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


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.[10] More 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.[13–15] Small defects can be healed by secondary intention. Akilov et al[16] 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.[2,3] In addition, anteromedial, anterolateral thigh, and pudendal artery thigh flaps can be used.[4,10] In 2003, Ellabban and Townsend[24] 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 al[25] 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.[26] Perforator 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.[28] With 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.[31] In 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.