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Scrotal Reconstruction

The aim is durable, comfortable coverage that protects the testes and preserves function. Choose the repair from the viable tissue, closure tension, defect depth and extent, contamination, prior treatment and patient goals. A percentage of skin loss can help describe a defect, but does not by itself determine the operation.[1][2]

Anatomy that changes the plan​

The scrotal wall contains thin, elastic skin and dartos tissue, which carries smooth muscle and a vascular network. Distinguish this wall from the external spermatic fascia, cremasteric coverings, internal spermatic fascia and tunica vaginalis surrounding the cord/testis, and from the testicular tunica albuginea itself. Preserve viable covering layers and avoid unnecessary cord or testicular dissection.[2][3]

Carrera's study of 15 male cadavers identified communicating lateral territories supplied by inferior external pudendal arteries and a central territory supplied by branches of the perineal arteries. Septal vessels contribute to this supply. This anatomy supports careful flap design; it does not make infected or extensively undermined scrotal tissue immune to ischemia.[4]

Scrotal skin has regionally overlapping sensory innervation. A flap can retain protective sensation when an appropriate neurovascular supply is preserved, but sensation, mobility and thermal function cannot be guaranteed from the flap name alone.[5][6]

Assess the cause before choosing coverage​

ContextMain planning issue
Fournier's gangreneResuscitation, urgent source control and complete debridement precede definitive coverage
Trauma or burnsAssess viability of the testes, cords, urethra and remaining skin; preserve salvageable tissue
Cancer resectionCoordinate margins, pathological assessment and reconstructive timing with the oncological plan
Genital lymphedemaSeparate fluid swelling from fibrotic/fatty tissue and assess the lymphatic problem as well as the skin defect
Hidradenitis suppurativaCombine medical and surgical disease control; deroofing or excision depends on the disease, rather than automatic total scrotectomy
Gender-affirming scrotoplastyPlan labia-majora tissue, urethral work, perineal closure and implant staging together
Webbing or bothersome laxityEstablish functional symptoms and goals; techniques and outcome evidence differ from postinfectious reconstruction

These populations should not share one pooled complication table.[1][7][8][9]

Choosing the reconstruction​

Primary closure or local scrotal advancement​

Use remaining healthy scrotal tissue when it reaches without excessive tension or compromise of perfusion. Some substantial defects can be closed because of skin redundancy, while smaller defects with scarring or poor tissue cannot. The frequently cited 50% threshold comes from retrospective experience and proposed algorithms, not a validated cutoff.[2]

Mobilize only as needed in the appropriate plane while preserving the skin–dartos blood supply. Routine septal division, gubernacular division or upward relocation of the testes should not be prerequisites for closure. If closure would compress the contents or place vascular supply at risk, choose another method. Small suitable wounds may heal by secondary intention, accepting the potential for prolonged healing, contraction and deformity.[2]

Split-thickness skin graft​

A graft is an established option for an extensive superficial defect with an adequately vascularized recipient surface. Exposed testes do not automatically require a flap. Viable spermatic coverings or an appropriately prepared granulating surface may support grafting. The absence of tunica vaginalis alone is not a universally accepted prohibition; assess the actual bed and protect the underlying structures.[2][10][3]

Preserve viable dartos and other useful tissue rather than removing it solely because it has been labeled a poor graft bed. Control infection and nonviable tissue, prevent collections and shear, and tailor the graft dimensions, meshing and fixation to the defect. A fixed one-to-two-week wait, 0.018-inch harvest, 2:1 mesh or one bolster duration is not a universal protocol.[3][11]

Testicular apposition and orchidopexy have been described to facilitate coverage. Tan reported a 27-patient technique series; Hayon described ten patients with orchidopexy and subsequent STSG, with median eight-month follow-up. These are selected operative approaches, not proof that every patient needs testicular fixation, cord mobilization or cord coiling. Discuss discomfort, adhesions and altered mobility when relevant.[10][11]

See Scrotal STSG and STSG principles.

Regional flap​

A flap is useful when the bed cannot support a graft, substantial dead space needs filling, or durable vascularized coverage is required for a deeper or combined perineal defect. Options include pudendal-thigh, medial-thigh, gracilis, ALT, groin and SCIP flaps. Select the pedicle, thickness and tissue components for the defect and available donor tissue; regional proximity does not establish universal superiority.[12][2]

The 2026 Alammar systematic review included 107 reports, 619 patients and 625 flaps. It reported flap loss in 1.6% of cases and uncommon use of free tissue transfer. This is useful descriptive experience, but the loss endpoint is not the rate of all complications or partial necrosis, and a flap-only literature review cannot establish superiority over grafts. Standardized functional and cosmetic measures were rarely used.[12]

SCIP lymphatic transfers for lymphedema serve a different objective from ordinary skin coverage after infection. Small technical cohorts should not be merged to claim that one perforator flap is the standard for every scrotal defect.[13][14] See Scrotal Flaps.

Testicular thigh pouches​

Temporary or definitive relocation can be considered when immediate scrotal coverage is unsuitable or a patient prefers an alternative after counseling. Avoid tension, compression or twisting of the cords; consider discomfort, altered appearance, accessibility of the testes and uncertain long-term reproductive effects.[2][15]

Okwudili's 12-patient series described temporary pouches followed by gradual return into the residual scrotum over months. Staniorski's 20-patient cohort combined pouches with fasciocutaneous perineal closure; at median nine months, one patient reported pouch pain and none requested elective scrotoplasty. The latter finding reflects that selected cohort's preferences, not a guarantee of lifelong satisfaction or normal fertility.[15][16]

Total scrotal skin loss does not automatically require thigh pouches before reconstruction. See Testicular Thigh Pouches.

Fournier's gangrene: sequence matters​

  1. Treat the emergency. Give broad-spectrum antibiotics, resuscitate and obtain urgent surgical source control. Debridement must proceed promptly and repeat as required; an uncertain diagnosis should not delay exploration when clinical suspicion is high.
  2. Reassess viability and contamination. Preserve living structures while removing necrotic tissue. Assess urinary and fecal diversion individually with the relevant team.
  3. Choose definitive coverage when the patient and wound are ready. Base timing on source control, tissue viability and reconstructive requirements, not one calendar interval or a mandatory sequence of pouches, grafts and flaps.[17][18][2]

NPWT may help manage a selected wound after adequate debridement. It is not a substitute for source control. Iacovelli's retrospective 92-patient cohort suggested better closure in a disseminated-disease subgroup, but treatment selection and subgroup comparisons limit causal inference. Its reported survival findings do not establish that NPWT prevents death. The current EAU chapter, whose stated adjunctive-treatment search ended in July 2017, found no evidence of benefit from NPWT and gives a weak recommendation to use adjunctive treatments only in clinical trials. This guidance and the limitations of later observational findings should both inform decisions.[19][17]

See Fournier's Gangrene for the full acute pathway.

Genital lymphedema​

Use an individualized plan combining skin care, appropriate decongestive treatment, management of the cause and selected surgery. Excision can relieve disabling advanced fibrotic disease, while physiological procedures may suit selected lymphatic anatomy. Surgery does not guarantee cure or eliminate the need for continuing care.[9]

Torio-Padron's retrospective 51-patient program combined perioperative decongestive therapy with tailored resection and primary closure. Three complications required revision surgery; the series does not prove that every genital defect can be closed primarily or that conservative care must last a fixed number of weeks. In Wisenbaugh's 11-patient massive-localized-lymphedema cohort, wound complications were common despite improved quality of life, and most patients gained weight after surgery.[20][21]

Ehrl treated nine patients, eight with giant disease and one with pitting edema; five received additional VLNT into the groin or scrotum. No recurrence was reported at median 49 months, including patients without VLNT. That small uncontrolled experience cannot establish that VLNT prevents recurrence or should accompany every excision. Counsel about donor morbidity, including donor-site lymphedema.[22][9]

See Excision and Reconstruction for Lymphedema and Complex Decongestive Therapy.

Gender-affirming and elective scrotoplasty​

Labia majora are the embryological homologues of the scrotum and a common source for scrotoplasty. Plan their vascularity and position with any urethral lengthening, phalloplasty and perineal reconstruction. Pigot's published modification specifically concerned surgery without urethral lengthening; it should not be applied indiscriminately to a different urethral plan.[23][8]

Miller reported 147 scrotoplasties, usually alongside phalloplasty, with mean 12.5-month follow-up. Distal flap necrosis occurred in six patients and large perineoscrotal dehiscence in seven. Three fistulas required repair, and all five reported scrotal/perineal hematomas required operative treatment. These are outcomes of a combined reconstruction, not isolated scrotoplasty risk estimates.[8]

Implant timing depends on healing, available space, concurrent procedures and patient preference. A historical series placed an implant at 12 months; it does not establish a universal six-to-twelve-month rule.[24] See the masculinizing surgery pathway.

For bothersome laxity or webbing, excision, advancement or Z-plasty may be considered after individualized assessment. Adult aesthetic evidence is largely case reports and technical descriptions. A pediatric series of 100 mixed procedures does not establish adult satisfaction, isolated-webbing success or safety alongside a penile prosthesis.[25][26]

Fertility, function and follow-up​

No human comparative evidence establishes that all flaps preserve fertility better than skin grafts. Demir's experiment evaluated rats at two months and found worse testicular histological measures with grafting. It cannot set a universal human operation preference or prove that a transferred groin flap restores native dartos thermoregulation. Clinical reviews emphasize how sparse objective reproductive outcomes remain.[27][2]

Discuss fertility goals before major reconstruction, with semen assessment or reproductive consultation when appropriate. Follow healing, pain, mobility, sensation, sexual function, appearance and disease recurrence. Evaluate infection, hematoma, threatened perfusion, graft/flap loss and urinary complications according to severity; they should not all be described as minor problems suitable for observation.[1][8][9]

See Also​

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

3. 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.

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. 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

6. 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

7. 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

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. European Association of Urology. Urological Infections Guidelines. 2026. Section 3.13: Fournier's gangrene. Guideline.

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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