Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 1200e1203

A free scapular skin flap for penile reconstruction

H. Wang, S.K. Li*, M.Y. Yang, Y.Q. Li, Q. Li, W. Chen, Y.Q. Wang

Plastic Surgery Hospital, PUMC & CAMS, Beijing, China

Received 2 July 2006; accepted 5 March 2007

KEYWORDSFree scapular skin flap;Penile reconstruction

Summary Introduction: There are many possible methods for penis reconstruction, amongthem, pedicled flaps, myocutaneous flaps, combined osseocutaneous flaps, and free skin flaps.This study evaluated the free scapular skin flap method for penile reconstruction.Methods: Fifteen men aged 20 to 48 underwent the procedure between March 2000 andFebruary 2006, with follow-up examinations from 6 months to 5 years.Results: Fourteen of the reconstructions were successful, with patients enjoying goodcosmetic results as well as functionality.Conclusion: The free scapular skin flap technique is a good method for penile reconstruction.ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Publishedby Elsevier Ltd. All rights reserved.

Penis reconstruction using a free scapular skin flap isa practical method with a simple technique, excellentconfiguration, good function and less secondary deformityof the donor site. Between March 2000 and February 2006,15 patients underwent penis reconstruction by transferringa scapular free flap with implanting a malleable penileprosthesis. Good cosmetic and functional results wereachieved.

Methods

Before surgery, the flap must be designed. First, thecircumflex scapular artery must be marked. The flap is

* Corresponding author. Address: Department of South 2, PlasticSurgery Hospital, PUMC & CAMS, BaDaChu Road, ShiJingShan Bor-ough, 100041 Beijing, People’s Republic of China. Tel.: þ86 1088703902; fax: þ86 10 68864137.

E-mail addresses: wanghao1117@sina.com, lisenkai@yahoo.com.cn (S.K. Li).

1748-6815/$-seefrontmatterª2007BritishAssociationofPlastic,Reconstrdoi:10.1016/j.bjps.2007.03.003

designed to be 12e14 cm in length and 14e16 cm in width,with the artery and its branch for axis. It includesthree parts; part A flap is 3.0e3.6 cm wide and is used forurethral reconstruction. Part B flap is 0.5e1.0 cm wideand is designated for the de-epidermis. Part C flap is 9e14 cm wide and is used to reconstruct the penis shaft(Fig. 1A, B).

The scapular skin is incised to the deep fascia accordingto the preoperation design. The flap is then lifted betweenthe fascia and muscular membrane to triangular space(Fig. 2). To make locating the scapular artery easier, it isimportant to cut the branch to the muscle and scapula.The scapular vessel should be dissected until the pedicleis 7 cm in length. The vessels are cut, the flap taken out,and the wound is covered by a split thickness skin grafttransplantation.

Now the operation begins on the recipient site. Theinferior epigastric vessel should be examined, and shouldbe cut near the rectus abdominis as distal as possible. Theadventita and periadventitial tissue should be excisedsharply.

uctiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

A free scapular skin flap for penile reconstruction 1201

The part B flap is used as de-epidermis for the gapbetween the reconstructed urethra and the penis body. Thepart A flap is overturned for the inner skin, and the part Cflap is also overturned for the penis shaft (Fig. 3). The distaledge of the part A flap is then sutured to that of the part Cflap to form a new urethral orifice. The new glans is recon-structed by local shaping (Fig. 4). The next step is anasto-mosis of the new partial urethra to the old urethralorifice with a Folly’s catheter in it. A malleable penile pros-thesis with silver silica gel is inserted into the reconstructedpenis. Its proximate part is fixed to the pubic periosteum.The donor vessel and receipt vessel are anastomosed usinga microsurgical technique. This closes the incision.

Figure 1 Design of flap.

Postsurgical procedures include 2 weeks of bed rest withthe penis elevated, frequent inspection of the flap, anti-coagulation medication and prevention of infection.

In obese patients, free skin graft or scrotal septum flapcan be used for urethral reconstruction to prevent a bigshaft or insufficient blood flow to the new urethra. Re-construction of the glans is achieved by split thickness skingraft transplantation in the distal part of penis.

Clinical results

Of the 15 procedures that were included in this study, 14were successful, with favourable cosmetic and functionalresults. One patient experienced failure due to venousthrombus, which was probably due at least in part to his 20-year smoking habit (Table 1).

Case 1

The patient, a 30-year-old, was burned 2 years ago byelectric shock. His penis was completely severed but hisscrotum, testicles and varicosity were left intact. It wasreadily apparent that the scar on his perineum had alreadybecome soft (Fig. 5). One year after undergoing penis re-construction with free scapular skin flap and a malleablepenile prosthesis implantation, he has satisfying erectionsand good cosmetic results, but he has not married (Figs. 6and 7).

Discussion

The advantages of the free scapular flap include ampletissue, invariable vessel direction, abundant blood supplyand less deformity. The scapula may be used for penis

Figure 2 Scapular skin flap.

Figure 3 Urethra reconstruction.

1202 H. Wang et al.

Figure 4 Penis shaping.

Table 1 Clinical information

Cases Success

Micropenis 2 2Infection 1 1Burn 8 8Self-inflicted penis cutting 4 3

Figure 5 Preoperation.

Figure 6 Postoperation 12 months.

support, but this study opted instead for a malleable penileprosthesis because of the difficulty of shaping bone. Theinferior epigastric vessel has a long pedicle, adequatediameter and invariable vessel direction, therefore it wasselected as the recipient vessel.

The sensory nerves of the scapular flap are the innerbranches of the posterior branches of two to four pectoralnerves. It is difficult to transfer the scapular flap withsensory nerves because they are detached from the vesselwith several branches. But this study revealed the flapregained sensitivity after 6 months. The extent of recoveryof sensitivity after was 3e4 cm below the top of the flap.The testing included perception of pain, feelings and two-point discrimination. Exploration is under way for a methodof scapular flap transplantation with neurovascular pedicle.

There are many methods for penis reconstruction.1e10

The forearm flap method, which is similar to the free scap-ular flap, is common but has some disadvantages, such asthin subcutaneous tissue, less tissue for transfer, thin re-constructed penis, lost forearm trunk vessel and reductionof muscular power. It is also inadequate for the patient withmore hair on the forearm. The advantage of the forearmflap is that it has good sensory nerves for its neurovascularpedicle.

Figure 7 Postoperation 12 months.

A free scapular skin flap for penile reconstruction 1203

Another method, the combined inguinal osseocutaneousflap, which is applied with a flap of pedicled superficialcircumflex iliac vessel combining iliac bone piece, has theadvantages of a hidden donor site and a simple procedurewith no microsurgical technique. But the combined flap hasdeficient blood supply for its vessel variation. The compli-cations include fat fluidity, infection and bone exposure.

Therefore the authors conclude that the free scapularflap is the preferred method for penile reconstruction.

References

1. Yang Mingyong, Li Shiyin, Li Senkai. Anatomical study forascending branch of circumflex scapular artery. Zhong HuaZheng Xing Shao Shang Wai Ke Za Zhi 1996;12:293e5.

2. Dabernig J, Shelley O, Cuccia G, et al. Urethral prelaminationin penile reconstruction with an osteo-cutaneous free fibularflap. J Plast Reconstr Aesthet Surg 2006;59:561e2.

3. Felici N, Felici A. A new phalloplasty technique: the free ante-rolateral thigh flap phalloplasty. J Plast Reconstr Aesthet Surg2006;59:153e7.

4. Hester TR, Hill HL, Jurkiewicz MJ. One-stage reconstruction ofthe penis. Br J Plast Surg 1978;31:279e85.

5. Chang TS, Huang WY. Forearm flap in one stage reconstructionof the penis. Plast Reconstr Surg 1984;74:251e8.

6. Biemer E. Penile construction by the radial arm flap. PlastReconstr Surg 1988;15:425e30.

7. Gilbert DA, Winslow BH, Gilbert DM, et al. Transsexual surgeryin the genetic female. Clin Plast Surg 1988;15:471e87.

8. Castro RB, Oliveira AB, Favorito LA. Utilization of skin flap forreconstruction of the genitalia after an electric burn. Int Braz JUrol 2006;32:68e9.

9. Seftel A. Penis reconstruction using three different operativemethods. J Urol 2005;174:2299.

10. Hu ZQ, Hyakusoku H, Gao JH, et al. Penis reconstruction usingthree different operative methods. Br J Plast Surg 2005;58:487e92.