Case 9 (2024): Unconventional Reconstruction of a Complex Genital Defect

Iman Ghanad; Amir K. Bigdeli

Journal of Plastic, Breast & Reconstructive Surgery·Begutachtete Open-Access-Fallberichte aus der ChirurgiePeer-Review · Open Access

Case 9 (2024): Unconventional Reconstruction of a Complex Genital Defect · JPBRS

Fallbericht

Case 9 (2024): Unconventional Reconstruction of a Complex Genital Defect

Iman Ghanad¹, Amir K. Bigdeli¹

¹BG Ludwigshafen, Germany

Veröffentlicht 31. März 2024107 Aufrufe5 Min. Lesezeit

Genital reconstructionDIEP flapRotation flap

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Zusammenfassung

Wichtigste Lernpunkte

Pearls

The unconventional use of bipedicular sliding DIEP flap may achieve outstanding results in covering complex genital defects.
Extensive preoperative planning can streamline the surgical procedure and decrease the duration of the operation.

Pitfalls

Non-Compliance can severely limit the options for defect reconstruction.
Tension-free flap surgeries are crucial for successful healing

Patient history

A 56-year-old male patient presented to the urological emergency department with progressively increasing swelling and redness in the genital area. Following the diagnosis of Fournier gangrene, the patient underwent multiple radical necrosectomies, bilateral hemiscrotectomies, and surgical displacement of the testicles into femoral scrotal compartments. Septic symptoms and acute kidney failure necessitated intensive care monitoring for the first sixteen days postoperatively. Subsequently, a significant soft tissue defect (17 x 24 cm) in the inguinal and genital region emerged, prompting referral to our hospital for specialized defect reconstruction. The patient's medical history revealed several underlying conditions including coronary artery disease, arterial hypertension, and type II diabetes mellitus with polyneuropathy. Initially, wound bed preparation was performed in our clinic for further reconstructive planning. It was noticed that the wound was suitable for split-thickness skin grafting. However, due to the patient's non-compliance and the necessity for postoperative bed rest, which the patient did not adhere to, the attempts at split-thickness skin grafting were futile on two occasions. Consequently, the patient decided to discharge himself voluntarily against explicit medical advice. Due to postoperative bleeding and persistent wound healing issues, the patient returned to our clinic for further surgical treatment.

Examination

Upon admission to our hospital, the 56-year-old male exhibited obesity. A 17 x 24 cm soft tissue defect could be identified in the inguinal and genital area with bilateral exposed testicles. The testicles were previously relocated into subcutaneous pouches in the thighs. No signs of infection could be detected.

Pre-operative considerations

Reconstructive surgery encounters a significant challenge when addressing complex soft tissue loss in the genital and inguinal regions. The inguinal area represents a crucial convergence point of essential anatomical structures. Several individual factors need consideration in developing the treatment plan, including the extent of the defect, potential exposure of anatomical structures, functional requirements, and the patient’s medical history. Given the patient’s prior non-compliance with strict bed rest, opting for free flap surgery carries a heightened risk of failure. Furthermore, previous attempts at split-thickness skin grafting were unsuccessful. Considering the size and position of the soft tissue defect, along with the patient’s specific circumstances of prior unsuccessful coverage attempts, we chose to perform defect reconstruction using a sliding triangular-shaped Deep inferior epigastric perforator (DIEP) flap. Alternatively, there was the option of reconstruction using bilateral Anterolateral thigh (ALT) flaps. Preoperative CT angiography and color-coded duplex sonography demonstrated robust medial abdominal perforators. Following preoperative surgical treatment plan was worked out for a one stage surgical attempt:

1. Extensive debridement of the wound bed to remove previously epithelialized skin areas due to the conducted split-thickness skin grafting.
2. Reconstruction of the soft tissue defect with a triangular-shaped DIEP flap.
3. Alternative: Reconstruction of the soft tissue defect using bilateral unipedicled ALT flaps.