Fournier's gangrene, a soft tissue infection which is aggressive and sometimes lethal, often passes through deep fascial planes of the penis, scrotum, perineum, and lower abdomen; however, it rarely extends upward into the high intermuscular plane. We managed a rare case of Fournier's gangrene with a high intersphincteric abscess from a perianal infection that resulted in a large defect in the anus and inferior aspect of the scrotum. A perforator-based island flap for the post-debridement defect was performed successfully. The perforator was selected near the defect along the lateral sacral border; the border of the flap design was adjacent to the defect, thus providing a sufficient angle of rotation near the pedicle with minimal dissection. Remnant undissected tissues around the pedicle prevented postoperative vascular complications. Additionally, the distal part of the flap design was elongated to the gluteal sulcus to be harvested as a very thin flap. This study suggests a perforator-based island flap as a secure and convenient option for covering a large defect involving the perianal region and inferior aspect of the scrotum.
Necrotizing fasciitis of the genital and perianal tissues resulting from urologic and colorectal infections is known as Fournier's gangrene. The disease can progress ag-gressively and become lethal. Fournier's gangrene often passes through deep fascial planes of the penis, scrotum, perineum, and lower abdomen. Initial treatment of Fournier's gangrene includes wide and radical debridement of infectious tissues to control the infection. Hence, most cases require perineoscrotal reconstruction after primary treatment [
Herein, we present our experience managing a very rare case of high intersphincteric abscess with Fournier's gangrene in a patient with perianal infection, and successful reconstruction of the consequent extensive perianal defect using a perforator-based island flap. The patient provided written informed consent for submission and publication of this report and accompanying images.
A 63-year-old non-insulin-dependent diabetic male sought evaluation in our emergency room for severe pain and swelling of the scrotum. He had experienced painful discharge around the anus for 1 week. An abdominal computed tomography scan revealed air collection in the scrotum, penis, and perineum, consistent with a diagnosis of Fournier's gangrene (
Abdominal computed tomography scan. Computed tomography shows air collection in the scrotum, penis, and perineum, consistent with Fournier's gangrene.
Reconstruction of the perianal defect using a perforator-based island flap. (A) Penis and scrotal infections are initially controlled by incision and drainage; however, the anal infection is not susceptible to the treatment. (B) Initial post-debridement photo representing the damaged lower anal sphincter; at this point, anal function is retained. (C) Anal sphincter and muscle are damaged severely after the fifth serial debridement and the wound is quiescent after which a vacuum-assisted wound closure system (VAC; KCI Medical) is applied. (D) The defect is visible in the perianal region and inferior aspect of the scrotum. The opening of the anus is already closed. (E) Posterior superior iliac spine and coccyx are marked and serve as surface landmarks of the lateral sacral border. We designed a 15×7 cm perforator-based island flap, which is elongated into the gluteal sulcus. (F) The flap is then elevated disto-proximally in the subfascial layer. Great care is taken near the perforator pedicle, leaving a 1-cm radius of undissected tissue. (G) The flap is transferred easily without pedicle perforator isolation. The donor site is closed directly. (H) Immediate postoperative view showing a thin and well-contoured flap to the anus and inferior aspect of the scrotum. (I) Patient had healed well without any complications at the 6-month fol-low-up.
Fournier's gangrene is a soft tissue infection around the perineum that rapidly spreads into surrounding tissues [
Recently, a need for flaps that allow for more options and customization in design while sparing muscle has arisen, resulting in the establishment of the perforator flap concept. With this new technique, clinicians can obtain flaps of larger dimensions compared with conventional musculocutaneous flaps; therefore, the perforator flap has become a more popu-larized and favored method where perforators are present. Buttocks have redundant perforators from the lumbar, superior gluteal, lateral sacral, inferior gluteal, and internal pudendal arteries, as described by Koshima et al. [
With perforator-based island flaps, these potential vascular problems are prevented by stopping flap elevation at the level of the perforator without trans-muscular dissection toward the proximal source vessel. Meticulous dissection or skeletonization of the perforator is not required if the elevated flap can move freely into the defective area without tension pivoting on a tissue pedicle surrounding the perforator [
Since Fournier's gangrene is an aggressive infectious disease, active debridement in the early stages of the disease is essen-tial. For defects resulting from debridement, especially in cases involving a perianal defect, our new method is more convenient and safer compared to other perforator flap techniques as it can ensure abundant blood flow and sufficient volume. Therefore, the posterior buttock perforator-based island flap is a good option for reconstruction of Fournier's gangrene as it can successfully cover a defect involving the perianal region and inferior aspect of the scrotum.
No potential conflict of interest relevant to this article was reported.