Anteriorly based pudendal thigh flap for scrotal reconstruction based on the deep external pudendal artery (DEPA) flap

Background

Major scrotal skin loss represents a significant challenge for reconstructive surgeons. Although many therapeutic methods have been established for the treatment of such defects, each technique has its own advantages and disadvantages. A posteriorly based pudendal thigh fasciocutaneous flap at the perianal region has been described for reconstruction of genital organs, but an anteriorly based pudendal thigh fasciocutaneous flap has not been described for scrotal reconstruction.

Aim

The aim of this study was to introduce and evaluate the use of an anteriorly based pudendal thigh flap for scrotal reconstruction.

Methods

Twenty flaps in 15 patients with major scrotal defects were subjected to reconstruction using this flap. The etiology of scrotal loss was Fournier gangrene in all cases. Five patients each underwent bilateral and ten patient unilateral reconstructions, by the anteriorly based pudendal thigh flap, based on the deep external pudendal artery (DEPA).

Results

All 20 flaps survived completely. Additionally, the donor site was closed directly, and the scar was hidden in the perineal crease. The donor site healed uneventfully, as one patient required a secondary procedure for healing.

Conclusion

An anteriorly based pudendal thigh flap is highly reliable for coverage of major scrotal defects. This flap allows adequate coverage with excellent aesthetic appearance of the scrotum.Level of Evidence: Level II, therapeutic study.

     

Surgical anatomy of the somatic terminal innervation to the anal and urethral sphincters: role in anal and urethral surgery

PURPOSE: The gross anatomy of the pudendal nerve branches was studied to identify more precisely the neuroanatomical relationship in the region of the anal canal, bladder neck and proximal urethra. Such knowledge is essential for the development of surgical techniques that avoid nerve injury in sphincteroplasty for anal and urinary stress incontinence, and in pudendal canal decompression. MATERIALS AND METHODS: The pudendal nerve terminal branches were dissected in 7 female and 5 male formalin fixed cadavers, including 6 fully mature neonates and 6 adults, a mean age of 37.6 years. The nerves were traced from the pudendal nerve to their termination in the anal and urethral sphincters, and pelvic floor muscles. RESULTS: The inferior rectal nerve occupied the lower half of the ischiorectal fossa. Immediately after emerging from the pudendal canal it extended a motor branch to the levator ani muscle and the cutaneous perianal and scrotal branches. The nerve terminated in the external anal sphincter at the 3 and 9 o'clock positions. Inside the pudendal canal the perineal nerve gave rise to a scrotal branch which joined the scrotal branch of the inferior rectal nerve to form the common scrotal nerve. About 2 to 3 cm. from the pudendal canal the perineal nerve extended a branch to the bulbocavernosus muscle and divided into the terminal scrotal and motor branches, which penetrated the striated urethral sphincter at the 3 and 9 o'clock positions. The deep dorsal nerve of penis or clitoris coursed forward into the ischiorectal fossa, emerged from the deep perineal pouch and penetrated the suspensory ligament to the dorsum of the penis or clitoris. CONCLUSIONS: The identification of the precise anatomical relation of the somatic nerve termination to the anal and urethral sphincters seems vital to avoid sphincter denervation during surgery for the correction of fecal and stress urinary incontinence.     

阴囊后动脉外侧支血管蒂阴囊皮瓣的临床应用

目的：提供一种理想的阴茎腹侧创面修复材料。方法：在有囊皮肤血供解剖学研究基础上，对合并阴囊分裂、阴茎、阴囊转位的尿道下裂，应用以阴囊后动脉外侧支为血管蒂的阴囊皮瓣修复尿道再造完成后阴茎腹侧遗留创面9例。结果：9例皮瓣全部成活，效果满意。结论：对于阴囊分裂合并阴茎阴囊转位的尿道下裂，应用阴囊后动脉外侧支为血管蒂的阴囊皮瓣，不但可修复阴茎腹侧创面，亦可同期矫正阴囊分裂和阴茎阴囊转位。     

阴股沟皮瓣的解剖及其在男性会阴部修复重建中的应用

目的明确阴股沟皮瓣解剖基础,为临床设计和应用此皮瓣提供解剖依据和手术方法。方法解剖研究15具成年男尸阴股沟区的血供和神经支配情况。依据研究结果为男性会阴部修复重建患者设计合理的皮瓣。结果阴股沟区动脉血液供应充足,静脉回流丰富,神经支配可靠。该区的动脉血供有阴部外浅动脉、闭孔动脉前皮支、阴囊后动脉的主干和外侧支,并且位置均比较恒定。三组血管网贯穿了皮瓣的上、中、下部。临床应用阴股沟皮瓣23例,皮瓣切取最大为17cm×9cm,最小8cm×5cm,均取得理想的治疗效果。结论阴股沟皮瓣血运丰富,切取方便,供区隐蔽,在修复、重建男性会阴部时,可以取上、中、下蒂皮瓣。术后皮瓣成活率高,外形及神经感觉均取得理想结果。     

Labioscrotal island flap in feminizing genitoplasty

Background/Purpose

Stenosis of the vaginal introitus is the most frequent complication after genital reconstruction for ambiguous genitalia associated with congenital adrenal hyperplasia (CAH). With the aim of enlarging the vaginal introitus, the authors present a technical modification of the introitoplasty that uses a bilateral cutaneous island flap based on the perineal superficial branches of the internal pudendal artery.

Methods

Eleven girls with CAH and Prader III to V genital ambiguity were included. Feminizing genitoplasty was performed in 1 stage. Bilateral cutaneous labioescrotal island flaps, based on the posterior labial artery, were included in the introitoplasty. The cosmetic results of the genitoplasty were evaluated by photographic analysis of the external genitalia.

Results

Integrity of the vaginal introitus as well as excellent integration of the flap and absence of additional scars in the donor area were assessed in all girls.

Conclusions

This modified island flap is technically feasible and reproducible producing no additional sequels in the donor area. It uses perineal skin that is usually excised in other techniques avoiding the use of harvesting skin from adjacent areas. Thus, it can be a useful additional procedure in the introitoplasty in association with the currently used techniques.     

阴囊皮肤多源性血供系统应用解剖学研究

目的探讨阴囊皮肤血供模式,明确可能的阴囊皮瓣供区。方法对10具(20侧)成年男尸阴囊皮肤进行解剖学研究。结果阴囊前动脉来自阴部外浅动脉,于阴茎根部侧方分成内、外侧支,分布于阴囊前外侧皮肤,内侧支口径为(0.54±0.34)mm和(0.69±0.09)mm;来自闭孔动脉前皮支的阴囊外侧动脉[出现率为85％,外径(0.62±0.19)mm]分布于阴囊外侧中1/3区皮肤;阴囊后动脉于阴囊后极处,分成阴囊后动脉外侧支与阴囊中隔动脉,前者[外径(0.8±0.1)mm]分布于阴囊后外侧区皮肤,后者[外径(0.9±0.2)mm]分布于阴囊中隔及阴囊中缝侧方皮肤。结论上述4组血管均在阴囊肉膜层内走行,其终末支血管相互吻合,在每一侧阴囊形成一个较为完整的动脉网络,由此提出4种类型的阴囊皮瓣切取方式,其他类型的阴囊皮瓣是上述阴囊皮瓣切取方式的变化形式。     

Scrotal reconstruction after Fournier's gangrene with simple skin grafting

Summary Fournier's gangrene is a rare but life-threatening condition in western countries; it consists of acute subcutaneous necrotizing infection of the genital and perineal region. Predisposing diseases are characteristically those which impair the patient's immunological defense and wound healing. After emergency debridement, there is extensive loss of scrotal and perineal tissue, usually these defects heal satisfactorily by secondary intention, and reconstructive procedures are seldom indicated. Defects of the penis, abdomen or thighs are split skin grafted, while for scrotal reconstruction, various methods are recommended, such as medial thigh fasciocutaneous flaps, bilateral superolateral thigh flaps or bilateral gracilis musculocutaneous flaps. In Fournier's gangrene due to predisposing disease, split-thickness skin grafting in scrotal reconstruction can, in the authors' opinion, achieve excellent results. In addition, it is the least disabling reconstructive procedure in such patients.     

阴股沟皮瓣的显微解剖研究

目的明确阴股沟皮瓣的解剖基础,为临床设计和应用提供解剖依据。方法对成年尸体11具（22侧）阴股沟区进行显微解剖研究。在尸体标本上,模拟临床皮瓣切取方式,对皮瓣内包含的血管、神经进行观测;然后进行深部组织解剖,追溯血管、神经来源,并做记录。结果阴股沟区动脉血液供应充足,静脉回流丰富,神经支配可靠。阴部外浅动脉起始点主干直径为2.14±0.23mm,又分为升支（阴部外浅动脉腹股沟支,血管直径为1.38±0.34mm）、降支（阴部外浅动脉会阴支,血管直径为1.21±0.24mm）。阴囊（唇）后动脉主干（血管外径为1.13±0.24mm）和外侧支（血管直径为0.67±0.33mm）。闭孔动脉前皮支（血管外径1.68±0.11mm）。并且位置比较恒定,其中以阴部外浅动脉和阴囊（唇）后动脉最为恒定;三组血管网贯穿了皮瓣的上、中、下部。神经支配主要有生殖股神经股支,髂腹股沟神经皮支,阴囊（唇）后神经三组。结论阴股沟皮瓣血运丰富,解剖简便易行,切取方便,供区隐蔽,再造性器官外形及神经感觉均较理想。     

A New Biaxial Epilated Scrotal Flap for Reconstructive Urethral Surgery

Purpose

We describe a new type of perineum based scrotal flap with biaxial vascularization supplied by both superficial perineal arteries. Flap length of up to 20 cm. may be attained for urethral reconstruction.

Materials and Methods

A total of 37 men with complex urethral stenosis of different etiologies underwent surgery using 1 of 3 urethroplasty techniques based on this new flap. The whole anterior urethra, including pendulous and bulbar segments, was reconstructed with a scrotal patch in 10 patients. A scrotal tubular flap was used as a substitute for the bulbar urethra in 7 patients and for the membranous portion in 4. Bulbar urethroplasty with a scrotal island patch was performed in 16 patients.

Results

Of the patients 86% achieved normal voiding after 1-stage urethroplasty. Mean followup was 39.5 months.

Conclusions

The excellent axial vascularization of this new flap permits successful resolution of the most complex urethral stenoses regardless of extension, location and etiology.     

联合应用包皮与阴囊独立皮瓣一期修复尿道下裂的探讨

目的：探讨阴囊及会阴型尿道下裂患者一期修复重建尿道的新术式。方法：联合应用包 阴囊两独立带蒂皮瓣施行尿道重建术一期修复阴囊及会阴型尿道下裂患者１３例。结果：１１例获得成功。２例术后出现尿瘘,其中１例经尿道扩张治疗。３周后尿瘘愈合,另１例行二期尿道成形术后尿瘘痊愈。结论：联合应用包皮与阴囊两独立皮瓣重建尿道的优势明显,更我的集中了目前治疗阴囊及会阴型尿道下裂众多术式的优点。获得满意疗效。     

Arterial vascularization of the human bulbo-uretral glands]

The study based on the dissection of 79 specimens of bulbo-urethral glands describes their arterial vascularisation. 1. The glands receive their main arterial vascularization from the artery of the bulb of the penis. The vessel reaches the surface of the gland from above and from both sides. 2. Supplementary sources of vascularization may take their origin from the int. pudendal artery, urethral art., perineal art., or an anastomosis between the cystic inferior art. and the pudendal int. artery. 3. The artery of the bulb of penis is variable. It may divide into two (often) or three (seldom) branches penetrating the bulb of the penis. One case with two arteries of the bulb (both from the pudendal int. artery), has been described. 4. The glandular arterioles ("short or intraglandular" ones) take their origine inside the gland (type I) or exist as supplementary arteries ("long or extracapsular" ones) branches from near arterial truncs (type II). If the gland is placed in the musculature of the uro-genital diaphragm and it is well separated from it by a connective-tissue capsule, the capsule receives its own ("capsular") branches, which are a supplementary source of vascularization for the gland (type III). 5. The existence of "long or extracapsular" branches is in connection with lobation of the gland. Every lobule receives its own branch from an "extracapsular" artery. 6. Only one slight right-left assymetry was observed.     

阴股沟皮瓣应用解剖学研究

目的明确阴股沟皮瓣的解剖学基础.方法对10具(20侧)成年女尸阴股沟区皮肤进行解剖学研究.结果阴股沟皮瓣存在多重血液供应;其中,闭孔动脉前皮支分布于皮瓣中部,浅出点距会阴正中线(3.0±0.5)cm,距阴道口前缘(1.7±0.4)cm距耻骨下支外侧缘(0.6±0.2)cm,管径(0.8±0.1)mm;阴唇后动脉主要供应大阴唇,并恒定地以本干的形式在大阴唇皮下与阴部外浅动脉形成血管吻合,在阴道口后缘前后各1.5cm的范围内,发出2、3支阴唇后动脉外侧支,外径为(0.7±0.3)mm,分布于阴股沟皮瓣后部;阴部外浅动脉斜形穿过皮瓣上端走向大阴唇,沿途发出柳枝状血管分支分布于皮瓣上端.结论阴股沟皮瓣阴道再造所利用的血管是阴唇后动脉外侧支,而非阴唇后动脉主干;由于闭孔动脉前皮支浅出点位置较高而且固定,以之为蒂形成的皮瓣不适用于阴道再造,而适合于会阴部较小皮肤缺损的修复.     

One-stage phalloplasty without sensory deprivation in female transsexuals

Summary Phalloplasty in transsexuals has, up to now, been done with cutaneous and myocutaneous flaps from the abdomen or thigh in multiple procedures requiring a long period of reconstruction. A one-stage phalloplasty in female transsexuals with a modified Chinese forearm flap is reported, including anastomosis of the cutaneous nerves with the genital branches of the ilioinguinal and iliohypogastric nerves and the perineal branches of the pudendal nerve to obtain true genital sensibility. Immediate hysterectomy and vaginal closure provide vaginal and labial skin for the neoscrotum and to cover the glans. A vaginal flap draped around the catheter forms the urethra, which is stripped through the dermal tube of the forearm flap acting as corpus spongiosum. Autogenous costal cartilage is used as a stent for reinforcement, substituting the corpora cavernosa. The donor forearm area is covered with split skin.     

Scrotal septocutaneous island flap for the reconstruction of the urethral fistula

We report the reconstruction of the urethral fistula using a scrotal septocutaneous island flap. A scrotal septocutaneous island flap is supplied by vascular networks in the scrotal septum area from both perineal arteries and posterior scrotal arteries. This flap is divided into two flaps, one for urethral lining and the other for the skin defect. We found it to be a simple, useful, and reliable alternative to other local flaps. However, hairless skin of the scrotum must be used for the urethral lining. The musculocutaneous flap is also reliable. However, use of the scrotal septocutaneous island flap can save the musculocutaneous flap for secondary procedures.     

One-stage phalloplasty in transsexuals

Until now, phalloplasty in transsexuals has been done with cutaneous and musculocutaneous flaps from the abdomen or the thigh in multiple procedures over a long period. We report a one-stage phalloplasty in female transsexuals with a modified Chinese forearm flap, including the cutaneous nerves anastomosed to the genital branches of the ilioinguinal and iliohypogastric nerves and the perineal branches of the pudendal nerve to obtain true genital sensibility. Immediate hysterectomy and vaginal closure are performed, providing vaginal skin to complete the neoscrotum built up with the labia and to cover the glans. A vaginal flap draped around the catheter provides the urethra, which is stripped through the dermal tube of the forearm flap acting as a corpus spongiosum. Autogenous costal cartilage is used as a stent for reinforcement, substituting for the corpora cavernosa. The donor forearm area is covered with split skin.     

Aesthetic Penoscrotal Resurfacing: Creating Propeller Flaps from Gluteal Folds

Background

Reconstruction of extensive penoscrotal defects is a surgical challenge. Resurfacing defects in highly complex three-dimensional structures and restoring their function are an essential part of the reconstruction of penoscrotal regions.

An assessment of the anatomical basis of the thoracoacromial artery perforator flap

BACKGROUND:

Musculocutaneous perforator flaps offer advantages over musculocutaneous flaps, including reduced donor site morbidity, more predictable reconstruction of soft tissue deformities, and a wider variety of flap options. Perforator flaps are becoming increasingly popular for many applications. In the present study, we set out to examine the various perforators of the thoracoacromial axis through the pectoralis major (PM) muscle with respect to their suitability for transfer to the head and neck region as a pedicled flap.

METHODS:

A series of 10 fresh cadavers were injected with lead oxide, gelatin and water (250 mL/kg) through the femoral vessels. The cadavers were cooled and the integument was removed. Perforating vessels from the underlying muscles were marked and the resulting angiograms of the integument and deep tissues were compared with the dissection notes describing the course, size and distribution of the perforating vessels.

RESULTS:

The perforators through the PM muscle to the overlying skin included three regional groups: perforators of the thoracoacromial axis; perforators of the medial intercostal vessels; and perforators of the lateral thoracic artery. The major group of perforators supplying the overlying skin was from the intercostal vessels. However, the thoracoacromial axis did consistently give rise to perforators in the upper portion of the PM muscle. In particular, there were reliable perforators from the clavicular and deltoid branches of the thoracoacromial artery.

DISCUSSION:

The present study illustrates the potential clinical applications of a series of perforator flaps based on the thoracoacromial axis, which may be useful in head and neck reconstructive surgery.     

Lateral Calcaneal Artery Adipofascial Flap for Reconstruction of the Posterior Heel of the Foot

Background

Soft tissue defects of the posterior heel of the foot present difficult reconstructive problems. This paper reports the authors'' early experience of five patients treated with a lateral calcaneal artery adipofascial flap.

Methods

Between 2003 and 2007, five patients (3 males and 2 females) with soft-tissue defects over the posterior heel underwent a reconstruction using a lateral calcaneal artery adipofascial flap and a full-thickness skin graft. The flap sizes ranged from 3.5 × 2.5 cm to 5.5 × 4.0 cm.

Results

All five flaps survived completely with no subsequent breakdown of the grafted skin, even after regularly wearing normal shoes. The adipofascial flap donor sites were closed primarily in all patients.

Conclusions

Lateral calcaneal artery adipofascial flaps should be included in the surgical armamentarium to cover difficult wounds of the posterior heel of the foot. These flaps do not require the sacrifice of a major artery to the leg or foot, they are relatively thin with minimal morbidity at the donor site, and leave a simple linear scar over the lateral aspect of the foot.     

One‐sided anterior urethroplasty: a new dorsal onlay graft technique

OBJECTIVE

To investigate the feasibility, tolerability, safety and efficacy of using a new surgical technique for the repair of anterior urethral strictures to preserve vascular supply to the urethra and its entire muscular and neurogenic support.

PATIENTS AND METHODS

In all, 24 patients (mean age 46 years) underwent a new one‐sided anterior dorsal oral mucosal graft urethroplasty while preserving the lateral vascular supply to the urethra, the central tendon of the perineum, the bulbospongiosum muscle and its perineal innervation. The cause of stricture was instrumentation in three cases (12%), unknown in five (21%), infection in four (17%), and lichen sclerosus in 12 (50%). The stricture site was bulbar in 12 cases (50%) and panurethral in 12 (50%). The mean stricture length was 4.2 cm in patients with bulbar strictures and 10 cm in patients with panurethral strictures. Of 24 patients, 20 patients (83%) had received previous treatments. Clinical outcome was considered a failure when any postoperative instrumentation was needed, including dilatation.

RESULTS

The overall mean (range) follow‐up was 22 (12–55) months. Of the 24 patients, 22 (92%) had a successful outcome and two (8%) were failures. One failure was treated using definitive perineal urethrostomy and another failure underwent successful internal urethrotomy.

CONCLUSIONS

The preservation of the one‐sided vascular supply to the urethra and its entire muscular and neurogenic support should represent a slight but significant step toward perfecting the surgical technique of urethral reconstruction using a minimally invasive approach.