Case Report: The Use of Dermal Substitute in the Reconstruction of Full-Thickness Burns to the Penis

T his case report describes the use of a dermal substitute (Integra®, Integra Lifesciences Corp., Plainsboro, NJ) in the reconstruction of full-thickness burns to the penis. Although this dermal substitute has been approved by the US Food and Drug Administration (FDA) for use in burn reconstruction, the authors present this case report to illustrate its efficacy in penile reconstruction. In the past, penile reconstruction has been attempted with skin grafts, local flaps, and even free flaps, which often result in scarring and an inability to achieve erections.^1–4 This dermal substitute provides a smooth, noncontracting neodermal bed for skin grafting. This eventually allowed the authors’ patient to achieve erection and have sexual intercourse. Case Report A 48-year-old black man sustained a work-related injury at a copper tubing plant. In this plant, copper is melted, formed into tubes, and ejected into a 700-ft long trough filled with water. The tubing is transported through the trough at a high velocity. The metal reaches a temperature of 1800^oF while being formed and is cooled to 500^oF upon striking the water. The patient was bent over this trough when the heated tubing grazed past the front of his trousers. The tubing burned through his clothing, causing a burn to his penis, proximal thigh, and suprapubic area. The patient was transported by ground to the triage area of the authors’ level I trauma center within 1 hour post-injury. The patient’s past medical history was significant for hypertension and early congestive heart failure. He did not have diabetes, coronary artery disease, pulmonary disease, or renal insufficiency. He had been diagnosed with herniated disks at L2, L3, L4, and L5 with resultant chronic lower back pain. The patient reported no known drug or food allergies. He denied alcohol or illicit drug use but admitted to smoking 1–2 packs of cigarettes a day. Past surgical history was significant for appendectomy and tonsillectomy. The patient had no history of urinary tract disease and denied any erectile dysfunction. There was no significant family history. A review of the patient’s systems was significant for exertional shortness of breath after climbing 2 flights of stairs and occasional constipation. His medications included digoxin 0.25mg, ramipril 2.5mg, and clonidine 0.1mg daily. On physical examination, the patient appeared to be moderately obese, seemed to be his stated age, and was not in acute distress. He was alert and oriented. His lungs were clear to auscultation bilaterally. His heart had a regular rate and rhythm and was without rubs, murmurs, or gallops. His abdomen was soft and non-tender with a well-healed right lower quadrant incision and normal, active bowel sounds. His right proximal anterior thigh had a 5cm x 3cm second-degree burn, and his suprapubic region had a 4cm x 3cm second-degree burn. There was a fourth-degree burn to the dorsal mid-shaft of the penis 3cm x 3cm in size. The burn extended through the skin, dermis, subdermal fat, and Buck’s fascia and into the corpora cavernosum. These tissues were exposed and bleeding. The ventral penis was completely intact. There was no injury to the scrotum. The testes were descended bilaterally and were without abnormal masses. The patient had an otherwise normal uncircumcised phallus with no urethral involvement. No inguinal hernias or lymphadenopathy were noted. The rectal exam revealed good sphincter tone with no masses. The prostate was 30g in size and without palpable nodularity. Methods The patient’s initial bleeding was controlled with compression and Vicryl suture ligation by the urology service in the triage area. An indwelling Foley catheter was placed without complication. The Burns and Plastic Service was then consulted, and the authors’ staff saw his wounds at this time (Figure 1). The patient was transferred to the Burn Step Down unit where the open full-thickness penile wound was cleansed and dressed daily in mafenide acetate cream (Sulfamylon, Mylan Laboratories Inc., Morgantown, WVa) and saline-moistened gauze. The partial-thickness burns to the suprapubic and thigh areas were treated with mafenide acetate cream and gauze initially, but this regime was changed after 2 days to a silver-impregnated dressing (Acticoat®, Smith & Nephew, Inc., Largo, Fla) that was activated with plain water daily and changed once every 3 days. Seven days after the initial injury, the patient was taken to the operating room. The thigh and suprapubic areas were progressively epithelizing and were not excised. The burn to the penis was explored and debrided of all necrotic tissue. The underlying hematoma was evacuated. There was a 1.5cm tear in the corporal body. This defect was reapproximated with simple interrupted 5.0 Monocryl suture. The wound bed was then prepared for grafting by judicious hemocautery, epinephrine-soaked gauze (1:100,000 dilution), and spray thrombin. Prior to hemostasis, the bed was inspected for well-perfused, viable, subdermal tissue as evidenced by glistening, healthy yellow fat and uniform bleeding. The dermal substitute was prepared per manufacturer protocol and meshed in a 1:1 fashion. The dermal substitute was contoured to the wound and affixed with a staple gun. The penis was positioned with the dorsum facing anterior and stretched gently caudad. This position was maintained with 2 laterally placed 3.0 chromic gut sutures in the distal foreskin and Steristrips, which held the suture strings against the medial thighs on either side (Figure 2). The dermal substitute was dressed with the silver-impregnated dressing and gauze. The silver-impregnated dressing was activated daily with plain water and changed completely after 3 days. Once adherence of the dermal substitute had been well established, the patient was discharged to home. He was asked to not engage in sexual activity and was prescribed amyl nitrate as needed to prevent erections. An indwelling Foley catheter was left in place. The patient was followed in the outpatient clinic weekly. Four weeks following the initial surgery, the patient was taken back to the operating room where the outer silastic layer of the dermal substitute was noted to be intact. The silastic layer was removed under which there was a viable, well-established neodermis. This neodermis was lightly debrided to create a uniform contour and to remove any excess granulation. Meticulous hemostasis was obtained as it had been previously. A very thin (0.004–0.005 in) split-thickness skin graft was obtained from the unburned proximal thigh and affixed to the wound bed with staples. The graft was placed unmeshed. The graft was dressed with petrolatum gauze and dry gauze sponges, and the penis was positioned again as before—dorsum facing anterior and stretched gently caudad. The patient stayed in the hospital until stable adherence of the graft was observed. The patient was then discharged home with a Foley catheter and asked to return for a 1-week follow-up. Instructions were given not to engage in sexual activity for the first 10 post-operative days. The patient reported no erections since the time of his injury. Results On post-operative Day 12, the patient’s grafts were healed with a 99% take. There was a 0.5cm area on the proximal mid-shaft where the skin graft did not take. This area was treated with bacitracin ointment and managed conservatively. The Foley catheter was removed, and the patient experienced no urinary difficulties. The patient had been compliant to all wound care instructions. There was no significant contracture of the penis. The patient was instructed to massage the area frequently and to resume sexual activity. At this point, the patient was unable to engage in sexual congress but was able to achieve partial erections. On post-operative Day 50, he was completely healed (Figure 3). The patient’s primary complaint was paresthesia over the graft on the dorsum of the penis. He reported that sensation to the ventral surface of the penis and the glans was intact. Three months after his procedure, the patient reported improved sensation over the graft and erections that enabled him to have normal sexual relations. The patient did not develop any urinary tract infections throughout the treatment course and did not have any difficulty with urination. Discussion Full-thickness burns to the penis present an unusual and challenging dilemma. In the past, full-thickness skin grafts, split-thickness grafts, and even microvascular free cutaneous flaps based on the radial artery have been employed with varying degrees of success.^1–3 The primary problem encountered, as with all burns, is scarring and contracture.⁴ This distorts the anatomy of the penis and prevents normal tumescence and function. The use of a dermal substitute helps circumvent or reduce the amount of scarring and contracture. This results in a better cosmesis and potentially better functional outcome. The dermal substitute used in this case is a bilaminar, temporary dermal substitute composed of a glycosaminoglycan matrix covered by a silicon outer layer. The outer layer controls water vapor transmission and helps prevent damage and bacterial colonization of the underlying tissues. The inner matrix material provides a template for angiogenesis and ingrowth of new dermal tissue. After 3–6 weeks, this results in a smooth, vascular neodermis that can support a very thin split-thickness graft. The authors have found that meshing the dermal substitute in a 1:1 fashion provides better contouring to the wound and thus better adherence and graft take. Once the neodermal bed has matured, the outer silicone layer is removed and a very thin, split-thickness, nonmeshed autograft is placed. The final result is a thin, pliable, and very cosmetically acceptable scar with minimal contracture and penile distortion. Conclusion The use of a dermal substitute is a viable and highly effective option in the treatment of full-thickness burns to the penis. The cosmetic and functional results are very encouraging in this single case report. The patient recovered from a full-thickness thermal injury to the dorsum of the penis to achieve erections suitable for sexual intercourse and had an excellent cosmetic result. This approach should certainly be considered when one encounters this rare, unusual, and potentially devastating injury.