Coverage of circumferential penile shaft defects with the bipedicled scrotal flap: a case series 以雙蒂側裂皮瓣修補環狀陰莖軸柱缺損：病例系列
Manzhi Wong Yee-Siang Ong Bien-Keem Tan 黄满志 王貽詳 陳彬錦
Received: 15 June 2013 / Accepted: 2 September 2013 /Published online: 18 October 2013 接收日期：2013 年 6 月 15 日／接受日期：2013 年 9 月 2 日／線上發布：2013 年 10 月 18 日
(C) Springer-Verlag Berlin Heidelberg 2013 (C) 施普林格-弗拉格柏林海德堡 2013
Abstract 摘要
Background Reconstruction of circumferential penile skin defects should address both cosmetic and functional concerns. Scrotal skin is an ideal replacement because its inherent elasticity allows erection. This characteristic also allows primary closure of the donor site. 環形陰莖皮膚缺損的背景重建應同時解決美觀和功能方面的問題。陰囊皮膚是理想的替代品,因為其固有的彈性可以允許勃起。這一特性也可以使供體部位實現原發性閉合。 The purpose of this paper is to describe our use of a bipedicled scrotal flap and our modifications. 這篇論文的目的是描述我們使用雙蒂皮瓣以及我們的改良方式。
Methods Five patients (age range, 19 to 76 years) over the last 7 years underwent reconstruction of circumferential defects with this technique. The underlying pathologic condition was siliconoma/paraffinoma , full-thickness burn , overly aggressive circumcision ( ), and traumatic avulsion . Follow-up ranged from 2 to 6 years. A bipedicled flap was elevated from the scrotum and inset over either the dorsal or ventral aspect of the penile defect. Flap delay was carried out before final division at 3 weeks. 方法
五名患者（年齡範圍為 19 至 76 歲）在過去 7 年內接受了此技術的環形缺損重建。潛在的病理情況包括矽膠腫/石蠟腫 、全層燒傷 、切除過度的包皮(< code2>< /code2>)和創傷性撕裂 。隨訪時間範圍為 2 至 6 年。從陰囊中抬高了一個雙蒂瓣，並置於陰莖缺損的背側或腹側。在最終切斷前 3 週進行了瓣片延遲。 The junction line on the penile shaft was designed as a Z-pattern which was off-center. Results Four patients healed uneventfully. One patient had flap tip necrosis due to insufficient delay, which resulted in mild ventral scarring. All were able to have normal erection. 陰莖軸上的接合線被設計為偏心的 Z 形圖案。結果：四名患者順利癒合。一名患者由於延遲不足導致瓣片壞死,造成輕度腹側疤痕。所有患者均能正常勃起。 Conclusions We have used the bipedicled scrotal flap in a staged manner for circumferential penile defects. 我們以分期方式使用雙脚撰局股部皮瓣修復了環形陰莖缺損。 The advantages of this technique were reliable coverage with an inconspicuous donor site, provision of expansile skin allowing normal erection and preservation of the penile-scrotal junction. 此技術的優點是可靠的覆蓋、不明顯的供體部位、提供可擴張的皮膚以允許正常勃起和保留陰莖－陰囊交接處。 The disadvantages were multistaged procedure, skin mismatch because of rugosity, and hair growth. 缺點包括多階段程序、因皮膚粗糖而導致肌膚不匹配,以及毛髮生長。
Level of Evidence: Level V, therapeutic study. 證據等級：第 V 級，療效研究。
Injuries to the male genitalia are devastating because of the ease with which delicate tissue is damaged resulting in scarring leading in turn to disfigurement and sexual dysfunction. Silicone injections, trauma, and burns are common causes of penile injury. 男性生殖器受傷是毀滅性的,因為細緻組織很容易受損,導致疤痕形成,進而造成變形和性功能障礙。矽矽注射、創傷和燒傷是導致陰莖受傷的常見原因。 Replacing the damaged tissues with wellmatched skin that expands with erection, is the best way to achieve a functional outcome. Although split-thickness or full-thickness skin grafting [1-3] is the simplest method, its disadvantages include poor take and graft contraction. 以經過良好匹配的皮膚取代受損組織,並使之隨勃起而擴張,是實現功能性結果的最佳方式。雖然分層厚度或全層厚度皮膚移植[1-3]是最簡單的方法,但其缺點包括移植皮膚附著率低和縮小。 Pedicled flaps from the groin, thigh, or abdomen [4-6] though robust are less expansile. The scrotum provides elastic and well-vascularized skin, with an inconspicuous donor site and is ideal for penile coverage. 腹股溝、大腿或腹部的蒂狀瓣片[4-6]雖然穩固,但展開能力較小。陰囊提供有彈性和血管充足的皮膚,捐贈部位不明顯,非常適合用於包覆陰莖。 The purpose of this paper is to describe our technique using a bipedicled scrotal flap [7-8], emphasizing the need for flap delay to improve reliability, specific placement of junction lines to reduce scarring, and lastly, preservation of the penile-scrotal junction. 本文的目的是描述我們使用雙足蹼皮瓣 [7-8] 的技術，強調延遲皮瓣的需要以提高可靠性、特定的接縫線位置以減少疤痕，最後是保留陰莖-陰囊連接部位。
Patients and methods 病人和方法
Between 2004 and 2011, five patients with circumferential penile skin loss underwent reconstruction with a bipedicled scrotal flap. The age of the patients ranged from 19 to 76 years (mean, 45 years). The underlying pathologic condition was siliconoma/paraffinoma , full-thickness burn , overly aggressive circumcision , and traumatic avulsion . Follow-up ranged from 2 to 6 years. 在 2004 年至 2011 年期間,有五名患者由於陰莖周圍皮膚缺失而進行重建,採用雙蒂腹皮瓣術。這些患者的年齡介於 19 至 76 歲之間(平均 45 歲)。病理診斷包括硅肉瘤/石蠟肉瘤、全層燒傷、過度激進的包皮切除術,以及創傷性撕裂。追蹤時間為 2 至 6 年。
Technique 技術
Our bipedicled scrotal flap is designed as a bucket-handle and incorporates the dartos muscle to improve its vascularity. Its dimensions should exceed that of the defect to allow for 我們的雙蒂鞋扣狀皮瓣設計具有提手狀,並包含達爾托斯肌以改善其血管供應。其尺寸應超過缺損以允許
我們的雙蒂鞋扣狀皮瓣設計具有提手狀,並包含達爾托斯肌以改善其血管供應。其尺寸應超過缺損以允許
erection. Scrotal skin is very expansile and up to two thirds of the scrotum can be used, while still allowing primary closure of the donor site [9]. The flap is extended in a superolateral direction towards the groin in order to gain length. 勃起。陰囊皮膚非常具有延展性,可以利用多達三分之二的陰囊面積,而且仍能夠進行原發性閉合，以獲得足夠的移位長度[9]。移植皮瓣朝上外側方向延伸至腹股溝部位。 Dissection proceeds quickly in the avascular subdartos plane except in the midline where septal vessels are encountered. These are carefully ligated to avoid a hematoma. 剝離在非血管性的次皮層平面迅速進行,除了在正中線處會遇到隔膜血管。這些血管會被小心地結紮,以避免血腫的出現。
The initial inset of the flap can be either over the dorsal or ventral aspect of the shaft (Figs. 1 and 2, respectively). A dorsal inset is easier, but the scrotal raphe is then conspicuous because of its odd location. 瓣膜的初始插入可以在骨幹的背側或腹側方面進行(分別見圖 1 和 2)。背側插入較容易,但由於位置異常,陰囊中縫因此顯著。 A ventral inset is ideal as the scrotal raphe blends in with its penile counterpart but a longer flap is then needed as it would be initially twisted. 腹部切口最佳,因為陰囊縫線與陰莖部分融為一體,但需要較長的翻瓣,因為最初會扭曲。
The flap handles are not tubed, and the suturing is left deliberately loose to allow for postoperative swelling. Any uncovered areas are temporarily skin grafted or closed by telescoping the penis inwards. The scrotal donor site is closed. 翻蓋處理不使用管狀物,縫合也故意留有一些空隙,以便術後腫脹。任何未覆蓋的部位暫時移植皮膚或以將陰莖內縮的方式閉合。供皮區域的陰囊已閉合。 Postoperatively, patients are placed in the Trendelenburg position and the scrotum is supported to minimize edema. 手術後,病患被置於特倫德倫堡位(頭低腳高位),並支撐陰囊以減少水腫。
We begin dividing the flap at 2 weeks. Over 5 days, the flap base is progressively narrowed, first on one side then on the other. This can be performed in the office setting under local anesthesia. 我們在 2 週後開始分離皮瓣。在 5 天內,皮瓣基部逐漸縮小,先在一側,然後在另一側。這可在診所環境下局部麻醉下進行。
The final inset is shown in Fig. 2e, which illustrates that the junction line is off-center and in a Z-pattern to reduce chordee. Post-op edema is expected, and the patient is counseled that this may persist for 6 months. 最終的插圖顯示在圖 2e 中,它說明接合線偏離中心,呈 Z 型模式以減少勃起彎曲。預期有術後水腫,並告知患者這可能持續 6 個月。 Thereafter, where appropriate, return to sexual activity is encouraged to prevent flap shrinkage and contracture. 其後,適當時候鼓勵恢復性活動,以防遮蓋縮小和收縮。
Results 結果
our of five patients healed without complications. Our first case developed ventral scarring from tip necrosis. This problem was rectified in subsequent cases by gradual flap division. Another patienthad congestion and superficial epidermolysis due to tight sutures. 五位病患中有四位順利痊癒,沒有併發症。我們第一個案例出現因前端壞死而造成的腹側疤痕。此問題在後續案例中透過逐步進行皮瓣分割而得到糾正。另一位病患則出現充血和表淺性表皮剝脫,這是由於縫合過於緊密所致。 This improved after release of the sutures. The residual wounds healed by secondary intention. Postoperatively, all patients had normal micturiction and erectile function. None required scar revision or contracture release. 在縫線釋放後,情況有所改善。殘餘的傷口透過二次愈合癒合。術後,所有患者都有正常的排尿和勃起功能。沒有人需要疤痕修復或收縮鬆解手術。 One Eurasian patient was troubled by hair growth over the flap. This improved with intense pulse light (IPL) treatment. 一名亞歐混血病患困擾於植皮瓣處出現毛髮生長。經過強脈衝光(IPL)治療後情況有所改善。
Case reports 病例報告
Case 1 (Fig. 1): A 53-year-old man presented with penile hardening after injecting himself with silicone. He complained of painful erections that prevented sexual intercourse. Circumferential excision of the distal penile 病例 1 (圖 1):一位 53 歲男性在自行注射矽膠後出現陰莖硬化。他抱怨勃起疼痛致無法進行性交。切除陰莖遠端周圍的組織。
Fig. 1 Inset of the scrotal flap over the dorsal penile shaft. a A 53-yearold man presented with penile siliconoma. There was a circumferential defect after complete excision of the diseased tissue. 圖 1 包皮皺褶填補陰莖背側的術中圖。a 一名 53 歲男性患有陰莖硅肪瘤。切除罹病組織後出現環形缺損。 b A bipedicled scrotal flap was elevated with careful ligation of the midline vessels. Lateral view of the elevated flap. The donor site was closed primarily. 雙蒂腹股溝皮瓣經仔細結紮中線血管後被抬起。 抬升皮瓣的側視圖。供皮區直接關閉。
The flap was inset over the dorsal aspect of the penis. e The flap base on the left was progressively narrowed before complete division. Notice that the flap was still vascularized by blood supply from the right flap base. A similar procedure was carried out on the right flap base. Final junction line was in a Z-pattern. months postoperatively 皮瓣置於陰莖背側。左側皮瓣基部逐漸收窄至完全分離。注意右側皮瓣基部仍由血管供應維持血液供應。 同樣的手術在右側皮瓣基部進行。最終縫合線呈 Z 型。術後數月
勃起。陰囊皮膚非常有伸縮性,可以利用陰囊高達三分之二的部分,同時仍能使供給部位達到基本閉合[9]。此皮瓣沿著上外方向延伸至腹股溝,以增加長度。
Fig. 2 Inset of the scrotal flap over the ventral penile shaft. a A 69-yearold man presented with full-thickness penile burns (left). A long bipedicled scrotal flap was elevated to cover the defect (right).b The flap 圖 2 陰囊皮瓣覆蓋於陰莖腹側。a 一名 69 歲男性患者出現全層深度陰莖燒傷(左)。一個長型雙蒂柄陰囊皮瓣被抬起以覆蓋缺損部位(右)。b 皮瓣
skin was required, followed by coverage with a bipedicled scrotal flap with an initial inset over the penile dorsum. He healed uneventfully and was able to have normal erections at 3 months. 需要皮膚移植,接著以一個雙蒂睪丸瓣瓣膚覆蓋陰莖背側。他順利癒合,三個月後能進行正常勃起。
Case 2 (Fig. 2): A 69-year-old man sustained fullthickness burns of the penis in the sauna. He had a circumferential skin defect after debridement. Excess scrotal skin was available. 病例 2 (圖 2)：一名 69 歲男性在桑拿浴室中遭受陰莖全層深度燒傷。清創後出現環狀皮膚缺損。剩餘陰囊皮膚可供利用。 Therefore, a long flap could be fashioned and applied to the ventral surface of the penis without tension. Flap delay was performed over 3 weeks, with the final appearance shown in Fig. 2e. 因此，可以製作一個長的瓣膜，並應用於陰莖的腹側表面，而不會造成張力。瓣膜延遲在 3 週內進行，最終的外觀如圖 2e 所示。 Postoperatively, the urologist documented normal erection with a tumescent test. He was treated with IPL for excessive hair growth over the scrotal flap. 手術後,泌尿科醫生記錄了正常勃起的睾丸腫脹測試結果。他接受了強脈衝光治療以控制囊袋皮瓣上過度生長的毛髮。
Discussion 討論
The scrotal bipedicled flap had little risk of tip necrosis in our technique where flap delay [10] was emphasized. From our earlier experience of using unipedicled or untrained bipedicled 陰囊雙足蒂皮瓣在我們的技術中,通過延遲翻瓣[10]而很少有梢端壞死的風險。從我們先前使用單足蒂或未經訓練的雙足蒂的經驗中,
was inset over the ventral aspect of the penile shaft. : Sequential flap division first on the left (c), then on the right before final inset in a Zpattern. e 6 months postoperatively 移植於陰莖軸的腹側。 ：先行左側(c)分割皮瓣,後右側 ,最後採 Z 形成型。手術後 6 個月
flaps (not included in this series), although coverage was achieved, there was flap tip necrosis resulting in localized scarring and chordee. For this reason, a staged approach with tip-training in an office setting was adopted. 瓣膜（不包含在本系列中），雖然已經達到覆蓋，但出現了瓣膜尖壞死導致局部瘢痕形成和勃起彎曲。因此採取了分階段的辦法，在診所環境中進行尖端訓練。 In addition, the junction line was designed in a Z-pattern to reduce the risk of chordee. 此外,接合線被設計成 Z 形模式以減少尿道彎曲的風險。
Chu and Shieh [8] recently reported a single case of a wide circumferential penile defect reconstructed using a similar technique. Our results further confirm the satisfactory cosmetic and functional results obtained with this flap design. 朱和謝[8]最近報告了一例利用類似技術重建的 寬周圍陰莖缺損的單一病例。我們的結果進一步證實了使用這種皮瓣設計獲得滿意的美容和功能性結果。 The bipedicled flap allowed the penile-scrotal angle to be preserved and was used for distal shaft defects not involving the root. In two cases (not in this series), where the entire penile shaft was denuded, we employed the penile submersion technique [11-12]. 雙蒂瓣片可保留陰莖-陰囊角度,用於不涉及根部的遠端軸缺陷。在兩個案例(不在本系列中),整個陰莖軸被剝奪,我們採用了陰莖沈浸技術[11-12]。 The penis was initially buried in a scrotal pocket and elevated in stages, distal to proximal up to the penilescrotal junction, where a " " was then fashioned. In this case, the reconstructed penis had a single ventral suture line. 陰莖最初埋於陰囊袋內,並分階段升至陰莖陰囊接合處,之後形成一個「 」。在這種情況下,重建的陰莖有一條單一的腹側縫線。
Bilateral unipedicled scrotal transposition flaps [13-17] have been described for total shaft defects. Accomplished in a single-stage, the paired flaps sandwich the shaft laterally and 雙側單蒂式陰囊轉位瓣[13-17]已被描述用於全體幹缺損。在單一階段完成,成對的瓣片在體幹的兩側夾持住。
雙側單蒂陰囊轉移瓣[13-17] 已被描述用於全長缺損。在單次手術中完成,配對的瓣片在側面包裏陰莖柱。
are united by dorsal and ventral suture lines. Compared with submersion, this technique results in an additional shaft scar, and risks delayed wound healing and distal necrosis. 由背側和腹側縫合線所連接。與浸沒相比,這種技術會產生額外的軸痕,並有延遲癒合和遠端壞死的風險。 A recent modification employed an inverted V-shape anastomosis at the ventral corona in an effort to reduce such problems [18]. 最近採用了反向 V 型吻合術於腹側冠狀溝,以降低此類問題[18]。
The drawbacks of our technique were first, multistaged procedure; second, skin mismatch because of rugosity; and third, hair growth. 我們技術的缺點有三點:第一是多階段的程序;第二是由於皮膚粗糙而造成的膚色不一致;第三是毛髮生長。 In addition, this technique could not be applied when scrotal skin was diseased, which was occasionally the case in Paget's disease and genital warts. The advantages included reliability, easy harvesting, and minimal donor site morbidity with use of redundant scrotal skin. 此外，此技術無法應用於陰囊皮膚已患病的情況，而這種情況偶爾會發生在佩吉特病和生殖器疣的情況下。優點包括可靠性、採集容易以及使用冗餘的陰囊皮膚時供體部位的發病率降低。
Acknowledgments We thank Mr. Michael Leow for his medical illustrations. 致謝
我們感謝 Michael Leow 先生提供醫學插圖。
Conflict of interest None 利益衝突 無
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Shin YS, Zhao C, Park JK (2013) New reconstructive surgery for penile paraffinoma to prevent necrosis of ventral penile skin. Urology 申 YS、趙 C、朴 JK(2013 年)預防陰莖亞麻脂肉瘤腹側陰莖皮膚壞死的新型重建手術。泌尿外科學
腹背縫合線相連。與浸沒相比,此技術會產生額外的軸疤痕, 並有延遲傷口癒合和遠端壞死的風險。
