Excision With Flap Reconstruction for Genital Lymphedema
A flap provides vascularized coverage after removal of diseased tissue. It is useful when the remaining healthy skin cannot close without tension, the recipient surface is unsuitable for grafting, dead space requires filling, or the defect needs a particular shape or tissue quality. Lymphatic reconstruction is an additional, selected objective; transferring skin or muscle does not by itself prove restoration of normal drainage.[1][2]
See debulking scrotoplasty for the excisional operation, modified Charles for the variable use of that name, and scrotal flaps for the broader coverage inventory.
Decide From the Defect and Donor Tissue
Assess penile versus scrotal involvement, the actual viable skin remaining, perfusion, prior groin operations or radiation, and the location of the testes, cords and urethra. A 50% skin-loss threshold is not a validated genital-lymphedema rule. Exposure of a viable testis does not automatically preclude grafting; what matters is an adequately vascularized recipient surface and the complete coverage requirement.[2][3]
| Finding | Reconstructive consideration |
|---|---|
| Sufficient healthy mobile skin | Tension-free closure or local advancement may provide coverage with limited donor morbidity. Preserve useful local vascularity. |
| Broad superficial defect with a suitable bed | Consider a graft; a regional flap is not obligatory simply because the defect is large. |
| Poor graft bed, deeper exposed structure, dead space or complex contour | A regional flap can supply vascularized tissue and appropriate bulk. Plan reach, tunneling, pedicle protection and donor closure. |
| Deficient lymphatic drainage with suitable donor/recipient anatomy | Discuss a lymphatic procedure in addition to the coverage plan. Imaging can assist selection, but no universal genital algorithm has been validated. |
| Prior failed closure, graft or flap | Reassess residual disease, perfusion, infection, mechanical tension and proximal obstruction before choosing the next operation. |
These are planning principles, not a mandatory progression through procedures.[1][2]
Coverage Options
| Option | Useful features and limitations |
|---|---|
| Local scrotal/perineal flaps | Use healthy adjacent tissue where available. Halperin's two cases suggest feasibility and a possible collateral-drainage advantage of posterior perineal tissue; they do not demonstrate better drainage, fertility or recurrence than another reconstruction.[4] |
| Pudendal-thigh flap | A potentially sensate regional skin option. Mopuri's five-case report describes a modified elevation and inset; it is not a comparative genital-lymphedema trial or a guarantee of normal sensation.[5] |
| Anterolateral thigh (ALT) | Can cover a larger or more complex defect. Thickness, arc of rotation, tunneling and donor morbidity matter. Yu's seven-patient series included both perineoscrotal wounds and ischial ulcers, with three minor wound dehiscences; it cannot supply a lymphedema-specific success rate.[6] |
| Gracilis or gracilis-perforator coverage | Muscle may help fill dead space; perforator designs can preserve muscle. Coskunfirat's seven cases were after Fournier gangrene and included two wound dehiscences. Despite the paper's title, there was no comparative demonstration of “superiority.”[7] |
| Internal pudendal artery perforator (IPAP) propeller flap | Can provide local contour and a concealed donor scar when the perforator and rotation are suitable. Han reported ten penoscrotal reconstructions with one partial distal necrosis. This is limited reconstructive experience, not proof that the flap has the lowest complication rate.[8] |
Detailed flap anatomy belongs in the linked scrotal flap overview and its foundations companions. Do not improvise a pedicle division or rotation angle from an outcome table.
Penile Coverage From Healthy Scrotal Tissue
A scrotal flap can cover a penile skin defect only when the proposed donor is suitable. Lymphedematous scrotal skin is not automatically an acceptable donor. Hair, bulk, contraction and loss of scrotal volume should be discussed.
Mendel's 22-patient retrospective penile-shaft series included diverse indications, particularly buried penis and foreign-material injection. Early dehiscence occurred in 31.8%, and late retraction in 27.3%; early and late revision rates were 9.1% and 27.3%, respectively. Only 12 patients returned the functional questionnaire. Their median satisfaction of 8/10 and postoperative erection-hardness score do not establish preservation of baseline erectile function or outcomes specific to genital lymphedema.[9]
Lymphatic Flaps: Promising, With Limited Comparative Evidence
SCIP lymphatic flaps combine soft-tissue coverage with transfer of lymphatic structures. The proposed drainage benefit should be distinguished from flap survival, and a pedicled lymphatic flap should not be conflated with a free vascularized lymph-node transfer. Selection requires specialist assessment of donor lymphatics, perfusion and potential donor-site harm.[1][10]
| Report | Actual population and interpretation |
|---|---|
| Abdelfattah 2023 | Twenty-six men: 15 isolated scrotal and 11 penoscrotal cases. All flaps survived, and symptom/cellulitis scores improved at a mean 44.9 months. This uncontrolled cohort does not establish comparative recurrence prevention or make every postoperative complication rate zero.[10] |
| Yamamoto 2022, 3R | Seven men had excision with SCIP lymphatic flap reconstruction. No genital complication or recurrence was observed over mean 22.7-month follow-up. Postoperative compression was not used in that study; this is a protocol observation, not proof that all patients can permanently stop compression.[11] |
| Ciudad 2025, CHASCIP | Eight men had excision and bilateral pedicled lymphatic SCIP flaps. No recurrence was observed at mean 34 months, but two patients had wound complications, including partial graft loss. There was no excision-only comparison.[12] |
These small series support further evaluation and individualized use. They do not establish lymphatic SCIP transfer as a mandatory standard, demonstrate cure, or justify pooling their populations into a single “zero complication” rate.
Interpret the Comparative Literature Carefully
Guiotto's review combined 20 studies and 151 patients published through 2016. The reported 54.2% complication rate in the flap group is a historical pooled observation across selected series. Patients receiving excision tended to have more advanced disease; the review identified no consensus treatment approach. Those numbers cannot rank a flap against primary closure, grafting or LVA for an otherwise identical patient.[13]
Likewise, results after Fournier gangrene, cancer, trauma and genital lymphedema are not interchangeable. Flap loss is only one endpoint: a surviving flap may still be associated with wound breakdown, bulk, altered sensation, recurrent edema or revision. Regional-flap experience can inform coverage, while lymphedema-specific drainage and recurrence require separate assessment.
Fertility and thermoregulation remain incompletely studied. Thin, pliable coverage is desirable, but small subjective reports cannot prove normal spermatogenesis or establish a fertility hierarchy among local flaps, thigh flaps and grafts. Address fertility goals separately when relevant.[4][3]
Historical proposals that a TFL muscle flap “absorbs lymph” were based on inferred mechanisms in a small mixed lower-limb/genital series. That report is not a basis for routine groin block dissection or a claim that any muscle flap restores lymphatic function.[14]
Recovery and Assessment
Monitor flap perfusion, compression or kinking of the pedicle, hematoma, infection, wound separation and urinary or fecal contamination. Protect the inset while planning mobilization and thromboprophylaxis according to the operation and patient. Begin or resume local support/compression only when appropriate for the reconstruction and coordinated with the lymphedema team.[1]
Follow wound healing, recurrence, lymphorrhea, cellulitis, voiding, sexual symptoms, donor morbidity and patient priorities over time. A technically viable flap is not the sole measure of success.
Related Pages
- Complex decongestive therapy
- Debulking scrotoplasty
- Modified Charles procedure
- Scrotal grafting
- Giant penoscrotal lymphedema
- SCIP flap foundations
References
1. International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2023 consensus document. Lymphology. 2023;56:133–151. Consensus document.
2. Schifano N, Castiglione F, Cakir OO, Montorsi F, Garaffa G. Reconstructive surgery of the scrotum: a systematic review. Int J Impot Res. 2022;34(4):359–368. doi:10.1038/s41443-021-00468-x
3. Karian LS, Chung SY, Lee ES. Reconstruction of defects after Fournier gangrene: a systematic review. Eplasty. 2015;15:e18. Full text.
4. Halperin TJ, Slavin SA, Olumi AF, Borud LJ. Surgical management of scrotal lymphedema using local flaps. Ann Plast Surg. 2007;59(1):67–72. doi:10.1097/01.sap.0000258448.17867.20
5. Mopuri N, O'Connor EF, Iwuagwu FC. Scrotal reconstruction with modified pudendal-thigh flaps. J Plast Reconstr Aesthet Surg. 2016;69(2):278–283. doi:10.1016/j.bjps.2015.10.039
6. Yu P, Sanger JR, Matloub HS, Gosain A, Larson D. Anterolateral thigh fasciocutaneous island flaps in perineoscrotal reconstruction. Plast Reconstr Surg. 2002;109(2):610–616. doi:10.1097/00006534-200202000-00030
7. Coskunfirat OK, Uslu A, Cinpolat A, Bektas G. Superiority of medial circumflex femoral artery perforator flap in scrotal reconstruction. Ann Plast Surg. 2011;67(5):526–530. doi:10.1097/SAP.0b013e318208ff00
8. Han SE, Kim EJ, Sung HH, Pyon JK. Aesthetic penoscrotal resurfacing: creating propeller flaps from gluteal folds. Eur Urol. 2018;73(4):610–617. doi:10.1016/j.eururo.2016.09.033
9. Mendel L, Neuville P, Allepot K, et al. Bilateral pedicled scrotal flaps as an alternative to skin graft in penile shaft defects repair. Urology. 2023;176:206–212. doi:10.1016/j.urology.2023.03.025
10. Abdelfattah U, Elbanoby T, Hamza F, et al. Treatment of advanced male genital lymphedema with a complete functional lymphatic-system pedicled transfer. Urology. 2023;175:190–195. doi:10.1016/j.urology.2023.02.006
11. Yamamoto T, Daniel BW, Rodriguez JR, et al. Radical reduction and reconstruction for male genital elephantiasis (3R SCIP-LFT). J Plast Reconstr Aesthet Surg. 2022;75(2):870–880. doi:10.1016/j.bjps.2021.08.011
12. Ciudad P, Escandón JM, Escandón L, Mayer HF, Manrique OJ. Surgical management of genital lymphedema using the combined Charles' procedure and lymphatic superficial circumflex iliac artery perforator flap transfer (CHASCIP). Microsurgery. 2025;45:e70075. doi:10.1002/micr.70075.
13. Guiotto M, Bramhall RJ, Campisi C, Raffoul W, di Summa PG. A systematic review of outcomes after genital lymphedema surgery: microsurgical reconstruction versus excisional procedures. Ann Plast Surg. 2019;83(6):e85–e91. doi:10.1097/SAP.0000000000001875
14. Chitale VR. Role of tensor fascia lata musculocutaneous flap in lymphedema of the lower extremity and external genitalia. Ann Plast Surg. 1989;23:297–304; discussion 305. Primary abstract.