Ballochmyle Hospital, Ayrshire

Transcription

1 TRAUMATIC AVULSION OF THE SKIN OF THE SCROTUM AND PENIS: USE OF THE AVULSED SKIN AS A FREE GRAFT By THOMAS GIBSON, M.B., F.R.C.S.(Ed.) Ballochmyle Hospital, Ayrshire AVULSION of the skin of the scrotum and penis is an uncommon injury which, in most cases, is due to the patient's trousers being caught by a horizontally rotating shaft. The loose folds of material are rolled up and within them the skin of the scrotum is caught and avulsed from behind forwards, dragging with it the skin of the penis as far as its attachment at the corona. The lesion appears to have increased in frequency in the past ten years, particularly in America, and this seems to be associated with the increasing use of farming machinery in that country, the power "take off" of a tractor being a common cause (Douglas, I95z ; Ferris, I949). The skin is stripped in part or completely from the testicles, the spermatic cords, and the shaft of the penis, the plane of cleavage passing through the layer of loose areolar tissue just deep to the dartos muscle of the scrotum and to the skin of the penis. Damage to the testicles and penis may occur but is uncommon, and the urethra in the perineum usually escapes. The methods of dealing with this lesion so far described may be summarised briefly :-- z. Scrotum.--(a) Where only a partial loss of skin occurs, primary closure may be possible because of the extreme laxity of scrotal skin. Even when the remaining portions are too small to provide complete primary cover they should be carefully preserved since they grow rapidly and may quickly cover the defect (Brunet, I95o). Both Ferris (z949) and Roth and Warren (z944) comment on the amazing regenerative powers of small fragments of scrotal skin. (b) Where skin loss is complete it has been the practice to bury the testes under normal skin at the edge of the wound either at the external inguinal ring (Ferris, z949) or in the thigh (Bruner, z95o; Pfeiffer and Miller, z95 o ; May, I95o; Whelan, z944 ; Owens, I942). The wound edges can then be drawn together and primary closure obtained. At a later date the scrotum is reconstructed in a single or multiple staged procedure from local flaps. (c) More recently, Douglas (z95 z) has described a case in which primary reconstruction was carried out by local thigh flaps, a reasonably good cosmetic appearance resulting. 2. Penis.--Most authors are agreed that the most suitable cover is a split-skin graft wrapped around the shaft and fixed by deep mattress sutures. Ferris (z949) makes the point that the suture line should be on the dorsum of the penis to avoid a ventral curvature from later contraction. The case to be described differs from those previously published in that the mass of avulsed skin, which was still attached at the base of the glans penis, was retained and the scrotal part, although devoid of blood supply, was used after suitable preparation as a free graft to cover the denuded testicles. As far as can be ascertained, this method has not previously been described, and its success and relative simplicity suggest that even when the avulsed skin is not available free grafting with thick split-skin grafts might be a most satisfactory procedure. 283

2 284 BRITISH JOURNAL OF PLASTIC SURGERY The idea, however, is not new, and has been considered and rejected by other authors. Thus Roth and Warren (1944) write : " The idea of utilising the avulsed skin of the penis and scrotum which had been preserved and brought to hospital with the patient was abandoned promptly." May (I95O) sums up the main objections as follows : "... the use of free skin grafts to cover the testicles is out of the question at least in total defects since the irregularity of the testicles and inadvisability to apply proper pressure do not favour regeneration of a free skin graft. The same is true if the torn off scrotal skin is available." Both of May's main objections to the method, viz., the irregular contours of the bed and the dangers of direct pressure over the testicles, have been overcome in the present case, and while, admittedly, only one case has so far been treated, it appears to be a much simpler and more rapid method than the multiple staged procedure commonly advocated. CASE REPORT On 3 Ist January 1953 the patient, an engineer, aged 27, was leaning over a horizontally rotating shaft when his trousers were caught and the skin of the scrotum and penis was avulsed but remained attached around the corona. The skin of the penis was turned completely inside out and pulled over the glans. Because of this, at the first hospital to which he was admitted an incision was made through the penile skin, the glans was drawn through, and a catheter passed per urethram to prevent urine soiling the tissues. It was unfortunate that this incision was made transversely and not in a longitudinal direction as it probably interfered with the blood supply to the remainder of the penile skin, The patient was later transferred to the Plastic Surgery Unit, Ballochmyle Hospital, where operation was carried out seven hours after injury. The pre-operative condition of the genitalia is shown in Fig. I. Each testicle hung freely, attached only by a 2 to 3 in. length of the spermatic cord, but neither was damaged. The wound was symmetrical, starting just anterior to the anus, and the margin throughout appeared to be the zone where the scrotal skin merges into the skin of the thighs and pubis. No fragments of scrotal skin remained attached at this margin or to the testes. The scrotal sac itself, which was attached to the penile skin by a very narrow and ragged bridge, was completely avascular but not grossly damaged apart from one or two small areas of bruising. A second attachment to the left testicle, which is seen in Fig. I, consisted of a twisted strand of avascular tissue. Operation.--Under general anaesthesia, the patient was placed in the lithotomy position and the wound thoroughly cleansed with Cetrimide, I per cent. The scrotal sac was detached by cutting through the strands of tissue connecting it to the penile skin and to the testis. This allowed the skin of the penis to be drawn over the shaft and retained in position by a few sutures to the pubic skin. The blood supply entering at the corona had, of course, been kinked for several hours and at first the penile skin appeared to he completely avascular. It improved in colour, however, as the operation proceeded, and it was hoped that it might survive completely. A catheter was now inserted so that the urethra could be easily located and damage to it avoided during the d6bridement of the perineum. When all damaged and necrotic tissue had been removed from the testes and perineum, the testes were placed side by side in their normal position just below the pubic arch and held there by a few deep catgut sutures to the Colles' fascia overlying the perineal muscles. The medial coverings of the testes were then stitched together, to obliterate as far as possible the space between theme and the spermatic cords were

3 TRAUMATIC AVULSION OF THE SKIN OF THE SCROTUM AND PENIS 285 similarly anchored. This preliminary fixation of the testiclcs to one another and to the Colles' fascia reduced the multiple irregularities of the defect to one central convex eminence. The detached scrotal sac was now carefully thinned with sharp curved scissors ; all loose tissue and dartos fibres were removed and only the skin itself was retained. This Proved to be a tedious procedure and great care had to be taken to avoid buttonholing the wrinkled tissue. The margin was excised for about ½ in. all round. When finally thinned the sac entirely lost its wrinkled appearance and appeared to be at least FIG. I Pre-operative photograph of the lesion. The scrotal sac is held aside to show the denuded testicles and the shaft of the penis. T h e twisted penile skin can be seen attached to the base of the glans. twice as large as the raw area to be covered. It was not a fiat sheet but retained the typical bag shape, the median raph6 being clearly visible. Having been placed in position over the testicles the median raph6 was tacked to the midline and the. junction between the testicles by a few stitches, and the margin was united to the wound edges around the defect and to the skin at the base of the penis. The ends of most of the marginal stitches were left long for the subsequent pressure dressing. The graft at this stage still lookcd much too large for the defect, but it was found, by packing ravine wool around the stitched edge and between this and the testicles, that the slack was readily taken up, and as the process continued it became obvious in addition that the skin over the testes became tense. A certain amount of indirect pressure could thus be applied to the graft and the risk of testicular damage from a direct pressure dressing avoided. The whole wound was packed firmly with ravine wool, particular care being taken around the testicles and spermatic cords to avoid excessive pressure 4 D

4 286 BRITISH JOURNAL OF PLASTIC SURGERY at any point. The lower poles of the testes were left uncovered, the tension sutures being tied around but not over them, and they were in fact exposed throughout treatment. The laxness of the subcutaneous tissues of the surrounding thigh and pubis was such that all the apparent excess of skin was taken up while a certain amount of blunt undermining occurred. The tension of the skin over the testicles was thus adjusted to maintain close apposition (Fig. 2). A light dressing was placed over the suture line and finally a plaster of Paris spica was applied around the hip and thighs to maintain the lithotomy position. As became apparent later, this plaster was not made sufficiently strongly ; it cracked shortly after FLAVINE WOOL SKIN GRAFT COLLES' FASCIA FIG. 2 Diagram illustrating the operative technique. The irregularities of the bed were reduced by suturing the testicles to one another and to Colles' fascia just below the pubis. Direct pressure on the testes was avoided by packing flavine wool around the wound margins until the skin tension of the graft over the testicles was evenly distributed and sufficient to maintain close apposition. The amount of blunt undermining of the margin which was necessary is shown. operation, allowing some adduction of the legs, which in turn slackened the pressure dressing particularly over the perineum and was probably responsible for the hmmatoma formation and the loss of the graft which occurred there. Subsequent Course.--The convalescence was remarkable for the complete absence of pain and discomfort. Catheter drainage was retained for nineteen days and during this period the patient received stilboestrol, 5 rag. t.i.d., to prevent erections and " Gantrisin '" (Sulphafurazole), o. 5 g. six-hourly, as a prophylactic against urinary infection. A constipating mixture was also administered and the bowels regulated by enemata. The penile skin was very oedematous on the day following operation and some degree of oedema persisted until healing was complete six weeks later. The area of the gra~t which was exposed over the lower poles of the testes was watched with interest. By the end of the second dayit was slightly oedematous and the ~edema was marked by the third day. This was taken to indicate that some vascularisation was occurring but, although pinkish in colour, the graft Showed no evidence of blanching on pressure. Later the surface became obscured by a light crust due, apparently, to leakage of the oedema fluid and it was impossible to observe further progress. This is the first occasion on which I have observed directly a full-thickness graft in the immediate post-operative phase and the early appearance of oedema was most interesting. The fluid could have

5 TRAUMATIC AVULSION OF THE SKIN OF THE SCROTUM AND PENIS 287 come only from the blood stream and presumably new blood-vessels had penetrated the graft by the second day. Scothorne and McGregor (1953) have noted a similar rapid vascularisation of full-thickness skin grafts in rabbits. The dressings were removed on the tenth day, and while it was difficult to be quite certain how much of the skin had survived, since vascularisation was not complete, the position (which was confirmed at the next dressing) appeared to be as follows :-- I. Penis.--All the skin had survived except for an annular area about ½ in. wide at the base. 2. Scrotum.--Approximately two~thirds of the free graft had survived. The skin over the testes had nearly all taken except for a doubtful area at the lower pole of the left testis. The area between testes and skin edge and that around the spermatic cords showed a patchy take but more than half of the skin had survived. Over the perineum a large hmmatoma separated the graft from its bed and the skill had taken only at the edges. As stated above, this was almost certainly due to the cracking of the P.O.P. splint and the subsequent slackening of the tension sutures. The hmmatoma was evacuated through an incision over it and a further pressure dressing applied with elastoplast and P.O.P. fixation. At the second dressing on the sixteenth day the necrotic areas were mostly well demarcated and were excised, the raw surfaces being covered with stamp grafts. The area over the lower pole of the left testis was still of doubtful viability and was left untouched. The stamp grafts took well and three days later a regime of daily baths was begun during which healing progressed rapidly. The doubtfully viable skin over the left testis separated as a slough and further small stamp grafts were applied to this site and to the only other unhealed area over the right spermatic cord on the fifth post-operative week. He was discharged, healed, six weeks after injury and resumed work one week later. Figs. 3 and 4 show the position four months after injury. There has been considerable contracture of the grafted area surrounding the testes and the deep grooves caused by the pressure dressing are practically obliterated although one or two small pockets require careful cleansing. The skin covering the testicles is lax and on palpation the testes have considerable free play. The cremaster muscles on both sides are functioning, that on the left being particularly brisk. A few hairs are beginning to grow from the scrotum but the crop is sparse. He is conscious of no disability and the cosmetic result is satisfactory and closely approaches the normal. All 0edema of the penile skin has gone and sexual potency and libido are unimpaired. COMMENT It is remarkable that primary free grafting has not been previously tried in these cases since it seems to be not uncommon to have the scrotal skin available (cf. Roth and Warren, 1944 ; Pfeiffer and Miller, 195o ; May, 195o). The avulsed :skin is unlikely to be grossly damaged since it is gripped between and protected by the folds of the trousers. Gross cellular damage will occur only where it is torn along the margin and through the subcutaneous tissues, and these areas are completely excised during preparation. Even when relatively large damaged areas exist they may be excised and still leave sufficient to cover the testes. The apparent impossibility of applying a graft to the freely hanging testicles can be readily overcome by the two measures described, namely, preliminary fixation of the testicles to each other and to Colles' fascia, and the application of a pressure dressing in such a way that no direct pressure, which might cause avascular necrosis, is put on the testicles themselves. A IOO per cent. "take" of the graft was not achieved, but sufficient survived to give complete healing and a good cosmetic result in six weeks.

6 288 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 3 Front view of the genitalia four months after injury. FIG. 4 T h e perineum four months after injury.

7 TRAUMATIC AVULSION OF THE SKIN OF THE SCROTUM AND PENIS 289 When the avulsed skin is not available there seems no reason why the raw surface should not be covered per primam with thick split-thickness grafts suitably tailored to the defect, using a technique similar to that described. SUMMARY I. A case of traumatic avulsion of the skin of the scrotum and penis is reported in which the skin was still attached at the base of the glans. 2. The defect was repaired by using the scrotal skin as a free graft, the main technical details of the operation being :-- (a) Fixation of the testes to one another and to their bed just below the pubis. (b) Thinning of the scrotal sac to full thickness skin. (c) Application of a firm pressure dressing but avoidance of any considerable direct pressure on the testicles themselves, (d) Fixation of the thighs in the lithotomy position until the grafts had taken. 3. About 6o per cent. of the graft survived, and with the subsequent application of a few small split-skin grafts healing was complete in six weeks. 4. The result was satisfactory, both functionally and cosmetically. 5. It is suggested that even where the avulsed skin is not available, the raw area may be covered with free split-thickness grafts using a similar technique, thus avoiding the flap operations commonly advocated. I am grateful to Mr J. Scott Tough for his permission to record this case ; to Mr L A. McGregor for his assistance and the line drawing ; and to Mr T. Meikle for the photographs. REFERENCES BRUNER, ft. M. (195o). Plast. reconstr. Surg., 6, 334. DOUGLAS, B. (1951). Ann. Surg., I33, 889. FERRIS, D. O. (1949). ft. Urol., 62, 523. MAY, H. (195o). Plast. reconstr. Surg., 6, 134. OWENS, N. (1942). Surgery, 12, 88. PFEIFFER, D. B., and MILLER, D. B. (195o). Plast. reeonstr. Surg., 5, 52o. ROTH, R. B., and WARREN, K. W. (1944)..7. UroL, 52, 162. SCOTHORNE, R. J., and McGREGOR, I. A. (1953). ft. Anat., Lond., 87, 379. WH LAN, E. P. (1944). Surg. Gynec. Obstet., 78, 649.