Restoration of Glans Penis Defect by a Bipedicled Foreskin Flap
Pin-Keng Shih, M.D.*; Hsiao-Su Wu, M.D.*; Sophia Chia-Ning Chang, M.D.Ph.D.*; Jack
Chung-Kai Yu, M.D., D.M.D.†, Chao-Hsiang Chang, M.D.ζ
*
Department of Plastic Surgery, China Medical University Hospital and School of Medicine,
China Medical University, Taichung, Taiwan
†
Section of Plastic & Reconstructive Surgery, Medical College of Georgia, Augusta, Georgia;
U.S.A
ζ
Department of Urology, China Medical University Hospital and School of Medicine, China
Medical University, Taichung, Taiwan
Brief/Running Title: Glans Penis Defect, Foreskin Flap
*Corresponding author:
Chao-Hsiang Chang, M.D.
Department of Urology, Chief,
China Medical University Hospital,
School of Medicine, China Medical University,
No.2 Yuh Der Road, Taichung City, 404, Taiwan.
Tel.: (886)-4-22052121 ext. 1509; Fax: (886)-4-22030777
E-mail: urology839@gmail.com
ABSTRACT
Plastic surgeons reconstruct hard and soft tissues in many parts of the human body. Penile
reconstruction is unique in that the target tissue has to be soft but intermittently rigid. There are
many ways to treat penile defects. The ideal reconstruction must take into considerations
sensation, cosmesis, and erectile functions. There is limited literature available on the
management of penile glans defect. In this report, we present the reconstruction of penile glans
defect, after surgical excision of Bowen’s disease, using a bipedicled foreskin flap of bucket
handle type. It is easy to perform, highly effective, and, importantly, both cosmetic and
functional outcomes at 1-year follow-up were quite satisfactory.
Key words: Glans Penis; Foreskin Flap; Bipedicled Flap.
INTRODUCTION
The penile defect, no matter traumatic or iatrogenic in origin, brings about the
physiological and psychological disabilities that can be substantial. In addition to the restoration
of the morphology in the detumesced state, glans reconstruction must restore erogenous
sensation and functions such as erection, urinary voiding, and ejaculation. These demands are
formidable challenges for plastic surgeons. Coverage for penile shaft skin defects are well
described in the literature with a variety of reconstructive options including anterior thigh flap,
scrotal flap1, and skin graft2. However, there is a paucity of descriptions for the reconstructive
method for penile glans defect. We present a case of penile glans defect with reconstruction by
bipedicled foreskin flap.
PATIENTS AND METHODS
Patients
A 52-year-old male developed repeated recurrent infection by genital herpes simplex virus
5 years before being referred to our clinic, with the initial presentation being penile glans ulcer
and wart-like lesions over foreskin (Fig. 1A). There was no palpable inguinal lymphadenopathy.
The patient was treated with regional electrocauterization. Venereal Disease Research
Laboratory test (VDRL) and HIV results were negative. Examination of the patient in our clinic
showed discoloration over penile glans and prepuce. The initial biopsy showed epitheloid
neoplasm, suggestive of squamous cell carcinoma in situ (Bowen’s disease). The patient was
treated with suprapubic cystostomy, partial resection of penile glans (Fig. 1B) and reconstruction
with local flap. The margins of the excision were free of tumor. A vascularized bipedicled
foreskin flap, 1.2 x 3 cm in size, of the bucket handle type (Fig.2A), was transferred from ventral
aspect to cover the penile glans defect (Fig. 2B), measuring 2.3 x 2.5 cm (Fig. 3A). The urethral
opening had a transient stent using a Foley catheter to prevent stricture.
RESULTS
He had an uneventful recovery, with no adverse events noted after operation (Fig.3B).
Histopathologic examination of the specimen revealed a focally severe squamous dysplasia,
consistent with Bowen’s disease. To date, one year after surgical treatment, the patient remains
highly satisfied with the cosmesis, sensory and sexual functions recovery, without clinical
evidence of disease recurrence.
DISCUSSION
Many studies described various methods to reconstruct penile defect. Bonnet et al
suggested the use of negative pressure therapy to enhance wound debridement and to promote
granulation tissue formation. A bilateral scrotal flap was used for further closure of this complex
wounds.3 Other alternatives including full thickness skin graft,4 local flap,5 and grafting of buccal
mucosa6. Of these options, the scrotal flap seemed to be the most popular because of low failure
rate due to its double blood supply (external and internal pudendal arteries and their branches). A
study presented by Zhao et al.’s analyzed 18 cases of penile defect treated with bilateral scrotal
skin flap or total anterior scrotal skin flap. The results showed reconstruction by a scrotal skin
flap capable of achieving reasonable cosmesis and penile length in most cases with acceptable
sensation and erectile function.1
We used a bipedicled foreskin flap of bucket handle type. There are several advantages.
First, this flap also had dual blood supply (two anterolateral and posterolateral superficial penile
arteries originated from inferior external pudental artery). Minimum flap necrosis occurred with
a scrotal flap. Second, the reserved redundant ventral foreskin was not only used for penile glans
defect reconstruction with tension-free closure, but also avoids limiting erectile function
associated with usinng foreskin. The glans penis defect reconstruction with a scrotal flap may
make penile glans tightly stretched and constrain erectile function. Third, the foreskin flap had
intact sensory and cosmetic function with very low risk for nerve injury. It is thus better than a
disfiguring scrotal flap. However, there are many limitations in this study. For example, the
defect was limited in size. This is because Bowen disease requires only minimum surgical
margin. For invasive cancers, traditional surgical excision would have resulting in larger defects,
requiring 2 cm margins.7 That is why we could preserve more foreskin for reconstruction. Should
the defect be much larger, this flap will be inadequate.
In conclusion, a bipedicled foreskin flap of a bucket handle type is a good choice for glans
reconstruction due to the proximity and its dual blood supplies, rendering flap ischemia less
likely. In our reconstruction approach, a bipedicled foreskin flap of a bucket handle type appears
to be a more effective alternative than other flaps because of easy preparation and transfer to the
defect area with well preservation of sensory, cosmetic and sexual functions. In treating penile
glans defects, we should keep in mind this alternative flap model.
References
1.
Zhao Y-Q, Zhang J, Yu M-S, et al. Functional restoration of penis with partial defect by
scrotal skin flap. J Urol. 2009;182:2358-2361.
2.
Fu Q. Repair of necrosis and defects of penile skin with autologous free skin flap. Asian J
Androl. 2006;8:741-744.
3.
Bonnet F, Paraskevas A, Petit F, et al. [Vacuum-Assisted Closure for the reconstruction of a
complex wound of the penis]. Ann Chir Plast Esthet. 2006;51:249-252.
4.
Ignjatovic I, Kovacevic P, Medojevic N, et al. Reconstruction of the penile skin loss due to
"radical" circumcision with a full thickness skin graft. Vojnosanit Pregl. 2010;67:593-595.
5.
Chu C-C, Chen Y-H, Diau G-Y, et al. Preputial flaps to correct buried penis. Pediatr Surg
Int. 2007;23:1119-1121.
6.
Venkov G, Laaser M-K. Reconstruction of tissue defects on the glans penis by
transplantation of buccal mucosa. Aktuelle Urol. 2008;39:219-224.
7.
Haseebuddin M, Brandes S-B. The prepuce: preservation and reconstruction. Curr Opin
Urol. 2008;18:575-582.
FIGURES LEGENDS
FIGURE 1.
Bowen’s disease of the glans penis. (A) Preoperation. (B) Perioperative view of
the glans and prepuce foreskin defect after resection.
FIGURE 2.
A bipedicle foreskin flap of bucket handle type. (A) The flap was designed in the
ventral aspect of penile prepuce and shaft. (B) The flap was transferred from the
ventral site to the dorsal aspect to cover the penile glans defect.
FIGURE 3.
Postoperative Appearance of penis. (A) Immediate postoperation. (B) One year
follow up.