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

Mehmet Dadaci, MD; Mehmet Emin Cem Yildirim, MD; Serhat Yarar, MD; Bilsev Ince, MD


Wounds. 2021;33(3):65-69. 

In This Article

Abstract and Introduction


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.


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 100 000 per year; the incidence in males, and older males in particular, is even higher, with 3.3 cases per 100 000 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.