Introduction
Fournier’s gangrene is a necrotizing fasciitis that affects the penoscrotal area and perineum [1]. Severe bacterial infection often leads to soft tissue necrosis that requires extensive debridement [2]. Accordingly, a large soft tissue defect is inevitable and often includes dead space caused by structural irregularity of the defect area contents [3]. The dead space most commonly occurs in the perineum or between the two testes and may become a source of recurrent infection when inadequately filled up [4]. Hence, soft tissue resurfacing and dead space obliteration are both required for successful reconstruction following Fournier’s gangrene [4,5]. Herein, we describe two cases of Fournier’s gangrene in the penoscrotal area that were successfully reconstructed using a pedicled anterolateral thigh (ALT) flap with a chimeric pattern.
Cases
This report was approved by the Institutional Review Board of Hanyang University Guri Hospital (IRB No. 2025-12-035). Written informed consent was obtained from all patients for publication of their clinical information and accompanying images.
We encountered two cases of Fournier’s gangrene in the penoscrotal region, both reconstructed using the same surgical approach (Fig. 1). After radical debridement, the penoscrotal defect demonstrated a trapezoidal-shaped dead space between the two testes. A pedicled ALT flap with a chimeric pattern was elevated through meticulous dissection. After detecting a healthy perforator using a hand-held Doppler, the fasciocutaneous component was harvested, proximally dissecting the lateral circumflex femoral artery descending branch main pedicle to about 15 cm. The main pedicle was then further dissected about 3 cm distally from the fasciocutaneous component perforator to harvest part of the vastus lateralis muscle as a separate muscle component of the chimeric flap, maintaining its vascular linkage to the dissected pedicle. The chimeric flap was then passed beneath the rectus femoris muscle and through an inguinal region subcutaneous tunnel toward the defect site. The muscle component was inset into the dead space between the testes, and the fasciocutaneous component was used to cover the penoscrotal defect. After complete reconstruction, patients were allowed to use a wheelchair at postoperative week 1, followed by ambulation at postoperative week 2.
Case 1
A 61-year-old man with diabetes mellitus presented with a sudden onset of extensive skin necrosis in the penoscrotal area, accompanied by high fever (Fig. 2). Immediate debridement was performed after the diagnosis of Fournier’s gangrene. Almost the entire scrotum was removed, together with half of the penile shaft skin. The configuration of the defect wound bed was uneven and included dead space between the testes. After additional wound irrigation and infection control for 2 weeks, flap coverage was planned. A pedicled ALT flap with a chimeric pattern was carefully elevated from the left thigh and inset into the defect. Complications such as flap loss, seroma formation, or recurrent infection were not observed, and the patient returned to normal daily activities while maintaining sexual function. No problems were noted in the reconstructed region throughout a 5-year follow-up period.
Case 2
A 58-year-old man with uncontrolled diabetes mellitus developed Fournier’s gangrene in the penoscrotal area (Fig. 3). The patient presented with extensive skin necrosis on the entire scrotum and part of the penile shaft, accompanied by high fever. Complete debridement resulted in an extensive defect with an irregular contour, with dead space between the testes. After infection control for 2 weeks, flap coverage was performed using a pedicled ALT flap with a chimeric pattern. The flap was appropriately elevated from the right thigh and inset into the defect. Reconstruction was successful without complications or recurrent infection. No problems were observed at the operative site during a 6-year follow-up, and sexual function was preserved.
Discussion
Fournier’s gangrene is a necrotizing fasciitis that rapidly involves the penoscrotal area and perineum, usually in immunosuppressed patients [6]. Extensive soft tissue necrosis is inevitable, and prompt debridement is essential to prevent life-threatening conditions. However, extensive debridement often results in large defects with dead space. The contour of the defect bed is uneven, owing to the structural complexity made by the two separate testes. Accordingly, dead space commonly remains in the perineum or between the testes at the periphery of the defect. This dead space should be meticulously filled to avoid recurrent infection. Optimal reconstruction of Fournier’s gangrene should address both soft tissue resurfacing and dead space obliteration.
Durable skin tissue is required to resurface such large defects. Because the defect is generally extensive, primary closure is not feasible. Skin grafting is a potential option for coverage of large defects; however, it often results in secondary contracture and poor durability, making it vulnerable to friction [7]. This often causes discomfort during sexual intercourse. Therefore, a flap with better durability harvested from a separate healthy region with sufficient dimensions to cover the defect would be a more ideal option. A pedicled ALT flap is an appropriate choice for this purpose because it provides sufficient dimensions with proper thickness and durability for resurfacing [8]. Its thickness can be modulated by selecting the appropriate plane from which to harvest from [9]. The flaps in our cases were harvested along the subfascial plane with a thickness of about 14 mm in both cases. This was thin enough to resurface the penoscrotal defects while maintaining natural contour and did not require additional debulking procedures during follow-up.
An appropriately contoured muscle component is also ideal for obliterating the dead space in this area. Such muscle components can be incorporated into the ALT flap. The conventional ALT musculocutaneous flap, which includes the muscle portion surrounding the perforator, represents a classic option for reconstruction. However, its utility in filling dead space is only useful when the cavity is located in the center of the defect. In addition, the muscle component cannot be positioned freely because it is fixed to the central portion of the skin flap. An ALT perforator flap with a chimeric pattern offers an appropriate solution to these limitations. The chimeric flap consists of two components: a fasciocutaneous portion and a muscle portion. The two components are separate but connected by one main pedicle [10]. The fasciocutaneous component is used for skin coverage, and the muscle component harvested from the vastus lateralis is used to fill the dead space located at the periphery of the defect.
In chimeric flaps, the muscle component can be inset independently, unlike in conventional musculocutaneous flaps. This independence allows the muscle to be positioned specifically to obliterate dead space while the fasciocutaneous paddle is oriented for optimal resurfacing, which is particularly advantageous when the cavity is deep or eccentrically located. In Fournier’s gangrene, residual cavities commonly persist within the perineoscrotal region and are often irregular in depth and extent. Accordingly, a pedicled chimeric ALT flap is a practical option because it can provide broad soft tissue coverage and targeted dead space obliteration in a single-stage reconstruction.
PDF Links
PubReader
ePub Link
XML Download
Full text via DOI
Download Citation 
Print 
