Scrotal dartos-fascio-myo-cutaneous flaps for penis elongation after catastrophic iatrogenic skin shaft sub-amputation: A case of recovery using an extremely adaptable flap

Abstract

IntroductionGenitalia are linked to self-esteem and male sexual identity, especially among young men, who sometimes require a surgical procedure to acquire more confidence. Among the surgical procedures requested for aesthetical purposes, circumcision is one of the most popular. Although it can be considered to be a simple surgical practice, it may cause severe complications such as penile skin necrosis.Presentation of caseWe report a case of a catastrophic situation after a circumcision performed on a 27-year-old HIV positive man resulted in a drastic reduction in the length of the penile shaft due to extensive skin loss; this was subsequently restored using dartos-fascio-myo-cutaneous flaps. Primary healing occurred in 10 days. No infection, dehiscence or flap ischemia were reported. Donor site morbidity was minimal. An adequate aesthetical appearance and satisfactory functional results were obtained.Discussion and conclusionVarious techniques are available for penile skin covering, such as skin grafts or cutaneous flaps. The skin of the scrotum seems to be the most suitable tissue to be used to reconstruct the skin covering of the shaft as it is the most similar. Dartos-fascio-myo-cutaneous flap is a single stage procedure that is easy and safe to perform. It can provide satisfactory cosmetic and functional results, offering a large amount of tissue, with minimal donor site morbidity.

Penile injuries in children

“…[5] When the amputated penis is not recovered or salvaged, a phalloplasty using the cavernosum remnant after their dissection from the pubic bone [6] and closure of the defect with scrotal fasciomyocutaneous flaps is better than applying a thin graft. [6,7] In the absence of the amputated penis and any residual erectile tissue, a penile transplantation has been successfully attempted in adults. [8] Phalloplasty using different flaps is also another option when none of the above solutions could be performed.…”

Rare Yet Devastating Complications of Circumcision

“…Although rare, traumatic complications of circumcisions have troubling consequences. Injury to the skin of the shaft [11,48], injury to the glans or urethra [49][50][51][52], or total amputation of the whole length of the phallus are reported [53,54]. These events, although very rare, are seen in rural regions where ritual mass circumcisions are performed by untrained individuals using primitive devices.…”

“…A proper reconstruction procedure leaves the patient with excess skin that allows room for erection, has excellent visual appeal, is free of hair and contractions, and provides decent sensation. The use of scrotal-dartos-fascio-myo-cutaneous flap has been reported to cover up a defect of skin after circumcision procedure [48].…”

Re: Sarah R. Ottenhof, Andrew Leone, Rosa S. Djajadiningrat, et al. Surgical and Oncological Outcomes in Patients After Vascularized Flap Reconstruction for Locoregionally Advanced Penile Cancer. Eur Urol Focus. In press. https://doi.org/10.1016/j.euf.2018.02.002

“…We recently published a paper assuming that the scrotum seems to be the most suitable tissue to reconstruct the skin coverage of the shaft as it is the most similar [2,3]. Its multiorigin vascular system provides its support basing each side on four different vessels: the anterior and lateral scrotal artery, the lateral branch of posterior scrotal artery, and the septal scrotal artery.…”