Reconstruction of Defects After Fournier Gangrene: A Systematic Review

Abstract

Background: Reconstruction of scrotal defects after Fournier gangrene is often achieved with skin grafts or flaps, but there is no general consensus on the best method of reconstruction or how to approach the exposed testicle. We systematically reviewed the literature addressing methods of reconstruction of Fournier defects after debridement.

Methods: PubMed and Cochrane databases were searched from 1950 to 2013. Inclusion criteria were reconstruction for Fournier defects, patients 18 to 90 years old, and reconstructive complication rates reported as whole numbers or percentages. Exclusion criteria were studies focused on methods of debridement or other phases of care rather than reconstruction, studies with fewer than 5 male patients with Fournier defects, literature reviews, and articles not in English.

Results: The initial search yielded 982 studies, which was refined to 16 studies with a total pool of 425 patients. There were 25 (5.9%) patients with defects that healed by secondary intention, 44 (10.4%) with delayed primary closure, 36 (8.5%) with implantation of the testicle in a medial thigh pocket, 6 (1.4%) with loose wound approximation, 96 (22.6%) with skin grafts, 68 (16.0%) with scrotal advancement flaps, 128 (30.1%) with flaps, and 22 (5.2%) with flaps or skin grafts in combination with tissue adhesives. Four outcomes were evaluated: number of patients, defect size, method of reconstruction, and wound-healing complications.

Conclusions: Most reconstructive techniques provide reliable coverage and protection of testicular function with an acceptable cosmetic result. There is no conclusive evidence to support flap coverage of exposed testes rather than skin graft. A reconstructive algorithm is proposed. Skin grafting or flap reconstruction is recommended for defects larger than 50% of the scrotum or extending beyond the scrotum, whereas scrotal advancement flap reconstruction or healing by secondary intention is best for defects confined to less than 50% of the scrotum that cannot be closed primarily without tension.

Keywords: Fournier gangrene; scrotal advancement flap; scrotal and perineal defects; skin graft; systematic review.

Figure 1

Citation flow diagram for the review process.

Figure 2

Medial circumflex femoral artery perforator flap (top). Early postoperative view (bottom). Reprinted with permission from Coskunfirat et al.

Figure 3

Anatomic illustration of the pudendal thigh flap with a V-Y design. (a) The flap pedicle. (b) Flap design and elevation. (c) The flap inset. Reprinted with permission from El-Khatib.

Figure 4

Proposed algorithm for reconstruction of Fournier defects.

Figure 5

Preoperative (top) and postoperative (bottom) split-thickness skin grafting after Fournier gangrene.