Penoscrotal defect reconstruction using loco‐regional flaps in treatment of extramammary Paget's disease: Experience and suggestion of a simplified algorithm

Abstract

Background: Reconstruction of penoscrotal defects resulted from margin-controlled excision of extramammary Paget's disease (EMPD) remains challenging, due to its unpredictably varying extents. The present study aimed to investigate outcomes of reconstruction of penoscrotal defects following radical excision of EMPD and to introduce a simplified algorithm for selecting reconstruction strategies.Methods: Patients with penoscrotal EMPD who were treated with wide excision and subsequent reconstruction from 2009 to 2020 were reviewed. Their demographics, operation-related characteristics, and postoperative outcomes were evaluated.Results: In total, 46 patients with a mean age of 64.9 years (range, 44-85 years) were analyzed. An average size of defects was 129.6 cm 2 (range, 8-900 cm 2 ). The most frequently involving anatomical subunit was scrotum, followed by suprapubic area and penile shaft. Twenty-six patients had defects spanning multiple subunits. The most commonly used reconstruction methods for each anatomical subunit were internal pudendal artery perforator (IPAP) flaps and/or scrotal flaps for scrotal defects, superficial external pudendal artery perforator (SEPAP) flaps for suprapubic defects, and skin grafts for penile defects. In all but four cases, successful reconstruction was achieved with combination of those reconstruction options. No major complications developed except for one case of marginal flap necrosis. All patients were satisfied with their aesthetic and functional results.Conclusions: Diverse penoscrotal defects following excision of EMPD could be solidly reconstructed with combination of several loco-regional options. A simplified algorithm using in combination of IPAP flap, SEPAP flap, scrotal flap, and skin graft may enable efficient and reliable reconstruction of penoscrotal EMPD defects. | INTRODUCTIONExtramammary Paget's disease (EMPD) is a rare, slow-growing intraepithelial adenocarcinoma localized to areas of apocrine gland distribution outside the mammary glands. It occurs most frequently in the external genitalia of women and less frequently in the external genitalia of men, perianal area, and axillary area. Clinically, EMPD manifests as an erythematous, eczematoid, and well-demarcated lesion with symptoms of pruritis and pain (Lloyd & Flanagan, 2000;