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Scrotal Reconstruction

Scrotal reconstruction encompasses a broad spectrum of techniques — from primary closure of small defects to complex flap-based reconstruction of total scrotal loss — with the choice of approach dictated by defect size, etiology, available tissue, and patient goals.[1][2][3]

Part I: Scrotal anatomy relevant to reconstruction​

Layers (superficial to deep)​

  • Skin — thin, rugated, pigmented, hair-bearing, highly elastic.
  • Dartos fascia — areolar connective tissue containing smooth muscle and the arterial network supplying the scrotal skin; continuous with Scarpa's fascia superiorly.[2]
  • External spermatic fascia (from external oblique aponeurosis).
  • Cremasteric muscle and fascia (from internal oblique).
  • Internal spermatic fascia (from transversalis fascia).
  • Tunica vaginalis (parietal and visceral layers — derived from peritoneum).
  • Tunica albuginea (dense fibrous capsule of the testis itself).

Vascular supply​

Carrera et al. (2009), in a microvascular cadaveric study of 15 specimens, identified two main vascular systems:[4]

  1. Inferior external pudendal arteries (from the femoral artery) — supply the lateral cutaneous territories of each hemiscrotum, entering at the midpoint of the scrotal root and fanning out to cover the entire hemiscrotum.
  2. Perineal arteries (from the internal pudendal artery) — supply the central cutaneous territory, running deeply on both sides of the scrotal septum.

The three territories (two lateral, one central) are widely inter-anastomosed, creating a rich, redundant vascular network that explains the scrotum's resistance to ischemia and capacity for healing.[4]

Key reconstructive properties​

  • Redundancy and elasticity — up to 50% of the scrotum can be resected and closed primarily given the redundant, elastic skin.[2]
  • Rich vascularity — the interconnected arterial network within Dartos fascia makes scrotal tissue highly resistant to infection and promotes rapid wound healing.[2][4]
  • Thermoregulation — the Dartos muscle and cremasteric reflex regulate testicular temperature; skin grafts and flaps lack this function to varying degrees.[5]
  • Sensation — innervated by the ilioinguinal nerve (anterior), genitofemoral nerve (anterolateral), posterior scrotal branches of the pudendal nerve (posterior), and perineal branch of the posterior cutaneous nerve of the thigh.[6]

Part II: Indications for scrotal reconstruction​

EtiologyKey features
Fournier's gangreneMost common indication; necrotizing fasciitis requiring aggressive debridement; defects range from partial to total scrotal loss
TraumaAvulsion injuries (machinery, road traffic), burns, gunshot wounds; often involves penile skin loss as well
Genital cancerPost-scrotectomy for squamous cell carcinoma, extramammary Paget's disease, sarcoma
Penoscrotal lymphedemaMassive localized lymphedema (MLL) or filarial lymphedema; resected tissue can weigh up to 61 kg
Hidradenitis suppurativaChronic inflammatory disease requiring wide excision of affected genital skin
Gender-affirming surgeryScrotoplasty in transgender men (female-to-male) as part of phalloplasty / metoidioplasty
Aesthetic / congenitalPenoscrotal webbing, scrotomegaly, concealed penis, bifid scrotum
[1][2][3][7][8][11][14][15][16][17]

Part III: Reconstructive ladder — approach by defect size​

A. Small defects (<50% scrotal skin loss) — primary closure​

Up to 50% of the scrotum can be resected and closed primarily given the redundant, elastic skin.[1][2] Key maneuvers to facilitate primary closure of larger defects:[2]

  1. Division of the scrotal septum — allows mobilization of contralateral scrotal skin.
  2. Mobilization of Dartos fascia off the tunica vaginalis — creates additional tissue laxity.
  3. Division of the gubernaculum — permits upward mobilization of the testes.
  4. Spermatic cord mobilization — securing the testicles at a more superior location at the penoscrotal junction reduces the volume of scrotal contents that need to be covered.

B. Moderate to large defects (>50% loss) — split-thickness skin graft​

STSG is the most commonly used technique for extensive scrotal defects, particularly after Fournier's gangrene.[2][7][18]

Technique (Hayon et al., 2021):[7]

  1. Orchidopexy first — after debridement, the testicles and inferior penis are brought together with interrupted Vicryl sutures; spermatic cords are mobilized and redundant cord is coiled under the abdominal wall.
  2. Wait for granulation — allow 1–2 weeks for granulation tissue to form before grafting.[2]
  3. Graft harvest — STSG at a depth of 18/1000 inch (0.046 cm), meshed 2:1.
  4. Graft application — applied to the tunica vaginalis of the spermatic cord (the optimal graft bed).
  5. Bolster dressing — sutured for 5–7 days to prevent shear.
  6. Outcomes — in 10 patients post-Fournier's, no chronic pain, discomfort, or need for revision at median 8-month follow-up.[7]

Critical graft-bed considerations:[2]

  • Tunica vaginalis — optimal graft bed (well-vascularized, promotes graft take).
  • Dartos fascia — poor graft bed.
  • Tunica albuginea — results in a fixed, unnatural appearance (graft adheres directly to testis).

Testicular apposition and wrap-around grafting (Tan et al., 2011): an alternative STSG technique in 27 patients — preserve viable spermatic fascia, suture the testes together with broad surface contact to allow fusion of testicular fascial layers into a single scrotal sac, then apply a wrap-around STSG. 66% achieved thin, pliable scrotums closely mimicking the original; 18% developed well-formed sacs with slight adhesions.[18]

C. Large / complex defects — flap reconstruction​

When defects are too large for primary closure or when exposed vital structures (testes, urethra, bone) preclude grafting, flap-based reconstruction is indicated.[3][8]

Alammar et al. (2026) — the most comprehensive systematic review to date — pooled 107 studies, 619 patients, 625 flaps for Fournier's-gangrene reconstruction:[3]

  • Regional flaps overwhelmingly preferred over free tissue transfer.
  • Flap-loss rate only 1.6% despite the high-risk patient population.
  • Primary indications — coverage of exposed vital structures (52%), functional restoration (39%), cosmesis (4%).

Commonly used flaps:

  • Pudendal thigh flap (Singapore flap) — based on the posterior labial / scrotal branches of the internal pudendal artery. Mopuri et al. (2016) used modified pudendal-thigh flaps in 5 patients producing a neoscrotum with natural appearance, good-quality skin, cushion to the testes, and protective sensation.[8] Karaçal et al. (2007) used neurovascular pedicled pudendal-thigh flaps in 10 scrotal defects (max 20 × 15 cm) — all donor areas closed primarily; satisfactory results in all patients, particularly regarding sensibility.[6]
  • Medial thigh flap / gracilis musculocutaneous flap — provides bulk and well-vascularized coverage. Particularly useful when muscle bulk is needed to fill dead space or cover exposed structures.[3]
  • Island groin flap — Sahai and Singh (2021), 30-year experience, single-stage scrotal reconstruction in 25 Fournier's patients and 4 avulsion injuries with good aesthetic results. For >50% defects a single groin flap sufficed; for total scrotal loss the groin flap was combined with two superior medial pedicle thigh flaps.[19]
  • Anterolateral thigh (ALT) flap — versatile fasciocutaneous flap based on the descending branch of the lateral circumflex femoral artery. Can be thinned for scrotal reconstruction; one of the most commonly utilized flaps in the Alammar systematic review.[3]
  • Superficial circumflex iliac artery perforator (SCIP) flap — an emerging option. B S et al. (2023) used pedicled SCIP flaps in 3 post-Fournier's patients (largest defect 22 × 10 cm) — all flaps survived with no significant complications and good functional / aesthetic outcomes.[20] Abdelfattah et al. (2023) used the SCIP-lymphatic pedicled flap in 26 patients with advanced genital lymphedema — 100% flap survival and dramatic reduction in cellulitis rates (p<0.05).[21]

D. Testicular thigh pouches — temporary or definitive​

When scrotal reconstruction is not immediately feasible, the testes can be temporarily relocated to subcutaneous thigh pouches:[2][9][22]

Temporary thigh pouches (Okwudili, 2016):[22]

  • 12 patients with >50% scrotal skin loss from Fournier's gangrene.
  • Testes placed in anteromedial thigh pouches after debridement.
  • Postoperatively, testes were gradually massaged back into the residual scrotal pouch over 3–8 months, acting as natural tissue expanders.
  • Normal testicular volume maintained (mean 19.0 cm³); no mortality; no need for specialized reconstructive surgery.

Definitive thigh pouches (Staniorski et al., 2023):[9]

  • 20 patients with large genital wounds (median wound area 443 cm²).
  • Testicular thigh pouches + fasciocutaneous flap perineal closure.
  • 100% perineal closure rate; 15% complication rate.
  • Only 1 patient reported pain related to thigh pouches; none desired elective scrotoplasty.

Limitations of thigh pouches:[2]

  • Unnatural genital appearance.
  • Difficulty performing testicular self-examination for cancer screening.
  • Must locate testes anteriorly to avoid pain with sitting.
  • Generally considered inferior to skin grafting when grafting is feasible.

Part IV: Specific clinical contexts​

A. Fournier's gangrene​

The most common and most studied indication. Staged management:[3][7][23]

Phase 1 — acute management:

  • Aggressive surgical debridement (often multiple OR returns).
  • Broad-spectrum antibiotics.
  • Source control (fecal diversion if perianal source).
  • Wound management with NPWT or conventional dressings.

NPWT. A multi-institutional cohort (92 patients) demonstrated NPWT in patients with disseminated Fournier's led to a higher cumulative rate of wound closure (OR 6.5, p = 0.036) and improved 90-day overall survival (HR 3.4 for non-VAC patients, p = 0.033).[24] A meta-analysis confirmed NPWT was associated with lower mortality but no difference in length of stay or number of debridements.[23] NPWT should be delayed until the wound is deemed stable after repeated debridements.

Phase 2 — reconstruction (once clean and granulating):

  • <50% loss → primary closure with redundant scrotal skin.
  • ≥50% loss → STSG onto tunica vaginalis (most common), or flap reconstruction if exposed structures.
  • Total loss → temporary thigh pouches → delayed STSG or flap neoscrotum.[3][10]

B. Penoscrotal lymphedema​

Surgical excision remains the only definitive treatment for advanced genital lymphedema.[11][12]

Massive localized lymphedema (MLL) — Wisenbaugh et al., 2018:[11]

  • 11 patients, mean BMI 60, mean resected tissue weight 21 kg (up to 61 kg).
  • No orchiectomy required in any patient.
  • 10 of 11 closed primarily (1 required STSG).
  • Wound complications common but manageable with local wound care.
  • Quality of life improved dramatically — mean score from 1.3 to 7.7 (out of 10).
  • Most patients gained weight after surgery (mean +5.2 kg), highlighting the need for comprehensive weight-loss programs.

Integrated approach — Torio-Padron et al., 2015:[12]

  • 51 patients (84% primary, 16% secondary lymphedema).
  • All underwent perioperative complex decongestive physiotherapy (CDP) combined with surgical reduction.
  • Defects closed primarily using adjacent healthy skin in all cases — no flaps or grafts needed.
  • Complication rate only 6% (2 hematomas, 1 dehiscence).
  • Significant improvement in quality of life (Glasgow Benefit Inventory).

Emerging — vascularized lymph node transfer (VLNT) — Ehrl et al., 2023:[25]

  • 9 patients with giant penoscrotal lymphedema.
  • Penoscrotal resection + reconstruction; 5 patients also received VLNT from the lateral thoracic region into the scrotum.
  • Median follow-up 49 months — no recurrence in any patient.
  • VLNT into the scrotum showed significantly improved lymphatic transport.

C. Gender-affirming surgery (transgender men)​

Scrotoplasty in transgender men is performed as part of phalloplasty or metoidioplasty, using the labia majora — the embryologic homolog of the scrotum — as the primary tissue source.[13][14][15]

Pigot et al. (2020) technique:[13]

  1. A pedicled horseshoe-shaped pubic flap + clitoral hood + U-shaped labia majora flaps are used.
  2. Cranially pedicled U-shaped labia majora flaps are rotated 90° medially to bring the neoscrotum in front of the legs.
  3. Pedicled labia majora fat pads are released bilaterally and relocated into the neoscrotum for bulkiness.
  4. Results in a neoscrotum resembling the biological scrotum in bulkiness, size, shape, tactile sensation, and anatomical position.

Largest series — Miller et al., 2021 (147 consecutive scrotoplasties with bilateral labia majora rotational advancement flaps):[14]

  • Distal flap necrosis 4.1% (most ipsilateral to groin dissection for phalloplasty).
  • Perineoscrotal junction dehiscence (>1 cm) 4.7%.
  • Scrotal hematoma 1.4%; perineal hematoma 2.0%.
  • Most wound complications managed conservatively.

Selvaggi et al. (2009) — over 300 scrotal reconstructions using V-Y advancement of the labia majora with rotation of superiorly based labial flaps; no major complications; patients uniformly pleased with the scrotum located in its natural position.[15]

Testicular implants are typically placed 6–12 months after scrotoplasty to allow tissue maturation.[15] See also Genital Reconstruction → Gender-Affirming Masculinizing Procedures.

D. Aesthetic scrotoplasty​

An increasingly recognized area addressing scrotomegaly (excessive scrotal laxity) and penoscrotal webbing:[1][16]

Thomas and Navia (2021) proposed a treatment algorithm:[16]

  • Scrotomegaly — vertical midline scrotal-skin resection (scrotal reduction / lift).
  • Penoscrotal webbing — Z-plasty at the penoscrotal junction.
  • Can be performed in isolation or combined with penile-prosthesis implantation.

Álvarez Vega et al. (2025) reported 100 consecutive Z-plasty procedures for pediatric penile / scrotal anomalies (bifid scrotum, penoscrotal webbing, chordee) — 98% primary healing, only 1% suture-line separation, 1% hypertrophic scar.[17]

Part V: Skin grafts vs. flaps — impact on testicular function​

A critical and often overlooked consideration is the effect of the reconstructive method on spermatogenesis and testicular function.

Demir et al. (2012), in an animal study comparing skin flaps vs. skin grafts:[5]

  • Flap group — testicular function (wet weight, germinal-epithelium height, Johnsen spermatogenesis score) was comparable to controls.
  • Graft group — significantly diminished testicular function: lower testicular weight, shorter germinal epithelium, lower Johnsen score.
  • The authors concluded that flaps may be the first choice for scrotal reconstruction when fertility preservation is a concern.

This finding is attributed to the superior thermoregulatory properties of flaps (which contain subcutaneous tissue and maintain some insulating / contractile function) compared with thin skin grafts that lack Dartos muscle and cannot regulate testicular temperature.[5]

Part VI: Complications​

ComplicationFrequencyManagement
Wound infection / dehiscence10–27% (highest after lymphedema surgery)Local wound care; antibiotics; rarely requires reoperation
Hematoma2–4% (flaps); 1.4% (scrotoplasty)Operative evacuation if large
Graft failure (partial)Uncommon with proper bed preparationRegrafting or secondary intention healing
Flap necrosis (partial)4.1% (labia majora flaps); 1.6% (Fournier's flaps)Conservative management; debridement if needed
Chronic painRare with proper techniqueThigh pouches: locate testes anteriorly to avoid sitting pain
Impaired spermatogenesisTheoretical with STSG (animal data)Consider flaps over grafts in young / fertile patients
Lymphedema recurrence9.1% (giant lymphedema); 0% with VLNTConsider VLNT at time of excision
Urethrocutaneous fistula2% (gender-affirming scrotoplasty)Surgical fistula repair
[1][2][3][5][9][11][14][25]

Part VII: Algorithm for scrotal reconstruction​

Based on the available evidence:[1][2][3][10]

  1. Acute phase — debridement, source control, NPWT if indicated; allow wound to declare its borders.
  2. Defect assessment:
    • <50% loss → primary closure using redundant scrotal skin (mobilize Dartos / divide septum / mobilize cords as needed).
    • ≥50% loss, clean granulating bed → STSG onto tunica vaginalis (meshed 2:1, 18/1000 inch depth); orchidopexy first.
    • >50% loss with exposed vital structures (testes, urethra, bone) → flap reconstruction (pudendal thigh, medial thigh, groin island, ALT, or SCIP).
    • Total scrotal loss, patient unstable or not a flap candidate → temporary testicular thigh pouches → delayed reconstruction.
  3. Special considerations:
    • Fertility concerns — prefer flaps over grafts (better spermatogenesis preservation).[5]
    • Lymphedema — perioperative CDP + surgical excision ± VLNT; primary closure usually achievable.[12][25]
    • Gender-affirming — labia majora rotational advancement flaps; testicular implants at 6–12 months.[14][15]

Cross-references​

References​

1. 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

2. Hamad J, McCormick BJ, Sayed CJ, et al. "Multidisciplinary update on genital hidradenitis suppurativa: a review." JAMA Surg. 2020;155(10):970–977. doi:10.1001/jamasurg.2020.2611

3. 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

4. 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(6):820–824. doi:10.1111/j.1464-410X.2008.08167.x

5. 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

6. Karaçal N, Livaoglu M, Kutlu N, Arvas L. "Scrotum reconstruction with neurovascular pedicled pudendal thigh flaps." Urology. 2007;70(1):170–172. doi:10.1016/j.urology.2007.03.049

7. 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

8. 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

9. Staniorski C, Myrga J, Hayden C, Sterling J, Rusilko P. "Fasciocutaneous flap perineal closure with testicular thigh pouch for scrotal defects: surgical technique and initial experience." Urology. 2023;182:231–238. doi:10.1016/j.urology.2023.07.039

10. McAninch JW. "Management of genital skin loss." Urol Clin North Am. 1989;16(2):387–397.

11. Wisenbaugh E, Moskowitz D, Gelman J. "Reconstruction of massive localized lymphedema of the scrotum: results, complications, and quality of life improvements." Urology. 2018;112:176–180. doi:10.1016/j.urology.2016.09.063

12. Torio-Padron N, Stark GB, Földi E, Simunovic F. "Treatment of male genital lymphedema: an integrated concept." J Plast Reconstr Aesthet Surg. 2015;68(2):262–268. doi:10.1016/j.bjps.2014.10.003

13. Pigot GL, Al-Tamimi M, van der Sluis WB, et al. "Scrotal reconstruction in transgender men undergoing genital gender-affirming surgery without urethral lengthening: a stepwise approach." Urology. 2020;146:303. doi:10.1016/j.urology.2020.09.017

14. Miller TJ, Lin WC, Safa B, Watt AJ, Chen ML. "Transgender scrotoplasty and perineal reconstruction with labia majora flaps: technique and outcomes from 147 consecutive cases." Ann Plast Surg. 2021;87(3):324–330. doi:10.1097/SAP.0000000000002602

15. Selvaggi G, Hoebeke P, Ceulemans P, et al. "Scrotal reconstruction in female-to-male transsexuals: a novel scrotoplasty." Plast Reconstr Surg. 2009;123(6):1710–1718. doi:10.1097/PRS.0b013e3181a659fe

16. Thomas C, Navia A. "Aesthetic scrotoplasty: systematic review and a proposed treatment algorithm for the management of bothersome scrotum in adults." Aesthetic Plast Surg. 2021;45(2):769–776. doi:10.1007/s00266-020-01998-3

17. Álvarez Vega DR, Mendelson JL, Gitlin JS, Joshi P, Hanna MK. "Optimizing pediatric genital reconstruction: the role of Z-plasty in enhancing aesthetic and functional outcomes." Urology. 2025. doi:10.1016/j.urology.2025.06.011

18. Tan BK, Rasheed MZ, Wu WT. "Scrotal reconstruction by testicular apposition and wrap-around skin grafting." J Plast Reconstr Aesthet Surg. 2011;64(7):944–948. doi:10.1016/j.bjps.2010.11.013

19. 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

20. 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

21. 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

22. 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

23. 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

24. Iacovelli V, Cipriani C, Sandri M, et al. "The role of vacuum-assisted closure (VAC) therapy in the management of Fournier's gangrene: a retrospective multi-institutional cohort study." World J Urol. 2021;39(1):121–128. doi:10.1007/s00345-020-03170-7

25. 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(24):7586. doi:10.3390/jcm12247586