Department of Surgery, Medical College, Nagpur, India

Transcription

1 SCROTAL AVULSION : A NEW TECHNIQUE OF RECONSTRUCTION BY SPLIT-SKIN GRAFT By C. BALAKRISHNAN, F.R.C.S. Department of Surgery, Medical College, Nagpur, India ACCIDENTAL avulsion of scrotal skin presents an interesting problem. Gibson (1954) gave a short review of the methods used for treating this injury, and presented a case in which the problem was tackled successfully from an angle which had been considered impracticable. He used the avulsed skin as a full-thickness free graft over the exposed testicles, securing a 6o per cent. take. He considered the possibility of scrota1 reconstruction by split-skin grafts, but could find no record of such a case. The case reported here shows that the procedure is quite practicable. Done in June I95 o, the case has been followed up long enough for an assessment of the result from the point of view of testicular function. Case Report.--On 26th June 195 o, at IO A.M., S. S., aged 25, was working near a flour mill when his clothes got entangled in running machinery and the scrotal skin was completely peeled off. He was.... brought to hospital at 7 P.M. and referred for plastic surgical treatment. Both testicles and portions of the cords were seen covered by the cremaster sheets which showed ripples of contraction on exposure. The raw area extended from the penoscrotal junction to the perineal body. Bleeding had stopped and there was no evidence of shock (Fig. I). At 9 P.M., eleven hours after injury, under spinal ana:sthesia, the raw area was washed clean with hydrogen peroxide and running saline. It was then covered with three separate sheets of split-skin graft cut from the thigh. One sheet was applied round each testicle, and the third sheet was applied centrally from the root of the penis to the perineal body. A FIG. i large number of blanket stitches were Scrotal avulsion eleven hours after injury, used to anchor the grafts to their mobile and uneven bed. A pad of flavine wool was built up carefully round the testicles and over the intervening depression. It was fixed in position by adhesive strapping without undue pressure. Urine was drained by catheter for five days. The patient co-operated very well in keeping the operation site immobile during this period. On 3oth June I95 o, at the first dressing, there was 9o per cent. take of the grafts. One month later healing was complete without any supplementary grafts. A small hydrocele developed on the left side (Fig. 2). On 27th December 195 the grafts had contracted down as expected. The scrotum presented a strange bifid appearance with each testicle completely covered by skin. 38

2 SCROTAL AVULSION: A NEW TECHNIQUE OF RECONSTRUCTION BY SPLIT-SKIN GRAFT 39 Flaps of the grafted skin were raised from the perineum and contiguous aspects of the testicles, using as far as possible the plane of cleavage just superficial to the tunica vaginalis. The flaps were rearranged fusing the cleft scrotum. There was slight marginal FIG. 2 FIG. 3 Fig. 2.--Five weeks after primary repair by split-skin graft. The testicles are separately covered and the scrotum is bifid. Fig. 3.--Seven months later, following fusion of the scrotum by rearranging grafted skin. FIG. 4 Testicular biopsy seven months after injury. Incomplete spermatogenesis. necrosis of one of the flaps, but healing was complete in twenty days and the result appeared to be satisfactory (Fig. 3). On 17th January 1951 seminal fluid examination showed non-motile spermatozoa, most of them without tails. The count was I5,ooo per c.mm. (normal 60,000). On 8th February I95I a biopsy was taken from the left testis, which was rather smaller than

3 40 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 5 Two and a half years later. The scrotum is almost normal in appearance except that it is hairless. Rugm are visible. FIG. 6 Testicular biopsy nearly four years after injury. A picture of atrophy. the right and appeared to have suffered more damage. There was moderate fibrosis of the tunica propria and increase of interstitial fibrous tissue. The tubules showed irregular outlines and desquamation of lining. The general picture suggested incomplete spermatogenesis (Fig. 4). On 7th January I953 the scrotum was almost normal in appearance (Fig. 5). The patient reported that his libido and sexual potency were normal. Seminal fluid showed normal sperms, 75 per cent. of which were actively motile after six hours. The result

4 scrotal AVULSION: A NEW TECHNIQUE OF RECONSTRUCTION BY SPLIT-SKIN GRAFT 41 was considered perfectly satisfactory from every point of view, but publication was delayed till a five-year follow-up could be obtained. On 9th March 1954 the patient reported that he had no children, though married for three years. The seminal fluid had a sperm count of 12,ooo per c.mm. Only 5 o per cent. were actively motile and 5 per cent. showed abnormal appearances. On 2nd December 1954 the count was 15,ooo; 7 per cent. were normal in shape, while 3 per cent. showed distortions. Only IO per cent. were actively motile after three hours. Biopsy from the left testis showed a picture of testicular atrophy. Most tubules were devoid of spermatogenic cells. Many were hyalinised or obliterated by fibrosis. Only a few showed spermatogenesis (Fig. 6). It appeared as if the testicles had recovered partially from the initial loss of function and settled down to atrophy once again. DISCUSSION i. The Injury.--In avulsion of the scrotum, the plane of cleavage is just superficial to the cremaster, and the testicles escape major damage. These two features of the injury are explained by the well-known cremasteric reflex. When the scrotal skin is painfully grasped by an avulsing force, the cremaster sheet contracts vigorously and draws the testicles away from the skin at the moment of avulsion. The common type of injury is due to clothes being caught in running machinery, but other types may be seen from time to time. Recently I had a case who was gored by a bull over the scrotum. The scrotal skin was first impaled and then avulsed. Even in this unusual case the cremaster was intact and the testicles were undamaged. The injury may be associated with thrombosis of the vessels in the spermatic cords. Temporary degenerative changes in the testicles may be the direct result of such vascular damage. As the blood supply gets re-established, recovery should occur. More progressive and permanent damage to the testicles will follow heavy scarring over the posterior aspect of the epididymis. The outlet to the secretions of the seminiferous tubules lies through nearly 2o ft. of a single fine tube which lies coiled up in the epididymis. Constriction of this tube from scarring will produce back-pressure effects ranging from partial to complete atrophy of the testicle. 2. The Repair.--The rapid provision of stable skin cover for the denuded testicles is of prime importance. There is nothing to recommend expectant treatment of even subtotal avulsions in the hope that the regenerative powers of small fragments of scrotal skin will ultimately provide epithelial coverage of the exposed testicles. A common method of dealing with the injury is to transplant the testicles under the skin of the groin. This is fatal to the spermatogenic function of the testicles. Reconstruction of the scrotum is worth attempting, even if it fails to avoid ultimate loss of testicular function. Such reconstruction by local flaps, either as a primary measure or as a delayed procedure after the emergency is tided over by transplantation of the testicles to the groin, has been advocated. These procedures are needlessly complicated and are based on a misconception that free grafts are bound to fail. The case for full-thickness free graft was presented by Gibson. The main advantage of such grafts over split-skin grafts is that there is less contraction following the initial take of the grafts. This advantage, however, is largely neutralised by the uncertain initial take of thick grafts. Gibson with his meticulous

5 4 2 BRITISH JOURNAL OF PLASTIC SURGERY technique got only 6o per cent. take. Supplementary split-skin grafts were required and healing was complete only in six weeks. The average split-skin graft appears to me to be the best and most certain method of obtaining rapid primary healing. In the case reported there was 90 per cent. initial take, and healing was complete in four weeks without any need for supplementary grafts. The disadvantage of the split-skin graft is its large factor of contraction after the initial take. In the technique I adopted, this contraction was fully compensated by the total coverage of the testicles and the perineal gap separately, permitting a very large surplus area of graft to take initially. When the contraction was complete in six months it was a simple matter to rearrange the available skin to form a scrotum with a degree of laxity approximating to normal. It was proved that grafted skin is sufficiently stable after six months to be raised as flaps and transposed. 3. The Result.--The cosmetic result in the case reported is excellent. The follow-up of this type of case from the point of view of testicular function appears to be very imperfect, and I have been unable to find even a single five-year result. The patient's statement that libido and sexual potency are normal is too often taken as proof of satisfactory testicular function. The case reported proves the fallacy of this assumption. It appears to me that testicular function goes through a cycle of changes following avulsion injury of the scrotum. There is an initial degenerative change, with desquamation of the lining of the seminiferous tubules, and the sperms produced are defective both in structure and in motility. Part of this degenerative change may be due to vascular damage. In the next stage recovery occurs, and normal spermatozoa are produced though in diminished numbers. In the third stage, function declines once again, with atrophy of many of the tubules, possibly due to back-pressure damage from obstruction to the long coiled tube of the epididymis. Perhaps the third stage is not inevitable if the technique of primary repair is good. The histological appearances of the seminiferous tubules in these three stages may be compared to the changes in renal tubules in different stages of nephritis. SUMMARY A new technique for reconstruction of the avulsed scrotum by split-skin grafts is described. This is a two-stage procedure. In the first stage the testicles are held apart and the whole available area grafted. Six months later, when the grafts have ceased to contract, the bifid scrotum is fused by local rearrangement of the grafted skin raised as flaps. A five-year follow-up of testicular function shows initial loss, intermediate recovery, and subsequent decline. I am grateful to Professors B. K. Aikat and J. B. Shrivastava and their staff for the laboratory and the histological reports. The photographs were taken by Mr B. K. Joshi Rao. REFERENCE GIBSON, T. (I954). Brit. J. plast. Surg., 6, 283.