The “Sombrero-Shape” Super-Thin Pedicled ALT Flap for Complete Scrotal Reconstruction Following Fournier's Gangrene

Abstract

When the scrotal sac is entirely debrided following a Fournier gangrene, testes exposure poses unique challenges for the reconstructive surgeon. Despite the anterolateral thigh (ALT) flap is considered a workhorse in such context, aesthetic results are often suboptimal because of the lack of natural ptosis and patchwork appearance. We describe the use of a super-thin pedicled ALT flap for total scrotal reconstruction, modified according to a peculiar flap design and inset technique. A 42-year-old man was referred to our department for delayed total scrotal reconstruction 8 months after a Fournier gangrene extensive debridement. A super-thin pedicled ALT flap from the right thigh was designed: in the central portion of the ALT, a lateral skin paddle extension was marked to guarantee adequate posterior anchorage during insetting and ptosis of the scrotal sac. This particular flap arrangement has inspired the name “sombrero” as the shape is akin to the famous hat. No secondary refinements were needed, and the patient showed satisfying aesthetic and functional results at 12 months' follow-up. The ALT flap design “sombrero” modification proposed in this article can improve scrotum cosmesis and patient satisfaction in a single-stage single-flap procedure.

Reconstruction of Acquired Defects of the External Genitalia

“…Recently described is the so-called sombrero-shaped ALT super thin flap, containing subcutaneous and superficial fascia, with very minimal adipose tissue. This flap has been designed for use in scrotal reconstruction 24 and is one that may be considered to restore aesthetic and physiological function. The utilization of flaps that bring enough tissue to perform these styles of reconstruction is thus a good option to mitigate testicular atrophy.…”

Crafting Contours: A Comprehensive Guide to Scrotal Reconstruction

“…In response to these limitations, there have been proposals for secondary cosmetic surgeries to enhance the appearance of scrotums reconstructed with STSG [49]. Reconstructive surgeons need to recognize that simply covering the testes with skin may diminish the patient's quality of life and lead to psychological distress [50][51][52].…”

“…The thickness of the fasciocutaneous ALT flap in Asians averages about 9.8 mm [80], and it is known to correlate with body mass index [81]. In obese patients, the flap will be even thicker, and therefore less preferable to SCIP flaps [51]. Other perforator flaps from the medial thigh also tend to accumulate subcutaneous fat, making their thickness dependent on the patient's degree of obesity [75].…”

Pushing boundaries: Anterolateral thigh free flaps for extensive scalp defects beyond previous limits, leveraging imaging modalities with ultrasound and indocyanine green

“…It was first described by YG Song in 1984 and has historically been regarded as the workhorse of flap microsurgery. This technique has undergone several modifications and its versatility has been demonstrated in various human anatomical sites, including the scalp reconstruction (Hong et al, 2005; Lamaris et al, 2017; Morrison et al, 2014; Park et al, 2022; Sapino et al, 2022). Although the LD flap is the most popular free flap for scalp reconstruction because of its advantages, including reliable vascularity, versatility, and bulkiness (Elia et al, 2019; Hierner et al, 2007; Trignano et al, 2013), it has drawbacks, including potential shoulder weakness (Beasley et al, 2004; Lamaris et al, 2017), and the ALT flap is also commonly used.…”