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Scrotal Reconstruction

Scrotal reconstruction aims for durable, comfortable coverage that protects the testes and preserves function. The repair is chosen from the viable tissue, closure tension, defect depth and extent, contamination, prior treatment and patient goals. Schifano's systematic review found that primary tension-free closure and local pedicled flaps allow good outcomes for most scrotal defects, and that STSG or distant flaps are needed only for extensive skin loss.[1]

Anatomy that changes the plan​

The scrotal wall contains thin, elastic skin and dartos, a layer that carries smooth muscle and the arterial network. The deeper coverings are the external spermatic fascia, cremasteric muscle and fascia, internal spermatic fascia and tunica vaginalis, then the tunica albuginea of the testis itself. Viable coverings are preserved, and cord or testicular dissection is kept to what is needed.[2][3]

Carrera's study of 15 male cadavers described two lateral cutaneous territories supplied by the inferior external pudendal arteries and a central territory supplied by continuations of the perineal arteries. The central arteries reach the scrotum posteriorly and run deeply on both sides of the septum. The three territories are widely inter-anastomosed, which supports reliable median island scrotal flaps. Infected or extensively undermined tissue can still become ischemic.[4]

Scrotal skin has overlapping regional sensory supply. Karaçal used proximally based neurovascular pudendal-thigh flaps for 10 scrotal defects (up to 20 × 15 cm), and Mopuri's modified pudendal-thigh flap gave protective sensation.[5][6]

Assess the cause before choosing coverage​

ContextMain planning issue
Fournier's gangreneResuscitation, urgent source control and complete debridement precede definitive coverage.
Trauma or burnsAssess viability of the testes, cords, urethra and remaining skin, and preserve salvageable tissue.
Cancer resectionCoordinate margins, pathological assessment and reconstructive timing with the oncological plan.
Genital lymphedemaSeparate fluid swelling from fibrotic and fatty tissue, and assess the lymphatic problem as well as the skin defect. Resected massive localized lymphedema has weighed up to 61 kg.
Hidradenitis suppurativaCombine medical and surgical disease control.[7]
Gender-affirming scrotoplastyPlan labia majora tissue, urethral work, perineal closure and implant staging together.
Webbing or bothersome laxityEstablish functional symptoms and goals. Techniques and outcome evidence differ from postinfectious reconstruction.

Choosing the reconstruction​

Primary closure or local scrotal advancement​

Remaining healthy scrotal tissue is used when it reaches without excessive tension or compromise of perfusion. Some large defects close because of skin redundancy, and smaller defects with scarring or poor tissue may not. The commonly cited 50% threshold comes from review recommendations and case series.[17] The EAU Fournier section cites a systematic review of 16 case series that recommended primary or secondary wound closure for scrotal defects up to 50%, and flaps or skin grafts for defects larger than 50% or extending beyond the scrotum (level of evidence 3).[2][17]

Mobilization is limited to what is needed, in the plane that preserves the skin–dartos blood supply. Septal division, gubernacular division and upward relocation of the testes are options. If closure would compress the contents or endanger the blood supply, another method is chosen. Small suitable wounds may heal by secondary intention, accepting prolonged healing, contraction and deformity.[2] See Scrotal Primary Closure for the maneuvers and outcome series.

Split-thickness skin graft​

A graft is an established option for an extensive superficial defect with a well-vascularized recipient surface. Viable spermatic coverings or an appropriately prepared granulating surface may support a graft.[2][10][3] The actual bed is assessed while the underlying structures are protected.[2][10][3]

Hayon described a technique in 10 patients after necrotizing fasciitis. Orchidopexy with interrupted Vicryl followed the initial debridement, with cord mobilization and coiling of redundant cord under the abdominal wall. A graft 18/1000 inch thick and meshed 2:1 was applied once no further debridement was planned, and a bolster was sutured on for 5 to 7 days. At median 8 months there was no chronic pain, discomfort or need for further intervention. These parameters come from Hayon’s 10-patient series.[11]

Tan preserved viable spermatic fascia, sutured the testes together with broad contact so the fascial layers fused into a single sac, and applied a wrap-around STSG. In 27 patients, 66% had thin, pliable scrotums that closely mimicked the original and 18% had well-formed sacs with slight adhesions.[10] These are selected operative approaches.

See Scrotal STSG and STSG principles.

Regional flap​

A flap suits a bed that cannot support a graft, substantial dead space, or a deeper or combined perineal defect that needs durable vascularized coverage. The pedicle, thickness and tissue components are chosen for the defect and the available donor tissue.[12][2]

Alammar's 2026 systematic review pooled 107 reports covering 619 patients and 625 flaps after Fournier's gangrene. Medial thigh, pudendal-thigh, ALT and gracilis flaps were used most, and regional flaps were used far more often than free tissue transfer. The indications were coverage of exposed vital structures (52%), functional restoration (39%) and cosmesis (4%). Flap loss was reported in 1.6% of cases. Standardized functional and cosmetic measures were rarely used.[12]

FlapReported experience
Pudendal-thigh (Singapore)Mopuri's modified flap in 5 patients gave a natural-looking neoscrotum with protective sensation. Karaçal's neurovascular flaps in 10 defects closed all donor areas primarily.[5][6]
Medial thigh and gracilisLocal tissue for advancement or a planned vascular flap. Muscle fills dead space or covers exposed structures.[12]
Island groinSahai reported 29 single island-groin-flap reconstructions (25 Fournier cases and 4 avulsions) over about 30 years, including defects larger than 50%. The authors separately described using a groin flap plus two superior medial pedicle thigh flaps for total scrotal loss; those combined-flap cases were outside the 29-case series.[28]
ALTA fasciocutaneous flap that can be thinned, and one of the most common in Alammar's review.[12]
SCIPThree post-Fournier patients (largest defect 22 × 10 cm) all had surviving flaps without significant complications.[13]

SCIP-lymphatic transfer for lymphedema serves a different purpose from skin coverage after infection. Abdelfattah's 26 patients had 100% flap survival and fewer cellulitis episodes.[14] See Scrotal Flaps.

Testicular thigh pouches​

Temporary or definitive relocation is considered when immediate scrotal coverage is unsuitable or when a patient chooses it after counseling. Cord tension, compression and twisting are avoided. Discomfort, altered appearance, access to the testes and uncertain long-term reproductive effects are discussed.[2][15][16]

Okwudili's 12 patients had more than 50% scrotal skin loss.[15] The testes went into anteromedial thigh pouches and were massaged back into the residual scrotum over 3 to 8 months.[15] Testicular volume was maintained (mean 19.0 cm³). Staniorski's 20 patients had definitive pouches with fasciocutaneous perineal closure.[16] Perineal closure was achieved in all 20, with three also needing abdominal STSG to complete closure; one reported pouch pain, and none requested elective scrotoplasty at median 9 months.[16]

Karian's review cites a series in which all 26 thigh pouches and 4 orchiectomies were rated aesthetically unsatisfactory.[2] See Testicular Thigh Pouches.

Fournier's gangrene: sequence​

  1. Treat the emergency. Give broad-spectrum antibiotics, resuscitate and obtain urgent surgical source control. The EAU guideline strongly recommends starting broad-spectrum antibiotics on presentation and repeated debridement within 24 hours of presentation. Debridement repeats as required, and an uncertain diagnosis does not delay exploration when suspicion is high.[17][18] 2.[2] Reassess viability and contamination. Preserve living structures while removing necrotic tissue. For extensive genital skin loss or injury from infection, shearing, or burns, AUA Statement 31 advises exploration and limited debridement of clearly nonviable tissue (Standard, Grade B).[29] Urinary and fecal diversion are assessed individually with the relevant team. 3.[17][18][2] Choose definitive coverage when the patient and wound are ready. Timing follows source control, tissue viability and reconstructive requirements.[17][18][2]

NPWT can help manage a selected wound after adequate debridement. In Iacovelli's retrospective 92-patient cohort, 14 patients with disseminated disease received NPWT and 16 received conventional dressings; NPWT was associated with higher 10-week wound closure in that subgroup (age- and sex-adjusted OR 6.5, 95% CI 1.1–37.4).[19] Among patients treated with conventional dressings, 90-day survival was 55% with disseminated disease versus 90% with localized disease; the disseminated/no-NPWT group had the lowest survival among all four groups (age- and sex-adjusted HR 3.4, 95% CI 1.1–10.4).[19] The EAU Fournier section found no evidence of benefit for NPWT (level of evidence 4) and gives a weak recommendation against adjunctive treatments outside clinical trials.[17] Its literature search ended in July 2017.[19][17]

See Fournier's Gangrene for the full acute pathway.

Genital lymphedema​

The plan combines skin care, decongestive treatment where appropriate, management of the cause and selected surgery. Excision relieves disabling advanced fibrotic disease, and physiological procedures may suit selected lymphatic anatomy.[9]

Torio-Padron's retrospective 51-patient program combined perioperative decongestive therapy with tailored resection and primary closure. Of the 51 patients, 49 had scrotal or penoscrotal disease and two had penile-only disease. All defects were covered with adjacent healthy skin rather than grafts or separate regional flaps; three complications (two hematomas, one dehiscence) required revision, and five patients later underwent surgery for scrotal disease recurrence.[20] In Wisenbaugh's 11-patient massive-localized-lymphedema series (mean BMI 60, mean resected weight 21 kg), 10 closed primarily.[21] Wound complications were common, quality-of-life scores rose from 1.3 to 7.7, and most patients gained weight afterward (mean +5.2 kg).[20][21]

Ehrl treated nine patients, eight with giant disease and one with pitting edema. Five received additional VLNT into the groin or scrotum. No recurrence was reported among Ehrl's nine treated patients at median 49 months, including those without VLNT; the two patients who received VLNT into the scrotum showed improved scrotal lymphatic transport on imaging three to four months after surgery.[22] Donor-site lymphedema is discussed as a morbidity of lymphatic transfer.[22][9]

See Excision and Reconstruction for Lymphedema and Complex Decongestive Therapy.

Gender-affirming and elective scrotoplasty​

The labia majora are the embryological homologues of the scrotum and a common source for scrotoplasty. Their vascularity and position are planned with any urethral lengthening, phalloplasty and perineal reconstruction.[8]

Pigot described a technique for scrotoplasty without urethral lengthening, reported in one 29-year-old patient. A pedicled horseshoe-shaped pubic flap, the clitoral hood and U-shaped labia majora flaps are used. The cranially pedicled labia majora flaps are rotated 90° medially to bring the neoscrotum in front of the legs, and pedicled labia majora fat pads are relocated into it for bulk. The meatus and vaginal orifice are diverted under the scrotum with a perineostomy. This modification applies to surgery without urethral lengthening.[23]

Miller reported 147 scrotoplasties with bilateral labia majora rotational advancement flaps, 133 of them with single-stage phalloplasty (mean follow-up 12.5 months). Distal flap necrosis occurred in 6 (4.1%), 5 of them ipsilateral to the groin dissection for phalloplasty. Large (more than 1 cm) perineoscrotal dehiscence occurred in 7 (4.7%). Three patients developed urethrocutaneous fistulas requiring repair. Two scrotal (1.4%) and three perineal (2.0%) hematomas all required operative treatment.[8]

Selvaggi described more than 300 scrotal reconstructions with V-Y advancement of the labia majora and rotation of superiorly based labial flaps. A testicular implant and erection prosthesis were placed 12 months after the original operation. Implant timing depends on healing, available space, concurrent procedures and patient preference.[24] See the masculinizing surgery pathway.

For bothersome laxity or webbing, excision, advancement or Z-plasty may be considered after individualized assessment. Thomas and Navia's systematic review found only 11 eligible articles, mostly case reports and technique descriptions. They propose vertical midline scrotal skin resection for scrotomegaly and a penoscrotal junction Z-plasty for webbing, alone or combined with penile prosthesis implantation.[25][1] In a separate pediatric series of 100 Z-plasties, 69 involved hypospadias repair or revision, 10 chordee correction and 21 other reconstructions; 98% achieved primary flap healing.[26] The number done for webbing was not reported separately, and the series provides no adult outcomes.[26]

Fertility, function and follow-up​

At two months in Demir’s rat experiment, grafted animals had lower testicular weight and Johnsen scores than untreated controls and lower germinal-epithelium height than both controls and flap-reconstructed animals; flap-reconstructed animals had testicular measures comparable with controls.[27] The authors suggested flaps as the first choice.[27] No human comparative study shows that flaps preserve fertility better than grafts, and objective reproductive outcomes remain sparse.[2] In young patients with fertility concerns, flap reconstruction is one option to discuss, based on this animal evidence.

Fertility goals are discussed before major reconstruction, with semen assessment or reproductive consultation when appropriate. Follow-up covers healing, pain, mobility, sensation, sexual function, appearance and disease recurrence. Infection, hematoma, threatened perfusion, graft or flap loss and urinary complications are evaluated by severity.[1][8][9]

Complications​

These rates come from different operations and populations, including combined gender-affirming reconstruction, Fournier flap reconstruction and lymphedema excision. Each rate applies to its cited cohort.[8][12][21]

ComplicationReported frequencyManagement
Wound complicationsCommon after lymphedema excision (Wisenbaugh)Local wound care.[21]
Hematoma1.4% scrotal and 2.0% perineal (Miller)Operative evacuation in that series.[8]
Flap necrosis or loss4.1% distal labia majora flap necrosis in Miller’s 147 scrotoplasty/perineal reconstruction cases (133 with concurrent phalloplasty); 1.6% flap loss across Fournier flap reconstructions in Alammar’s reviewConservative management or debridement.[8][12]
Perineoscrotal dehiscence4.7% (Miller)Mostly conservative.[8]
Urethrocutaneous fistula3 of 147 (Miller)Surgical repair.[8]
Impaired spermatogenesisAnimal data with graftsDiscuss reproductive goals.[27]
Lymphedema recurrenceNone at median 49 months (Ehrl, n = 9)Small uncontrolled series.[22]

Outline of the approach​

  1. Acute phase. Stabilize the patient and debride nonviable tissue. In Fournier’s gangrene, start broad-spectrum antibiotics on presentation and begin repeated debridement within 24 hours; reassess for further necrosis. NPWT, if selected after adequate source control, has unproven benefit in Fournier’s gangrene.[17][19] 2.[2] Defect assessment. Consider primary closure or local scrotal advancement when viable tissue reaches without excessive tension or perfusion compromise.[2] Larger defects with a vascularized bed may be grafted. Exposed vital structures without a suitable graft bed, deep dead space or combined defects favor a flap. If immediate coverage is unsuitable, temporary thigh pouches are an option.[2][17] 3.[17][18][2] Special settings. Lymphedema needs decongestive therapy and excision, with or without VLNT. Gender-affirming scrotoplasty uses labia majora flaps.[8][20][22]

See Also​

References​

1. 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

2. Karian LS, Chung SY, Lee ES. Reconstruction of defects after Fournier gangrene: a systematic review. Eplasty. 2015;15:e18. Full text.

3. 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.

4. Carrera A, Gil-Vernet A, Forcada P, et al. "Arteries of the scrotum: a microvascular study and its application to urethral reconstruction with scrotal flaps." BJU Int. 2009;103(6):820–824. doi:10.1111/j.1464-410X.2008.08167.x

5. Karaçal N, Livaoglu M, Kutlu N, Arvas L. "Scrotum reconstruction with neurovascular pedicled pudendal thigh flaps." Urology. 2007;70(1):170–172. doi:10.1016/j.urology.2007.03.049

6. 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

7. Hamad J, McCormick BJ, Sayed CJ, et al. "Multidisciplinary update on genital hidradenitis suppurativa: a review." JAMA Surg. 2020;155(10):970–977. doi:10.1001/jamasurg.2020.2611

8. Miller TJ, Lin WC, Safa B, Watt AJ, Chen ML. "Transgender scrotoplasty and perineal reconstruction with labia majora flaps: technique and outcomes from 147 consecutive cases." Ann Plast Surg. 2021;87(3):324–330. doi:10.1097/SAP.0000000000002602

9. 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

10. Tan BK, Rasheed MZ, Wu WT. "Scrotal reconstruction by testicular apposition and wrap-around skin grafting." J Plast Reconstr Aesthet Surg. 2011;64(7):944–948. doi:10.1016/j.bjps.2010.11.013

11. 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

12. 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

13. BS S, Khanna A, Taylor D. "Pedicled superficial circumflex iliac artery perforator (SCIP) flap for perineo-scrotal reconstruction following Fournier's gangrene." ANZ J Surg. 2023;93(1-2):276–280. doi:10.1111/ans.18066

14. 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

15. 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

16. 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

17. European Association of Urology. Urological Infections Guidelines. 2026. Section 3.13: Fournier's gangrene. Guideline.

18. 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

19. Iacovelli V, Cipriani C, Sandri M, et al. "The role of vacuum-assisted closure (VAC) therapy in the management of Fournier's gangrene: a retrospective multi-institutional cohort study." World J Urol. 2021;39(1):121–128. doi:10.1007/s00345-020-03170-7

20. 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

21. 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

22. Ehrl D, Heidekrueger PI, Giunta RE, Wachtel N. "Giant penoscrotal lymphedema — what to do? Presentation of a curative treatment algorithm." J Clin Med. 2023;12(24):7586. doi:10.3390/jcm12247586

23. Pigot GL, Al-Tamimi M, van der Sluis WB, et al. "Scrotal reconstruction in transgender men undergoing genital gender-affirming surgery without urethral lengthening: a stepwise approach." Urology. 2020;146:303. doi:10.1016/j.urology.2020.09.017

24. Selvaggi G, Hoebeke P, Ceulemans P, et al. "Scrotal reconstruction in female-to-male transsexuals: a novel scrotoplasty." Plast Reconstr Surg. 2009;123(6):1710–1718. doi:10.1097/PRS.0b013e3181a659fe

25. Thomas C, Navia A. "Aesthetic scrotoplasty: systematic review and a proposed treatment algorithm for the management of bothersome scrotum in adults." Aesthetic Plast Surg. 2021;45(2):769–776. doi:10.1007/s00266-020-01998-3

26. Álvarez Vega DR, Mendelson JL, Gitlin JS, Joshi P, Hanna MK. "Optimizing pediatric genital reconstruction: the role of Z-plasty in enhancing aesthetic and functional outcomes." Urology. 2025;204:186–191. doi:10.1016/j.urology.2025.06.011

27. 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

28. 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

29. Morey AF, Broghammer JA, Hollowell CMP, et al. Urotrauma Guideline 2020: AUA Guideline. J Urol. 2021;205(1):30–35. doi:10.1097/JU.0000000000001408. Full guideline, published 2014; amended April 2017 and August 2020.