Midline raphe scroti artery flap for penile shaft reconstruction

Abstract

Aim: To investigate a novel method for penile shaft reconstruction. Methods: Penile tissue loss is caused by injury, infections, obesity or cancer resection. Reconstructive techniques comprise skin grafts with the risk of scarring and tissue rigidity. To develop an alternative reconstructive procedure, the pertinent vascular anatomy was studied on fresh cadavers instilled with red latex, which permitted the design of the midline raphe scrotal artery flap (MiRA). After anatomical proof-of-feasibility, penile reconstruction was performed in adult patients with classic buried penis or after cancer resection. Results: Anatomical studies revealed a novel finding of two scrotal septa, each with the terminal branch of the internal pudendal artery. Pedicled on both arteries, a neurovascular island flap could be harvested. In the presence of excess scrotal tissue, the entire circumference of the penile shaft could be covered by this flap. Patients with penile skin defects and excess scrotal tissue were eligible for flap harvest. The flap was raised either as an extended island flap pedicled on both septal arteries for complete penile shaft coverage, or as a VY-flap for partial reconstruction; the donor site was closed primarily. Post-operative complications included swelling or partial wound dehiscence. There were no flap losses or perfusion problems. Patients reported full sensitivity to the penile shaft skin and sufficient skin elasticity for erection.

Genital Wound Repair and Scarring

“…In case of traumatic tissue loss, half of the scortal sac can be reconstructed from the remaining scrotal tissue [ 11 ], which is highly similar to the wound healing characteristics of the spiny mouse Acomys [ 54 ]. Furthermore, excess skin is useful for defect coverage of the penile shaft in obese men [ 55 , 56 ], after trauma [ 57 ] or tumor excision [ 30 , 57 ] or for genital reassignment surgery [ 58 ]. Of note, skin adjacent to the outer genitalia, e.g., groin, suprapubic or perineal skin in the vicinity of the thigh, have a tendency to excessive scarring, whereas hypertrophic scarring is rarely found in genital skin [ 15 ].…”

“…Granuloma formation is followed by chronic inflammatory response and subsequent ulcer formation and tissue loss. The only rescue is the radical excision of all foreign body material and plastic surgical tissue reconstruction [ 30 , 57 ].…”