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Scrotal Flap Reconstruction

A flap supplies vascularized tissue when the recipient surface is unsuitable for a graft, substantial dead space needs filling, or a combined scrotal/perineal defect needs durable coverage. Skin-loss percentage and testicular exposure alone do not dictate a flap. Some extensive or total superficial defects can be grafted, while smaller deep defects may need a flap.[1]

Choose tissue according to the defect, perfusion, prior surgery, donor availability and patient goals. The scrotal overview compares closure, graft and pouch options.

Planning principles​

  • Obtain infection source control and a viable wound before definitive reconstruction; a flap is not a way to cover untreated necrosis.
  • Assess the required skin area, depth, dead space, reach, thickness and future access to the testes and urethra.
  • Preserve the planned arterial inflow and venous drainage. Prior debridement, scars, radiation or inguinal surgery can alter otherwise favorable anatomy.
  • Plan positioning, donor closure and graft requirements together. Do not assume that every donor can be closed primarily or that one flap provides normal sensation and thermal function.
  • Discuss staged contour revision, pain, loss, wound problems and donor morbidity alongside the expected coverage benefit.[1][2]

Carrera's 15-cadaver study identified interconnected external-pudendal lateral territories and a central territory supplied through perineal branches and the septum. It also describes the risk of injuring fine septal vessels during dissection. Preserve the actual supply rather than relying on a blanket assertion that every scrotal flap tolerates wide undermining.[3]

Flap families​

OptionUseful features and considerations
Pudendal-thigh / SingaporeNearby pliable tissue; protective sensation may be retained when the appropriate neurovascular supply is preserved. Reach and donor condition determine suitability.[4]
Medial thighLocal tissue for advancement or a planned vascular flap; thickness, pedicle design and bilateral requirements vary with the defect.[2][1]
MCFAP / gracilis perforatorA muscle-sparing perforator option. Coskunfirat reported seven post-Fournier reconstructions, including two wound dehiscences; the title's “superiority” is not supported by a comparative trial.[5]
Island groinEstablished regional option; tailor thickness and reach. Sahai's 29-patient experience spans a 30-year practice period, not 30-year follow-up for every patient.[6]
SCIPCan provide relatively thin skin with a concealed donor; anatomy, reach and donor closure need individual planning. A three-patient post-Fournier series does not establish a zero complication rate or superiority.[7]
ALTCan cover a larger defect; thickness, tunnel geometry and donor morbidity matter. Yao's scrotal series contained only three patients.[8]
Posteromedial thigh / vPMTPerforator-based advancement or propeller designs. Wishart reported 21 flaps in 12 patients with overlapping perianal, vulvar and scrotal defects; only three patients had scrotal involvement.[9]
GracilisMuscle can fill dead space; skin components and perfusion require appropriate design. Perineal oncology cohorts cannot supply a universal scrotal complication rate.[10][1]
VRAMAbdominal tissue may suit a larger combined pelvic/perineal defect; consider abdominal-wall morbidity, previous operations and stoma plans.[1]
IGAP / gluteal fold or posterior thighAdditional regional options for appropriately located combined defects; consider positioning, sitting comfort and prior donor treatment. Gluteal hidradenitis results are not isolated-scrotal outcomes.[11][1]

No validated table establishes universal maximum flap dimensions, a fixed “best” tissue match or a reliable ranking of complication rates across these techniques.

What the outcome literature supports​

The Alammar 2026 systematic review included 107 reports, 619 patients and 625 flaps after Fournier's gangrene. It reported flap loss in 1.6% of cases. This endpoint does not include all wound problems or necessarily every partial necrosis, and a flap-only review cannot establish superiority over grafting. Standardized functional and cosmetic outcomes were uncommon.[2]

Comparisons with oncological perineal reconstruction need particular care. Singh's 40-patient gracilis cohort followed abdominoperineal resection or pelvic exenteration: 12.5% had donor and 40% recipient complications. The reported obesity and smoking associations concerned minor complications. The study does not establish that gracilis has the highest scrotal risk or that VRAM has the lowest.[10]

Erectile-function scores are not sperm counts or fertility outcomes. Yao reported no significant change in sperm counts or IIEF in three ALT recipients, without a graft comparator. Demir studied rats. These sources do not prove that flaps preserve human spermatogenesis better than grafts or that muscle bulk restores normal scrotal thermoregulation.[8][12]

Distinct clinical applications​

Extramammary Paget's disease​

Kim's 46-patient margin-controlled excision series used IPAP and/or scrotal flaps for scrotal defects, SEPAP for suprapubic defects and skin grafts for penile defects, often in combination. This is an institutional reconstruction algorithm, not proof of a universal SCIP-based solution. Preserve the oncological margin and surveillance plan.[13]

Penile coverage using scrotal tissue​

The sensate EPAP hemi-scrotal flap is a different application: healthy scrotal tissue is transferred to a penile defect. Tsukuura described one 40-year-old man after penile replantation, with a 9 × 14-cm flap and seven-month follow-up. Doppler planning and isolation of the perforator/anterior scrotal nerve were part of that report. The absence of pain or stretching in one patient does not establish a pain-free result for everyone or require freeing the tunica vaginalis.[14]

See EPAP hemi-scrotal flap.

Genital lymphedema​

Coverage and lymphatic reconstruction are separate objectives. Abdelfattah described a functional lymphatic SCIP-based transfer in 26 patients. Ehrl's nine-patient series included eight giant cases and one with pitting edema; five received VLNT to the groin or scrotum, and no recurrence was reported in the whole cohort at median 49 months. These uncontrolled results do not isolate the added benefit of VLNT or justify its routine use with every excision.[15][16]

The ISL consensus supports individualized treatment, with continuing skin care/decongestive management and counseling about donor-site lymphedema and other morbidity when lymphatic transfer is considered.[17]

Combined muscle and skin transfer​

TUGPAP combines upper gracilis and profunda perforator tissue. Ciudad's 28-patient report covered breast, head/neck and pelviperineal defects; its flaps used two vascular pedicles with recipient anastomoses. It should not be described as a routine single-pedicle local scrotal operation or as established superiority over other regional flaps.[18]

See Also​

References​

1. Karian LS, Chung SY, Lee ES. Reconstruction of defects after Fournier gangrene: a systematic review. Eplasty. 2015;15:e18. Full text.

2. 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

3. Carrera A, Gil-Vernet A, Forcada P, et al. Arteries of the scrotum: a microvascular study and its application to urethral reconstruction with scrotal flaps. BJU Int. 2009;103:820–824. doi:10.1111/j.1464-410X.2008.08167.x.

4. 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

5. 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

6. Sahai R, Singh S. Thirty-year experience of utility of island groin flap for scrotal-defect single-stage reconstruction. J Plast Reconstr Aesthet Surg. 2021;74(10):2629–2636. doi:10.1016/j.bjps.2021.03.036

7. BS S, Khanna A, Taylor D. Pedicled superficial circumflex iliac artery perforator (SCIP) flap for perineo-scrotal reconstruction following Fournier's gangrene. ANZ J Surg. 2023;93(1-2):276–280. doi:10.1111/ans.18066

8. Yao H, Zheng D, Wen J, et al. Reconstruction of major scrotal defects by anterolateral thigh flap. Cell Biochem Biophys. 2014;70(2):1331–1335. doi:10.1007/s12013-014-0060-z

9. Wishart KT, Fritsche E, Scaglioni MF. Pedicled vertical posteromedial thigh (vPMT) flap for the reconstruction of extensive perianal-genital defects. J Plast Reconstr Aesthet Surg. 2021;74(1):123–129. doi:10.1016/j.bjps.2020.08.001

10. Singh M, Kinsley S, Huang A, et al. Gracilis flap reconstruction of the perineum: an outcomes analysis. J Am Coll Surg. 2016;223(4):602–610. doi:10.1016/j.jamcollsurg.2016.06.383

11. Unal C, Yirmibesoglu OA, Ozdemir J, Hasdemir M. Superior and inferior gluteal artery perforator flaps in reconstruction of gluteal and perianal / perineal hidradenitis suppurativa lesions. Microsurgery. 2011;31(7):539–544. doi:10.1002/micr.20918

12. 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

13. Kim WJ, Kim SH, Sung HH, Lee KT, Pyon JK. Penoscrotal defect reconstruction using loco-regional flaps in treatment of extramammary Paget's disease: experience and suggestion of a simplified algorithm. Microsurgery. 2023;43(4):316–324. doi:10.1002/micr.30988

14. Tsukuura R, Engmann T, Miyazaki T, Yamamoto T. The sensate external pudendal artery perforator (EPAP) hemi-scrotal flap for the circumferential skin defect of the penile shaft: a case report and literature review. Microsurgery. 2025;45(7):e70123. doi:10.1002/micr.70123

15. 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

16. Ehrl D, Heidekrueger PI, Giunta RE, Wachtel N. Giant penoscrotal lymphedema—what to do? Presentation of a curative treatment algorithm. J Clin Med. 2023;12:7586. doi:10.3390/jcm12247586.

17. Executive Committee of the International Society of Lymphology. The Diagnosis and Treatment of Peripheral Lymphedema: 2023 Consensus Document. Lymphology. 2023;56:133–151. Consensus.

18. Ciudad P, Huang TC, Manrique OJ, et al. Expanding the applications of the combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap for extensive defects. Microsurgery. 2019;39(4):316–325. doi:10.1002/micr.30413