoral artery that forms the anterior scrotal arteries, and (3) the cremasteric branch of the inferior epigastric artery. We present a case of a skin defect of the penis treated immediately with an axial-pattern scrotal flap. The patient was 27-year-old man. He has suffered from Fournier’s gangrene at penoscrotal region. Nevertheless, a skin defect developed at the ventral side of the penis at the end of the illness. A flap was designed from the anterior side of the scrotum over the estimated route of the anterior scrotal artery for coverage of the defect (Fig. 1). The dimensions of the flap were 10 × 5 cm. The flap was elevated with the anterior scrotal artery and tunica dartos of the scrotum. The donor site was closed easily, primarily using the advantage of the flexibility of the scrotum. The patient has healed without any complication. The view of the donor area was satisfactory, and the view of the repaired area was acceptable (Fig. 2).Fig. 1.: The 5 × 10-cm flap was designed from the anterior side of the scrotum over the estimated route of the anterior scrotal artery. ASA, anterior scrotal artery. The designed flap with the anterior scrotal artery was elevated.Fig. 2.: Postoperative view of the flap and donor area.The primary goal of reconstruction in patients with penile skin loss is simple and efficient coverage. Additional goals are to obtain cosmetic and functionally acceptable results. Skin grafts are used frequently for coverage of defects of the penis.1,2 However, the penis needs skin laxity for erection. Adequate skin flexibility, fine skin quality, adequate skin secretion protecting skin humidity cannot be achieved, plus its volume remains deficient and it causes an aesthetically unacceptable appearance. Moreover, graft take is challenging problem for infected areas. However, flaps can be used for infected areas.3 We feel that this the most important advantage over split-thickness grafts. Distant flaps have usually been applied in cases such as wide penis injuries.4,5 In partial skin losses, it is not preferred because of disadvantages such as skin inelasticity, aesthetically bad appearance, long operative time, and donor-site defect. The presented flap is an axial-based flap. For this reason, its extensibility in size and its survival without any circulation problem beside its thin base are its principal advantages compared with the other regional random flaps. Although its hair-bearing skin texture sounds like a disadvantage, it was not noted by our patient. We conclude that these skin defects of the penis, even those extending to half of its size, can be safely treated definitively with the presented flap in the acute setting. Tonguç Isken, M.D. Murat Onyedi, M.D. Cenk Şen, M.D. Hakkı Izmirli, M.D. Ergin Yucel, M.D. Department of Plastic and Reconstructive Surgery Kocaeli University Faculty of Medicine Kocaeli, Turkey