Scrotal Reconstruction
Choose a technique from the cause, viable tissue, defect depth, closure tension and patient goals. This atlas links the individual procedures; the scrotal reconstruction overview explains the evidence and operative choices in more detail.
Decision Framework
Assess the wound and the patient
- Establish whether infection, trauma, lymphedema, cancer treatment, congenital anatomy or elective symptoms are driving the reconstruction.
- Assess testicular and cord viability, available skin, the actual vascularity of the recipient bed, dead space, and any penile, urethral or perineal injury.
- Include wound-healing risks, mobility, fertility goals, comfort, appearance and the patient's preference about staged procedures or implants.
Scrotal redundancy often permits primary closure. A systematic review of Fournier reconstruction (16 case series, 425 patients, including two women) proposed primary closure, secondary healing or a scrotal advancement flap for defects of less than 50% of the scrotum, and a graft or flap for larger defects or defects that extend beyond the scrotum.[1] The EAU Urological Infections guideline (2026) summarizes this as level 3 evidence.[1][11] A small scarred defect may need a graft or flap, and a larger defect may have enough healthy tissue for closure. The 2022 systematic review of scrotal reconstruction concluded that tension-free primary closure and local pedicled flaps usually suffice, and that split-thickness skin grafts (STSGs) or distant flaps are needed mainly for extensive skin loss.[13] Healthy native dartos is vascularized tissue and is preserved where possible.
Match the operation to the defect
| Finding | Options and limits |
|---|---|
| Healthy skin reaches without excessive tension | Primary closure or local scrotal advancement, preserving perfusion and comfortable testicular position |
| Superficial skin loss with a vascularized recipient bed | STSG may cover an extensive or total defect |
| Bed unsuitable for graft, deep dead space or combined perineal loss | Consider a regional flap with the necessary tissue components and a reliable pedicle |
| Immediate scrotal coverage unsuitable | Temporary or definitive thigh pouches may be considered after counseling |
| Fibrotic or fatty genital lymphedema | Tailored excision and coverage, with continuing conservative care; physiological lymphatic procedures require separate selection |
| Absent testis with an acceptable healed or reconstructable envelope | Offer prosthesis counseling; immediate or delayed placement depends on context and patient preference |
The choice should protect viability and comfort without unnecessary septal division, cord dissection or testicular repositioning.[1][3][4][5] Apposition, orchidopexy and expansion techniques are selected operations.[1][3][4][5]
Evidence that affects counseling
- Graft versus flap. No reliable human comparative evidence establishes a fertility advantage. A systematic review found no conclusive evidence that flap coverage of exposed testes is better than a skin graft.[1] In a rat experiment, grafts gave a lower germinal epithelium height and Johnsen score than flaps.[6]
- Flap outcomes. The 2026 Alammar systematic review of Fournier reconstruction included 619 patients and 625 flaps, with flap loss reported in 1.6%.[7]
- Lymphedema. Advanced excision and selected physiological procedures can improve symptoms. Continue individualized skin care and decongestive management, and discuss donor-site risks.[8][9]
- Implants. Discuss size, position, firmness, complications and the option to decline.[10][5]
Fournier's gangrene
Debridement, resuscitation and broad-spectrum antibiotics come first. WSES-AAST suggests orchiectomy or other genital surgery only when strictly necessary, with urologic consultation when appropriate .[21] The EAU guideline gives strong recommendations to start broad-spectrum antibiotics on presentation and to begin repeated debridement within 24 hours. A 2024 JAMA Surgery review advises debridement as soon as possible, ideally within 6 hours, and repeat debridement every 12 to 24 hours until no necrotic tissue remains.[11][12] EAU 2026's disease-management text calls for suprapubic urinary diversion with debridement, although its graded recommendations do not address diversion.[11] WSES-AAST suggests a multidisciplinary, tailored surgical approach ; its discussion individualizes urinary and fecal diversion, notes that urethral catheterization often provides satisfactory urinary diversion, and lists extensive penile or perineal debridement, urethral involvement, and periurethral abscess as common reasons for suprapubic drainage.[21] Anal sphincter involvement, fecal incontinence and continued fecal contamination of the wound are common reasons to consider colostomy.[21] Reconstruction follows once no further debridement is planned and the patient is medically stable.[3]
In the Hayon technique, the testes are brought together with the inferior penis after initial debridement using interrupted absorbable sutures, redundant cord is coiled under the abdominal wall, and a meshed STSG is placed once debridement is complete.[3] After adequate debridement, NPWT has been used for wound management and, in a 13-patient Fournier series, to fix genital STSGs; comparative benefit for graft fixation remains uncertain.[21][22] The EAU guideline found no evidence of benefit for NPWT in Fournier's gangrene (level 4) and gives a weak recommendation to use adjuncts only in clinical trials.[11]
Reported series
These are mostly small uncontrolled series. None establishes superiority of one technique.
| Series | Design | Reported result |
|---|---|---|
| Hayon 2021[3] | 10 patients after Fournier debridement; orchidopexy, then STSG (0.018 inch, meshed 2:1) under a bolster sutured for 5 to 7 days | Median follow-up 8 months. No chronic pain, discomfort or further intervention. Median stay after graft 9 days |
| Alwaal 2015[2] | 54 adults with genital STSG (13 tissue loss, 13 lymphedema, 12 buried penis, others) | Graft take above 90% in 52 of 54 |
| Sahai 2021[14] | Single-surgeon island groin flap series: 25 Fournier, 4 avulsion | Defects over 50% covered by one groin flap. The authors also describe adding two superior medial thigh flaps for total loss, but the analyzed series included island groin flap reconstruction alone. Results reported as satisfactory, without complication denominators in the abstract |
| Mopuri 2016[15] | 5 patients, modified pudendal thigh flap | Technique and vascular basis described |
| Lee 2012[16] | Retrospective series of 7 (6 Fournier, 1 extramammary Paget disease); gracilis plus internal pudendal artery perforator flap | All flaps survived. Mean defect 10.1 by 9.3 cm |
| Okwudili 2016[4] | 12 men with more than 50% scrotal skin loss; temporary anteromedial thigh pouches | No mortality. Residual scrotum expanded over 3 to 8 months to accept the testes, with normal testicular volume. Mean follow-up 14.8 months |
| Staniorski 2023[20] | 20 patients; thigh pouches with fasciocutaneous perineal closure | Perineal closure in all; abdominal STSG was needed to complete overall closure in 3. Complications in 3 (15%). Median follow-up 9 months. One patient had thigh-pouch pain and none requested scrotoplasty |
| Wisenbaugh 2018[17] | 11 patients with massive localized scrotal lymphedema (mean resected tissue 21 kg) | One graft, the rest closed primarily. Wound complications were common. Mean weight change +5.2 kg. Quality of life 1.3 to 7.7 of 10 at mean 26 months |
| Abdelfattah 2023[19] | 26 men with advanced genital lymphedema; excision with SCIP lymphatic flap | Flap survival 100%. Cellulitis rates fell. Mean follow-up 44.9 months. Uncontrolled |
| Singh 2016[18] | 40 gracilis perineal reconstructions after abdominoperineal resection or exenteration (not scrotal) | Donor-site complications 12.5%, recipient-site 40%. Obesity (OR 7.5) and active smoking (OR 9.3) were associated with minor complications |
Most patients in the Wisenbaugh series gained weight after surgery, so a weight-management plan is paired with excision of massive localized lymphedema.[17]
Concurrent procedures
Scrotal reconstruction is often combined with other operations. In Hayon's 10-patient technique, orchidopexy approximated the testes before STSG; fixation is selected according to the planned reconstruction.[3] Penile shaft reconstruction is common when Fournier's gangrene, lymphedema or buried penis involves the penoscrotal unit (see penile reconstruction). Perineal defects can be closed with fasciocutaneous flaps. A testicular prosthesis can be placed at orchiectomy or in a staged procedure.
Follow-up
Assess wound healing, collections, threatened perfusion, pain, testicular position and accessibility, sexual function and recurrence of the underlying disease. After Fournier’s gangrene, also assess bowel and urinary symptoms and psychosocial function; a 2026 review of five retrospective studies (291 patients overall; moderate-to-critical risk of bias) suggested these may be long-term concerns, although functional outcomes were inconsistently reported.[23] Treat significant necrosis, bleeding or dehiscence according to severity. Graft fixation and mobilization schedules depend on the reconstruction. The Hayon protocol used a bolster for 5 to 7 days; neither prolonged bed rest nor a particular dressing duration is universal.[3]
Treatment Database
| Procedure | Domain | Best for / indication |
|---|---|---|
| Primary Closure / Local Advancement | Primary Closure | Healthy remaining scrotal skin that reaches without excessive tension or compromised perfusion. |
| Scrotal Skin Grafting (principally STSG) | Skin Graft | Superficial loss with an adequately vascularized recipient bed when primary closure is unsuitable. |
| Scrotal Flap Reconstruction (all flap families) | Flap Reconstruction | Deep defects, dead space or a recipient bed unsuitable for grafting. |
| Testicular Thigh Pouch (Temporary, Definitive, or Hiawatha Neoscrotum) | Testicular Thigh Pouch | Selected extensive scrotal loss requiring temporary or definitive testicular thigh placement, including alongside perineal flap closure. |
| Testicular Prosthesis (Saline / Silicone) | Testicular Prosthesis | Post-orchiectomy, anorchia, atrophic testis, or neoscrotal augmentation. |
| Testicular Reimplantation (autotransplantation / traumatic replantation) | Testicular Reimplantation | High intra-abdominal testis autotransplantation or traumatic testicular replantation. |
| Complex Decongestive Therapy (CDT) | Lymphedema Surgery | Individualized skin care, decongestive treatment and maintenance before or after selected surgery. |
| Lymphaticovenous Anastomosis (LVA) | Lymphedema Surgery | Compression-refractory genital lymphedema with functional residual lymphatics. |
| Vascularized Lymph Node Transfer (VLNT) into Scrotum / Groin | Lymphedema Surgery | Selected lymphatic dysfunction after specialist assessment; limited genital comparative evidence. |
| Debulking Scrotoplasty (Excision + Primary Closure) | Lymphedema Surgery | Disabling fibrotic disease with sufficient healthy tissue for closure after excision. |
| Modified Charles Procedure (Excision + STSG) | Lymphedema Surgery | Selected advanced disease requiring excision and grafting; balance morbidity against other reconstructive options. |
| Excision + Flap Reconstruction (GL) | Lymphedema Surgery | Large genital-lymphedema defects with exposed vital structures or after failed simpler approaches. |
| SCIP Lymphatic Flap Transfer (3R — Yamamoto) | Lymphedema Surgery | Male genital elephantiasis treated by radical reduction plus pedicled SCIP lymphatic + skin flap. |
| CHASCIP — Combined Charles + Lymphatic SCIP Flap (Ciudad) | Lymphedema Surgery | Reported combined excision and lymphatic SCIP reconstruction for advanced penoscrotal disease. |
| Complete Functional Lymphatic-System Pedicled Transfer (Abdelfattah) | Lymphedema Surgery | Advanced scrotal / penoscrotal lymphedema; single pedicled SCIP flap resurfaces scrotum and penis. |
| Lymphatic System Transfer (LYST) — SCIP with Lymph Nodes + Afferent Vessels | Lymphedema Surgery | Reported lymphatic transfer approach; genital indications and comparative benefit require careful verification. |
| Suction-Assisted Protein Lipectomy (SAPL / Liposuction) | Lymphedema Surgery | Solid adipose/fibrotic component of late ISL Stage II–III extremity lymphedema; limited genital role. |
| BLOOM — Bariatric + VLNT (Sim) | Lymphedema Surgery | Reported combined bariatric and lymphatic operation; not an established genital-specific pathway. |
| Giant Penoscrotal Lymphedema (Elephantiasis) | Combined / Salvage | Advanced genital disease: individualized conservative care, excision and selected reconstruction. |
| Total Penis-Scrotum-Lower-Abdominal-Wall VCA (Johns Hopkins / GUVCA) | Combined / Salvage | Total external genital plus lower abdominal-wall loss in highly selected GUVCA candidates. |
References
1. Karian LS, Chung SY, Lee ES. Reconstruction of defects after Fournier gangrene: a systematic review. Eplasty. 2015;15:e18. Full text.
2. 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.
3. 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
4. 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
5. Hayon S, Michael J, Coward RM. The modern testicular prosthesis: patient selection and counseling, surgical technique, and outcomes. Asian J Androl. 2020;22(1):64–69. doi:10.4103/aja.aja_93_19
6. 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
7. 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
8. Executive Committee of the International Society of Lymphology. The Diagnosis and Treatment of Peripheral Lymphedema: 2023 Consensus Document. Lymphology. 2023;56:133–151. Consensus. doi:10.2458/lymph.6372
9. Guiotto M, Bramhall RJ, Campisi C, Raffoul W, di Summa PG. A systematic review of outcomes after genital lymphedema surgery: microsurgical reconstruction versus excisional procedures. Ann Plast Surg. 2019;83(6):e85–e91. doi:10.1097/SAP.0000000000001875
10. Atwater BL, Kirkik D, Wilson SK, et al. Short-term revision rate of Rigicon Testi10™ testicular prosthesis in adolescents and adults: a retrospective chart review. Int J Impot Res. 2025;37(4):303–309. doi:10.1038/s41443-024-00893-8
11. European Association of Urology. Urological Infections Guidelines. 2026. Section 3.13: Fournier's gangrene. Guideline.
12. 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
13. Schifano N, Castiglione F, Cakir OO, et al. Reconstructive surgery of the scrotum: a systematic review. Int J Impot Res. 2022;34(4):359–368. doi:10.1038/s41443-021-00468-x
14. 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
15. 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
16. Lee SH, Rah DK, Lee WJ. Penoscrotal reconstruction with gracilis muscle flap and internal pudendal artery perforator flap transposition. Urology. 2012;79(6):1390–1394. doi:10.1016/j.urology.2012.01.073
17. 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
18. Singh M, Kinsley S, Huang A, et al. Gracilis flap reconstruction of the perineum: an outcomes analysis. J Am Coll Surg. 2016;223(4):602–610. doi:10.1016/j.jamcollsurg.2016.06.383
19. 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
20. 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
21. Tarasconi A, Perrone G, Davies J, et al. "Anorectal emergencies: WSES-AAST guidelines." World J Emerg Surg. 2021;16:48. doi:10.1186/s13017-021-00384-x.
22. Orhan E, Şenen D. "Using negative pressure therapy for improving skin graft taking on genital area defects following Fournier gangrene." Turk J Urol. 2017;43(3):366–370. doi:10.5152/tud.2017.92845
23. Wimmer L, Fankhauser CD, Mattei A, Schneidewind L, Aschwanden FJ. "The Forgotten Suffering of Patients who Survived Fournier’s Gangrene: A Systematic Review of Long-term Outcomes and Quality of Life Impairment." Eur Urol Focus. 2026;12(3):576–579. doi:10.1016/j.euf.2026.04.002