Scrotal Reconstruction
This page hosts the Decision Framework and Treatment Database for scrotal reconstruction — Fournier's gangrene, scrotal-genital lymphedema, AABP with scrotal involvement, trauma, oncologic excision, hidradenitis suppurativa, congenital anomaly, aesthetic concerns, and post-orchiectomy prosthetic placement.
For technique-level deep-dive on Fournier's, MLL/VLNT, GAS scrotoplasty, aesthetic, and testicular thigh pouches, see Scrotal Reconstruction Techniques.
Decision Framework
The scrotum is highly elastic and redundant — up to 50% of the scrotum can be resected and closed primarily because of the inherent laxity provided by the dartos fascia and rugated skin.[3] When grafts are required, they must be applied to the tunica vaginalis of the spermatic cord (an excellent graft bed); grafting to the dartos fascia or directly to the tunica albuginea of the testis produces poor take and an unnatural fixed appearance.[3][4] The contemporary anchors are the Schifano 2022 Int J Impot Res systematic review of scrotal reconstruction, the Hayon 2021 orchidopexy + STSG framework for post–Fournier's-gangrene defects, the Alammar 2026 Burns SR of flap reconstruction after Fournier's gangrene (n = 625 flaps; flap-loss rate only 1.6%), the Sahai 2021 30-year island-groin-flap series (n = 29), the Mopuri 2016 modified-pudendal-thigh-flap series, the Lee 2012 combined gracilis + internal pudendal-artery-perforator series, the Singh 2016 gracilis-perineum complication-rate analysis (obesity OR 7.5; smoking OR 9.3), the Abdelfattah 2023 SCIP complete-functional-lymphatic-system pedicled transfer (n = 26 advanced genital lymphedema; 100% flap survival; cellulitis dramatically reduced), the Wisenbaugh 2018 massive-localized-lymphedema (MLL) series (mean +5.2 kg post-op weight gain despite excision; QoL 1.3 → 7.7), the McDermott 2024 JAMA Surg NSTI review (NPWT lower mortality, no LOS difference), the Hayon 2020 modern-testicular-prosthesis review, the Atwater 2025 Rigicon Testi10™ saline series (Kaplan-Meier survival 99.8% at 54 months), and the Thomas 2021 aesthetic-scrotoplasty SR + algorithm.[3][4][5][2][6][7][8][9][10][11][12][13][14][15]
Assess Clinical Context
| Variable | Sub-Categories |
|---|---|
| Etiology | Fournier's gangrene (most common) / scrotal-genital lymphedema / AABP with scrotal involvement / trauma (avulsion, degloving, burns) / oncologic excision (extramammary Paget's, SCC) / hidradenitis suppurativa / congenital (bifid scrotum, penoscrotal transposition) / aesthetic (laxity, penoscrotal web) / post-orchiectomy (intact skin, absent testis) |
| Defect extent | ≤50% (primary closure feasible) / >50% with adequate wound bed (graft) / >50% with exposed structures (flap) / total scrotal loss (combined flaps or thigh pouches) |
| Wound-bed quality | Clean / granulating / contaminated / actively infected / irradiated |
| Testes status | Present + viable + accessible / present but exposed / absent (post-orchiectomy) / damaged or atrophic |
| Concurrent defects | Penile shaft loss / perineal extension (Fournier's) / abdominal-wall involvement / lymphedema-related upper-leg or pubic disease |
| Patient factors | BMI, diabetes, smoking, immunosuppression, fertility goals, mobility (sitting tolerance for thigh pouches) |
Reconstructive Goals
Three explicit functional goals govern technique selection:[3]
- Natural scrotal appearance — restoration of bilateral hemiscrotal contour and rugation.
- Testes easily palpable — preserves lifelong cancer self-examination; thigh pouches impair this and should be reserved for selected indications.
- Testes mobile enough to avoid pain or discomfort with sitting — thigh-pouch testes should be positioned anteriorly when used, to avoid posterior-pressure pain.
Technique Selection by Defect Size and Wound Bed
| Clinical Scenario | First-Line | Alternative(s) | Avoid |
|---|---|---|---|
| Defect ≤50%, clean wound bed | Primary closure with septum division + dartos mobilization off tunica vaginalis + gubernaculum division + spermatic-cord mobilization with superior testis repositioning at penoscrotal junction[3] | Local advancement flap | Closure under tension causing testicular displacement |
| Defect >50%, clean granulating bed | STSG (meshed 2:1, depth 0.046 cm / 0.018″) on the tunica vaginalis after 1–2 weeks of granulation[3][4] | Pudendal-thigh flap (Mopuri 2016)[11]; island groin flap (Sahai 2021 — 30-yr experience, n = 29) | Grafting onto dartos fascia or directly onto tunica albuginea of testis (fixed, unnatural appearance) |
| Defect >50% with exposed corpora / cord / urethra | Regional pedicled flap — pudendal-thigh / island-groin / gracilis myofasciocutaneous / ALT (Alammar 2026 SR — flap-loss rate 1.6% across n = 625) | Combined gracilis + IPAP flap (Lee 2012; defects up to 30 × 15 cm covered; 100% flap survival) | STSG over exposed cord or testis |
| Total scrotal loss | Combined flaps — groin flap + bilateral superior-medial pedicle thigh flaps (Sahai 2021) | Definitive testicular thigh pouches + fasciocutaneous perineal closure (Staniorski 2023; 100% perineal closure; 0% elective scrotoplasty desire at 9 mo) | Testicular thigh pouches in patients prioritizing palpability and natural appearance |
| Genital / scrotal lymphedema (advanced) | Radical excision + primary closure ± SCIP lymphatic flap (SCIP-LFT) to restore lymphatic transport (Abdelfattah 2023 n = 26; 100% flap survival; cellulitis dramatically reduced)[1][10] | Excision + STSG on tunica vaginalis | Excision alone in patients with persistent lymphatic obstruction (recurrence) |
| Massive localized lymphedema (MLL) of scrotum | Excision + closure with comprehensive weight-loss program — Wisenbaugh 2018 documents mean +5.2 kg post-op weight gain despite excision; QoL 1.3 → 7.7[8] | SCIP-LFT for residual lymphatic obstruction | Excision alone without metabolic / weight intervention |
| Post-orchiectomy with intact scrotal skin | Testicular prosthesis — saline (Rigicon Testi10™ 99.8% Kaplan-Meier at 54 mo; Atwater 2025) or silicone (96.1% satisfaction; 25.5% report "too firm")[13][14] | Combined orchiectomy + immediate intravaginal prosthesis exchange (Bush 2012)[16] | Routine deferred prosthesis when immediate placement is feasible (only ~⅓ of offered men accept; offering rate is the dominant gap) |
| Aesthetic — bothersome scrotal laxity / penoscrotal webbing | See Male Cosmetic Genital Surgery for reduction scrotoplasty, penoscrotal-web Z-plasty, Bagnara V-I reconfiguration, and Borsellino raphe approach | — | Aesthetic-only intervention without addressing concurrent buried-penis or lymphedema disease |
Graft vs Flap vs Thigh-Pouch Sub-Comparison
| Factor | STSG | Pedicled Flap | Testicular Thigh Pouch |
|---|---|---|---|
| Wound-bed requirement | Clean, well-granulated tunica vaginalis | Tolerates contaminated / exposed-structure beds | Bypasses need for scrotal coverage entirely |
| Defect size | Moderate (>50% but not total) | Large to total | Total scrotal loss / staged bridge |
| Spermatogenesis preservation | Inferior (animal data — Demir 2012)[17] | Superior — comparable to native scrotum | Comparable to native (testes intact) |
| Thermoregulation | Not restored (no dartos / cremaster) | Partially restored (muscle bulk insulation) | Native (testes in thigh subcutaneous tissue) |
| Cancer self-examination | Preserved | Preserved | Impaired — testes not in scrotal position |
| Sitting tolerance | Native | Native | Pain risk if testes positioned posteriorly — anterior placement preferred[3] |
| Surgical complexity | Lower | Higher | Lower (temporary) / Moderate (definitive) |
| Donor-site morbidity | Minimal (thigh harvest) | Variable (gracilis 12.5–14% donor; recipient 22–40%; obesity OR 7.5 / smoking OR 9.3 — Singh 2016)[9] | Minimal |
| Best evidence | Hayon 2021 n = 10 (no chronic pain at 8 mo; acceptable cosmesis); Ye 2015 NPWT pre-/post-graft (98% take)[4][18] | Alammar 2026 SR n = 625 (1.6% flap loss); Sahai 2021 30-yr groin flap (n = 29); Mopuri 2016 pudendal-thigh n = 5; Lee 2012 gracilis + IPAP n = 7 (100% survival)[2][5][11][19] | Okwudili 2016 temporary n = 12 (all expanded sufficiently; no mortality); Staniorski 2023 definitive n = 20 (100% perineal closure; 0% elective scrotoplasty desire)[20][21] |
Fournier's-Gangrene-Specific Phased Algorithm
| Phase | Intervention | Notes |
|---|---|---|
| Phase 1 — Acute | Aggressive surgical debridement (often serial returns to OR); broad-spectrum antibiotics; fecal diversion (colostomy or Flexi-Seal) when perineum involved[22]; NPWT once wound stable[12] | Early NPWT may interfere with wound checks — withhold until repeat-debridement window closes |
| Phase 2 — Wound-bed preparation | NPWT for granulation 1–2 weeks; orchidopexy to mobilize and secure testes[4][18] | Coil redundant cord under abdominal wall; bring testes together with interrupted sutures |
| Phase 3 — Definitive reconstruction | Defect-size-driven choice (Step 3 matrix). NPWT post-graft secures STSG and improves take to ~98%[18] | Anaerobic-NSTI caveat: NPWT may be less effective; monitor for increased debridement / readmission[12] |
Concurrent Procedures
Scrotal reconstruction is rarely isolated:[3][4][21]
- Orchidopexy — required in nearly all cases with exposed testes; secures testes in optimal position before grafting or flap coverage.
- Penile shaft reconstruction — combined penoscrotal reconstruction is common in AABP, Fournier's gangrene, and lymphedema (cross-link to Penile Reconstruction).
- Perineal reconstruction — fasciocutaneous-flap closure of perineum when scrotal and perineal defects coexist.
- Fecal diversion — colostomy or Flexi-Seal in Fournier's gangrene with perineal involvement.
- Testicular prosthesis — simultaneous with orchiectomy or staged; intravaginal placement at orchiectomy provides orthotopic positioning.
Postoperative Management & Surveillance
- Bolster dressing for STSG: petrolatum gauze + cotton gauze (mineral-oil-soaked) + dry gauze, sutured to scrotum × 5–7 days to prevent shear.[4]
- NPWT for staged complex wounds: continue until wound bed is stable; transition to grafting or flap coverage.[12]
- Wound-dehiscence rate is high in obese / Fournier's / lymphedema cohorts — managed with local wound care without need for reoperation in most cases.[8]
- Weight-management counseling for MLL — comprehensive plan should accompany surgery (Wisenbaugh 2018: mean +5.2 kg post-op weight gain despite excision).[8]
- Quality-of-life monitoring — QoL scores rise from 1.3 → 7.7 on 10-point scale after MLL excision; documented improvement in sexual / urinary / mobility domains.[8]
- Lifelong testicular self-examination — counsel patients with native scrotal coverage to perform monthly self-exam; testes in thigh pouches lose this surveillance benefit.[3]
Treatment Database
| Procedure | Domain | Best for / indication |
|---|---|---|
| Primary Closure (≤50% scrotal skin loss) | Primary Closure | ≤ 50% scrotal loss — exploit native dartos elasticity. |
| Scrotal Skin Grafting (STSG / FTSG) | Skin Graft | > 50% scrotal loss with clean granulating bed; FTSG for selective penile resurfacing. |
| Scrotal Flap Reconstruction (all flap families) | Flap Reconstruction | > 50% scrotal loss or exposed vital structures unsuitable for grafting. |
| Testicular Thigh Pouch (Temporary, Definitive, or Hiawatha Neoscrotum) | Testicular Thigh Pouch | Extensive scrotal loss not suitable for graft or flap; temporary bridge or definitive neoscrotum. |
| Testicular Prosthesis (Saline / Silicone, all ages and indications) | 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 | Foundation therapy across all genital-lymphedema stages and perioperative optimization. |
| Lymphaticovenous Anastomosis (LVA) | Lymphedema Surgery | Compression-refractory genital lymphedema with functional residual lymphatics. |
| Vascularized Lymph Node Transfer (VLNT) into Scrotum / Groin | Lymphedema Surgery | Sclerosed lymphatics or giant penoscrotal lymphedema; LVA-ineligible cases. |
| Debulking Scrotoplasty (Excision + Primary Closure) | Lymphedema Surgery | Genital lymphedema with ≤ 50% scrotal skin diseased; primary closure after excision. |
| Modified Charles Procedure (Excision + STSG) | Lymphedema Surgery | Severe genital lymphedema / elephantiasis when lymphatic-reconstruction expertise unavailable. |
| 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 | ISL Stage III penoscrotal lymphedema; combined Charles excision with lymphatic SCIP flaps. |
| 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 | Lymphedema with concomitant chronic venous disease. |
| 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 | Concurrent obesity and lymphedema; combined sleeve gastrectomy with gastroepiploic VLNT. |
| Giant Penoscrotal Lymphedema (Elephantiasis) — Curative Algorithm | Combined / Salvage | End-stage ISL III giant penoscrotal lymphedema; integrated excision plus lymphatic 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. Yamamoto T, Daniel BW, Rodriguez JR, et al. Radical reduction and reconstruction for male genital elephantiasis: superficial circumflex iliac artery perforator (SCIP) lymphatic flap transfer after elephantiasis tissue resection. J Plast Reconstr Aesthet Surg. 2022;75(2):870–880. doi:10.1016/j.bjps.2021.08.011
2. 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
3. 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
4. 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
5. 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
6. 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
7. 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
8. 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
9. 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
10. 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
11. 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
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. 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
14. 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
15. Thomas C, Navia A. Aesthetic scrotoplasty: systematic review and a proposed treatment algorithm for the management of bothersome scrotum in adults. Aesthet Plast Surg. 2021;45(2):769–776. doi:10.1007/s00266-020-01998-3
16. Bush NC, Bagrodia A. Initial results for combined orchiectomy and prosthesis exchange for unsalvageable testicular torsion in adolescents: description of intravaginal prosthesis placement at orchiectomy. J Urol. 2012;188(4 Suppl):1424–1428. doi:10.1016/j.juro.2012.02.030
17. 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
18. Ye J, Xie T, Wu M, Ni P, Lu S. Negative-pressure wound therapy applied before and after split-thickness skin graft helps healing of Fournier gangrene: a CARE-compliant case report. Medicine (Baltimore). 2015;94(5):e426. doi:10.1097/MD.0000000000000426
19. 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
20. 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
21. 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
22. Ozkan OF, Koksal N, Altinli E, et al. Fournier's gangrene current approaches. Int Wound J. 2016;13(5):713–716. doi:10.1111/iwj.12357