Assessment of Outcomes After Limberg Flap Reconstruction for Scrotal Defects in Patients With Fournier’s Gangrene

Background. Fournier’s gangrene (FG) is a rarely encountered necrotizing fasciitis principally affecting skin and subcutaneous tissues of the genital region, perineum, and abdominal wall. The overall incidence of FG is 1.6 cases per 100 000 per year; the incidence in males is higher. Management techniques described in the literature have both advantages and disadvantages, and there is no gold standard treatment technique. Objective. This study evaluated whether the Limberg flap can be used reliably in scrotal defects with fewer complications than are seen with traditional techniques. The results of unilateral or bilateral Limberg flaps for scrotal reconstruction after FG were assessed. Materials and Methods. This retrospective, single-center study analyzed records from 29 male patients with scrotal defects after multiple debridements who were treated from January 2013 to January 2018. Twenty-one patients (72.4%) with hemiscrotal defects and 8 patients (27.6%) with defects involving greater than 50% of the scrotal surface were included in this study. Demographic data that were analyzed included smoking history, comorbid conditions, time of surgery, and time of follow-up. Flap dimensions were measured. Patients were evaluated in terms of flap viability and postoperative complications. Results. Mean age was 64 years (range, 47–80 years). The mean follow-up period was 16 months (range, 12–26 months). Dehiscence with seroma were detected in 4 patients (13.7%) on postoperative days 4 and 5. The average size of the flaps was 11 cm × 15 cm. Seroma and dehiscence were encountered in 4 patients (13.7%) during postoperative follow-ups. No postoperative infection was observed in any patient, and no partial or total flap loss was reported. Conclusions. These results suggest that use of the Limberg flap technique for scrotal reconstruction following FG has the important benefits of being easily harvested while providing tension-free repair and acceptable cosmetic results.

Introduction

Fournier’s gangrene (FG) is a rarely encountered, necrotizing soft tissue infection affecting principally the skin and subcutaneous tissue of the genital region, perineum, and abdominal wall. The overall incidence of FG is 1.6 cases per 100000 per year; the incidence in males, and older males in particular, is even higher, with 3.3 cases per 100000 in men 50 to 79 years of age.¹ The condition can spread rapidly through soft tissue, and as a result, can be fatal. Multisystem failure is the main cause of mortality; hemodynamic resuscitation, broad-spectrum antibiotics, and surgical debridement should be initiated as early as possible.

Multiple debridements should continue until healthy tissues are seen. Scrotal defects resulting from debridement may lead to functional, aesthetic, and psychological problems in these patients. The benchmarks of successful scrotal reconstruction include the preservation of the physiological functions of the testes, an aesthetically acceptable scrotal appearance, relatively hairless coverage, and closure of the donor area.

Local fasciocutaneous flaps, split- thickness skin grafts, and several muscle flaps were defined in the literature for scrotal reconstruction after multiple debridement procedures.^2-4 These methods offer both advantages and disadvantages, and no studies have identified a gold standard technique.

The rhombic transposition flap was described by Limberg. Used in every anatomic area for decades, the Limberg flap is mostly employed in plastic surgery, general surgery, neurosurgery, and ophthalmology. In the literature, studies have demonstrated that this flap is very useful and reliably safe, and the technique is relatively easy to learn and teach.^5-9 In addition to these benefits, the Limberg flap may be advantageous for managing scrotal defects because it allows for primary closure of the donor area, and since it is a thin flap, it does not compromise fertility. The technique also has satisfactory cosmetic results. To date, there are no studies that explore all of these advantages.

In addition, a review of the literature did not yield any reports examining unilateral and bilateral Limberg flaps in scrotal repair. In this study, the authors aimed to assess the results of unilateral or bilateral Limberg flaps which are used for scrotal reconstruction after FG.

Materials and Methods

This retrospective, single-center study included 29 male patients with scrotal defects after multiple debridements who were treated from January 2013 to January 2018. The Meram Faculty of Medicine, Necmettin Erbakan University Clinical Research Ethics Committee in Konya, Turkey, approved the study. The patients were referred for perineal reconstruction from the general surgery and urology departments. Patients with defects involving less than 50% of the scrotal surface as well as those with irregular follow-up visits and those lost to follow-up were excluded from the analysis. Twenty-one patients (72.4%) with hemiscrotal defect and 8 patients (27.6%) with defects involving greater than 50% of the scrotal surface were included in this study. During the hospitalization of patients, this multidisciplinary process was managed by the departments of infectious diseases, general surgery, and urology.

Surgical technique

Patients in this analysis all had undergone elective defect repair surgery following consecutive debridements and regression of inflammation. All patients underwent Limberg flap reconstruction at the lithotomy position under spinal anesthesia. Defect area was measured after debridement, and flap markings were done to cover the entire defect. In each case, a pedicle flap was marked on the proximal one-third of the anteromedial thigh according to defect size (Figure 1). Following skin incisions, the suprafascial plane was used for harvesting the flap to preserve the superficial lymphatic nodes. The harvested flap was subsequently placed on the defect area and secured with a fixation suture on a key point. In patients with double-sided defects in the scrotal area, bilateral Limberg flaps were harvested from both thighs, placed in the midline, and sutured to each other. In 8 patients with unilateral total and contralateral partial defects, a unilateral Limberg flap was sutured to the opposing side so that scrotal tissue could be released. Fat tissue was trimmed in cases of excess. Tension-free flap transposition was obtained in all cases. Donor areas were closed following the Hemovac (Zimmer Biomet) drain placement.

Infection control

Before and after the reconstruction of the scrotum, the infectious disease physicians followed the patients’ wound cultures and infection parameters (leukocyte count, c-reactive protein concentration, and other common acute phase reactant markers). The infection committee generally started patients on a triple antibiotic regimen that included an aminoglycoside, metronidazole, and cephalosporin. Then, the antibiotic regimen was adjusted as needed according to each patient’s wound culture findings. When a patient’s wound culture showed no growth and infection parameters reached normal levels, the antibiotics were stopped.

Postoperative follow-up

Before discharge, the wounds were photographed to establish a baseline for recovery, and flap dimensions were measured. Patients were given advice about personal care and strategies for cleaning themselves. They were advised to wash daily but to keep the wound site dry and ventilate the inguinal and perineal regions. On follow-up visits, patients were evaluated in terms of flap viability and postoperative complications.

Results

Demographic data were analyzed regarding smoking, comorbidities, time of surgery, and time of follow-up. The mean age was 64 years (range, 47–80 years). Eleven patients (37.9%) had diabetes mellitus, 2 (6.8%) had both hypertension and diabetes mellitus, 2 (6.8%) had diabetic nephropathy, and 1 (3.4%) had a diagnosis of incidental lung malignancy. In 4 of the 11 patients with diabetes, one of which also had diabetic nephropathy, dehiscence with seroma occurred.

The mean hospitalization period was 7 days (range, 5–10 days). The average size of the flaps was 11 cm × 15 cm (Figure 2 and Figure 3). Hemovac drains were removed on the second postoperative day; average fluid in drain was 15 µL/day. Dehiscence with seroma of the recipient site was detected in 4 (13.7%) patients on postoperative days 4 and 5. No complications of donor sites were detected. After the wound care period, the flaps were revised, and the defect areas were again repaired by primary closure.

The mean follow-up period was 16 months (range, 12–26 months). Despite poor patient self-care, no postoperative infections developed in any patient, and no partial or total flap loss was observed.

Discussion

Fournier's gangrene is a rapidly progressing polymicrobial disease caused by anaerobic bacteria in the cutaneous, genitourinary, and colorectal areas and causes polymicrobial infections in the genital, perineal, and anorectal regions. The most commonly isolated pathogens include streptococci, staphylococci, Escherichia coli, and less frequently, fungi.¹⁰More than 40% of these patients develop sepsis.¹¹ Therefore, broad-spectrum antibiotics as an empirical treatment should be started immediately. Management of predisposing factors and aggressive surgical debridement generally causes an improvement in the patient’s clinical condition.¹²

After FG debridement, scrotal reconstruction is complex due to difficult skin closure as well as the desire to achieve satisfying aesthetic results and testicular functionality. Many reconstructive options have been used, ranging from simple skin grafts and fasciocutaneous flaps to musculocutaneous and perforator flaps.^13–15Small defects can be healed by secondary intention. Akilov et al¹⁶ proposed that patients with scrotal defects, including those that involved less than 50% of the scrotum, healed secondarily and required longer hospital stays than were needed for patients with loose wound closure.

For defects affecting less than 50% of the total area, scrotal advancement flaps can be used; the authors’ institution does employ this technique for patients with small defects. In the literature, there are a number of studies that demonstrated successful reconstruction outcomes with local scrotal advancement flap in defects smaller than 50% of the total scrotal surface.^17-19 However, testicle placement in pouches created in the proximal medial thigh may cause spermatic cord necrosis. Therefore, patients who had scrotal defects larger than half the total scrotum surface were included.

Split-thickness skin grafts (STSGs) can be used if the tunica vaginalis is intact, and the advantages of that procedure include ease of surgical procedure and good cosmetic results (if there is no intact tunica vaginalis, STSG cannot be used).^20-23 The literature reports the use of STSG for scrotal defects does, however, carry the risk of several complications and disadvantages. Graft contraction is problematic, and pain or discomfort may arise owing to stiffness and immobility between the graft and testes. Local or total graft loss may result from seroma, bleeding, shearing, and infection. The STSG is vulnerable to trauma because it cannot protect the testicles as much as flap reconstruction

In cases with larger defects, local pedicled muscle flaps, such as the gracilis flap and the vertical rectus abdominis muscle (VRAM) flap, can be used, especially if the tunica vaginalis is no longer present.^2,3In addition, anteromedial, anterolateral thigh, and pudendal artery thigh flaps can be used.^4,10 In 2003, Ellabban and Townsend²⁴ presented a case report in which VRAM and gracilis muscle flaps were used for reconstruction of major scrotal defects. Removal of the rectus abdominis muscle and gracilis muscle, however, may interfere with muscle function. Balbinot et al²⁵ demonstrated a relationship between lower limb abduction and gracilis muscle flap.

Some scrotal defects may be repaired through use of a posterior thigh flap supplied from a pedicle originating at the inferior gluteal artery. This technique requires the patient position be changed during the surgery.²⁶Perforator flaps also present some challenges due to long surgical duration and increased surgical difficulty because microsurgical dissection is required. In addition, donor sites in some perforator flap cases preclude primary closure.²⁷

Various reconstruction options with fasciocutaneous flaps prepared from the lateral areas of the perineal defect have been reported in the literature.²⁸With respect to flaps in which the medial part of the thigh was used, the connection between the medial and distal muscle fascia was completely removed when the flap was harvested in the subfascial plane.²⁶ Because the inclusion of muscle fascia may cause damage to the lymphatic system, all Limberg flaps employed in this study were harvested in the suprafascial plane.

One of the options for providing temporary testicular coverage until reconstruction is complete is transposition of the testes to the subcutaneous tissues of the upper thigh region. This strategy is not without disadvantages; changes in spermatogenesis have been described, in addition to testicular atrophy and chronic pain due to local temperature increases.^29,30 Risk for these changes should be taken into consideration when planning the reconstruction. Tissue expander applications are also among some of the selected techniques described in the literature.³¹In this study, testicular transposition was not performed to avoid causing negative spermatogenetic changes. Rapid and safe reconstruction was planned for large defects, so tissue expansion was not used.

The Limberg flap is a simple and suitable method that has been used reliably by several disciplines for decades and should be explored in cases of large scrotal defects. There is no need for microsurgical dissection, and primary closure of the donor site is almost always feasible. After harvesting the flaps, fat tissue can be trimmed slightly in patients who have an excess fat layer, thinning the layer in such a way that the flap circulation is not disturbed. The entire procedure can be performed with the patient remaining in the same position, enabling even inexperienced surgeons to execute the procedure. In addition, the Limberg flap provides acceptable cosmetic results.

Given that the mean patient age was 64-years-old and the youngest patient was 47-years-old, the observations from this study are difficult to apply to a younger patient population looking to preserve fertility. All of the patients in the study had children and did not wish to have more; therefore, this parameter was not taken into consideration in postoperative follow-up. The damage caused by FG varied in these patients, and spermiogram tests were not taken before the surgery. Consequently, objective postoperative evaluation of this parameter would have been not been possible. In addition, all the patients included in this study had some intact scrotal skin still present; as a result, the flap thickness could be compared with the skin on the opposite side. Thus, the flap approximated the thickness of normal scrotal tissues closely enough to avoid a temperature increase.

Limitations

Limitations of this study are its retrospective design and the inclusion of a limited number of patients.

Conclusions

The Limberg flap reconstruction in scrotal defects following FG has important benefits: (1) it can be easily harvested, (2) it provides tension-free repair, and (3) it has acceptable cosmetic results. The authors conclude that use of a Limberg flap (designed from the thigh) offers a satisfying outcome in patients requiring reconstruction of scrotal defects. Additional prospective studies in a younger patient population are needed to establish the viability of the technique in patients with severe defects who are looking to preserve fertility.

Acknowledgements

Authors: Mehmet Dadaci, MD¹; Mehmet Emin Cem Yildirim, MD²; Serhat Yarar, MD³; and Bilsev Ince, MD¹

Affiliations: ¹Necmettin Erbakan University, Konya, Turkey; ²Bilecik Education and Research Hospital, Bilecik, Turkey; and ³Konya Numune Hospital, Konya, Turkey

Correspondence: Mehmet Emin Cem Yildirim, MD, Bilecik Education and Research Hospital, Plastic Reconstructive and Aesthetic Surgery Clinic, 1st Floor, Bilecik, 11040 Turkey; dr.cem_yildirim@hotmail.com

Disclosure: The authors disclose no financial or other conflicts of interest.

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