Scrotal Reconstruction
Choose a technique from the cause, viable tissue, defect depth, closure tension and patient goals. This atlas links the individual procedures; the scrotal reconstruction overview explains the evidence and operative choices in more detail.
Decision Framework
Assess the wound and the patient
- Establish whether infection, trauma, lymphedema, cancer treatment, congenital anatomy or elective symptoms are driving the reconstruction.
- Assess testicular and cord viability, available skin, the actual vascularity of the recipient bed, dead space, and any penile, urethral or perineal injury.
- Include wound-healing risks, mobility, fertility goals, comfort, appearance and the patient's preference about staged procedures or implants.
Scrotal redundancy often permits primary closure, but 50% skin loss is a descriptive guide, not a reliable treatment cutoff. A small scarred defect may need a graft or flap; a larger defect may have enough healthy tissue for closure. Native dartos is useful vascularized tissue and should not be removed merely to obtain a supposedly mandatory graft plane.[1][2]
Match the operation to the defect
| Finding | Options and limits |
|---|---|
| Healthy skin reaches without excessive tension | Primary closure or local scrotal advancement, preserving perfusion and comfortable testicular position |
| Superficial skin loss with a vascularized recipient bed | STSG may cover an extensive or total defect; exposed testes alone do not rule out grafting |
| Bed unsuitable for graft, deep dead space or combined perineal loss | Consider a regional flap with the necessary tissue components and a reliable pedicle |
| Immediate scrotal coverage unsuitable | Temporary or definitive thigh pouches may be considered after counseling; they are not required for all total defects |
| Fibrotic or fatty genital lymphedema | Tailored excision and coverage, with continuing conservative care; physiological lymphatic procedures require separate selection |
| Absent testis with an acceptable healed or reconstructable envelope | Offer prosthesis counseling; immediate or delayed placement depends on context and patient preference |
The choice should protect viability and comfort without unnecessary septal division, cord dissection or testicular repositioning. Apposition, orchidopexy and expansion techniques are selected operations, not required steps of every closure.[1][3][4][5]
Evidence that affects counseling
- Graft versus flap: no reliable human comparative evidence establishes a universal fertility advantage. A rat experiment cannot rank human reconstruction; both donor and recipient morbidity matter.[1][6]
- Flap outcomes: the 2026 Alammar review included 619 patients and 625 flaps, with 1.6% reported flap loss. This does not mean a 1.6% overall complication rate and does not compare flaps with grafts.[7]
- Lymphedema: advanced excision and selected physiological procedures can improve symptoms, but uncontrolled series do not prove cure or that a lymphatic flap prevents recurrence. Continue individualized skin care and decongestive management, and discuss donor-site risks.[8][9]
- Implants: discuss size, position, firmness, complications and the option to decline. A manufacturer's retrospective device-survival estimate is not a guarantee of satisfaction or lifelong durability.[10][5]
Fournier's gangrene
Urgent debridement, resuscitation and broad-spectrum antibiotics come first. Repeat source control as needed. Urinary and fecal diversion are individualized; perineal involvement alone does not mandate a colostomy or rectal device. Reconstruct when tissue viability, infection control and the patient's condition permit, rather than after a fixed one-to-two-week interval.[11][12]
NPWT can be considered for selected wound management or graft fixation after adequate debridement. It does not replace source control, and improved take in a single case is not a promised result. The EAU Fournier section gives a weak recommendation to restrict adjuncts to trials, based on a stated search through July 2017; later observational results do not establish a mortality benefit.[11]
Follow-up
Assess wound healing, collections, threatened perfusion, pain, testicular position and accessibility, sexual function and recurrence of the underlying disease. Treat significant necrosis, bleeding or dehiscence according to severity. Graft fixation and mobilization schedules depend on the reconstruction; neither prolonged bed rest nor a particular dressing duration is universal.[1][2]
Treatment Database
| Procedure | Domain | Best for / indication |
|---|---|---|
| Primary Closure / Local Advancement | Primary Closure | Healthy remaining scrotal skin that reaches without excessive tension or compromised perfusion. |
| Scrotal Skin Grafting (principally STSG) | Skin Graft | Superficial loss with an adequately vascularized recipient bed when primary closure is unsuitable. |
| Scrotal Flap Reconstruction (all flap families) | Flap Reconstruction | Deep defects, dead space or a recipient bed unsuitable for grafting. |
| Testicular Thigh Pouch (Temporary, Definitive, or Hiawatha Neoscrotum) | Testicular Thigh Pouch | Extensive scrotal loss not suitable for graft or flap; temporary bridge or definitive neoscrotum. |
| Testicular Prosthesis (Saline / Silicone) | Testicular Prosthesis | Post-orchiectomy, anorchia, atrophic testis, or neoscrotal augmentation. |
| Testicular Reimplantation (autotransplantation / traumatic replantation) | Testicular Reimplantation | High intra-abdominal testis autotransplantation or traumatic testicular replantation. |
| Complex Decongestive Therapy (CDT) | Lymphedema Surgery | Individualized skin care, decongestive treatment and maintenance before or after selected surgery. |
| Lymphaticovenous Anastomosis (LVA) | Lymphedema Surgery | Compression-refractory genital lymphedema with functional residual lymphatics. |
| Vascularized Lymph Node Transfer (VLNT) into Scrotum / Groin | Lymphedema Surgery | Selected lymphatic dysfunction after specialist assessment; limited genital comparative evidence. |
| Debulking Scrotoplasty (Excision + Primary Closure) | Lymphedema Surgery | Disabling fibrotic disease with sufficient healthy tissue for closure after excision. |
| Modified Charles Procedure (Excision + STSG) | Lymphedema Surgery | Selected advanced disease requiring excision and grafting; balance morbidity against other reconstructive options. |
| Excision + Flap Reconstruction (GL) | Lymphedema Surgery | Large genital-lymphedema defects with exposed vital structures or after failed simpler approaches. |
| SCIP Lymphatic Flap Transfer (3R — Yamamoto) | Lymphedema Surgery | Male genital elephantiasis treated by radical reduction plus pedicled SCIP lymphatic + skin flap. |
| CHASCIP — Combined Charles + Lymphatic SCIP Flap (Ciudad) | Lymphedema Surgery | Reported combined excision and lymphatic SCIP reconstruction for advanced penoscrotal disease. |
| Complete Functional Lymphatic-System Pedicled Transfer (Abdelfattah) | Lymphedema Surgery | Advanced scrotal / penoscrotal lymphedema; single pedicled SCIP flap resurfaces scrotum and penis. |
| Lymphatic System Transfer (LYST) — SCIP with Lymph Nodes + Afferent Vessels | Lymphedema Surgery | Reported lymphatic transfer approach; genital indications and comparative benefit require careful verification. |
| Suction-Assisted Protein Lipectomy (SAPL / Liposuction) | Lymphedema Surgery | Solid adipose/fibrotic component of late ISL Stage II–III extremity lymphedema; limited genital role. |
| BLOOM — Bariatric + VLNT (Sim) | Lymphedema Surgery | Reported combined bariatric and lymphatic operation; not an established genital-specific pathway. |
| Giant Penoscrotal Lymphedema (Elephantiasis) | Combined / Salvage | Advanced genital disease: individualized conservative care, excision and selected reconstruction. |
| Total Penis-Scrotum-Lower-Abdominal-Wall VCA (Johns Hopkins / GUVCA) | Combined / Salvage | Total external genital plus lower abdominal-wall loss in highly selected GUVCA candidates. |
References
1. Karian LS, Chung SY, Lee ES. Reconstruction of defects after Fournier gangrene: a systematic review. Eplasty. 2015;15:e18. Full text.
2. Alwaal A, McAninch JW, Harris CR, Breyer BN. Utilities of split-thickness skin grafting for male genital reconstruction. Urology. 2015;86:835–839. doi:10.1016/j.urology.2015.07.005.
3. Hayon S, Demzik A, Ehlers M, et al. Orchidopexy and split-thickness skin graft for scrotal defects after necrotizing fasciitis. Urology. 2021;152:196. doi:10.1016/j.urology.2021.02.007
4. Okwudili OA. Temporary relocation of the testes in anteromedial thigh pouches facilitates delayed primary scrotal wound closure in Fournier gangrene with extensive loss of scrotal skin — experience with 12 cases. Ann Plast Surg. 2016;76(3):323–326. doi:10.1097/SAP.0000000000000505
5. Hayon S, Michael J, Coward RM. The modern testicular prosthesis: patient selection and counseling, surgical technique, and outcomes. Asian J Androl. 2020;22(1):64–69. doi:10.4103/aja.aja_93_19
6. Demir Y, Aktepe F, Kandal S, Sancaktar N, Turhan-Haktanir N. The effect of scrotal reconstruction with skin flaps and skin grafts on testicular function. Ann Plast Surg. 2012;68(3):308–313. doi:10.1097/SAP.0b013e318214534f
7. Alammar A, Laing K, Somasundaram J, Wallace DL, Rogers AD. Flap reconstruction following Fournier's gangrene: a systematic review of techniques and outcomes. Burns. 2026;52(3):107888. doi:10.1016/j.burns.2026.107888
8. Executive Committee of the International Society of Lymphology. The Diagnosis and Treatment of Peripheral Lymphedema: 2023 Consensus Document. Lymphology. 2023;56:133–151. Consensus.
9. 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
10. Atwater BL, Kirkik D, Wilson SK, et al. Short-term revision rate of Rigicon Testi10™ testicular prosthesis in adolescents and adults: a retrospective chart review. Int J Impot Res. 2025;37(4):303–309. doi:10.1038/s41443-024-00893-8
11. European Association of Urology. Urological Infections Guidelines. 2026. Section 3.13: Fournier's gangrene. Guideline.
12. McDermott J, Kao LS, Keeley JA, et al. Necrotizing soft-tissue infections: a review. JAMA Surg. 2024;159(11):1308–1315. doi:10.1001/jamasurg.2024.3365