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=== Fournier's Gangrene, Trauma, and Cancer ===
=== Fournier's Gangrene, Trauma, and Cancer ===
There are various categories of injuries to the scrotum that result in the loss of scrotal skin tissue. Scrotoplasty in these conditions is to remove necrotic skin and reconstruct the scrotum.
There are various categories of injuries to the scrotum that result in the loss of scrotal skin tissue. Scrotoplasty in these conditions is needed to remove necrotic skin and reconstruct the scrotum.


The first category of scrotal injury includes [[Fournier gangrene|Fournier's Gangrene]], which is a necrotic infection of the soft tissue around the genital. This infection is commonly caused by a poly microbic flora in the individuals who has co-morbidities such as immunocompromised conditions, diabetes mellitus, colorectal infection. To stop the [[necrotizing fasciitis]] from spreading, the treatment requires an aggressive surgical [[debridement]] which often results in the loss of the scrotal skin. After the patient is stable and cleared from the infection, scrotal reconstruction is needed to restore its function the scrotum.<ref>{{cite journal | vauthors = Schifano N, Castiglione F, Cakir OO, Montorsi F, Garaffa G | title = Reconstructive surgery of the scrotum: a systematic review | journal = International Journal of Impotence Research | volume = 34 | issue = 4 | pages = 359–368 | date = May 2022 | pmid = 34635818 | doi = 10.1038/s41443-021-00468-x | s2cid = 238586767 }}</ref>
The first category of scrotal injury includes [[Fournier gangrene|Fournier's Gangrene]], which is a necrotic infection of the soft tissue around the genital. This infection is commonly caused by a poly microbic flora in the individuals who has co-morbidities such as immunocompromised conditions, diabetes mellitus, colorectal infection. To stop the [[necrotizing fasciitis]] from spreading, the treatment requires an aggressive surgical [[debridement]] which often results in the loss of the scrotal skin. After the patient is stable and cleared from the infection, scrotal reconstruction is needed to restore its function the scrotum.<ref>{{cite journal | vauthors = Schifano N, Castiglione F, Cakir OO, Montorsi F, Garaffa G | title = Reconstructive surgery of the scrotum: a systematic review | journal = International Journal of Impotence Research | volume = 34 | issue = 4 | pages = 359–368 | date = May 2022 | pmid = 34635818 | doi = 10.1038/s41443-021-00468-x | s2cid = 238586767 }}</ref>

Revision as of 17:34, 1 August 2022

Scrotoplasty
Other namesOscheoplasty
SpecialtyPlastic surgery

Scrotoplasty, also known as oscheoplasty, is a form of male genital plastic surgery to create or repair the scrotum. The history of male genital plastic surgery is rooted in many cultures and dates back to ancient times.[1] However, scientific research for male genital plastic surgery such as scrotoplasty began to develop in the early 1900s.[1] There are a variety of reasons why scrotoplasty is done. Some transgender men and intersex or non-binary people who were assigned female at birth may choose to have this surgery to create a scrotum, as part of their transition. Other reasons for this procedure include addressing issues with the scrotum due to birth defects, aging, or medical conditions such as infection. For newborn males with penoscrotal defects such as webbed penis, a condition in which the penile shaft is attached to the scrotum, scrotoplasty can be performed to restore normal appearance and function. For older male adults, the scrotum may extend with age. Scrotoplasty or scrotal lift can be performed to remove the loose, excess skin. Scrotoplasty can also be performed for males who undergo infection, necrosis, traumatic injury of the scrotum.

Reasons for getting a scrotoplasty

Buried Penis and Penoscrotal Webbing

Buried penis is a condition when the penis is attached to their scrotum with an excess of skin. This condition can affect both newborn and adult males. Scrotoplasty can be performed to remove the extra skin in the scrotal area and reshape their scrotum. Penoscrotal webbing is another condition, where the skin connecting the penis to the scrotum extends along the underside of the penis shaft like a web.[2] This condition is easily confused with buried penis. Both conditions affect newborn and adult males but they do not always require surgery. Scrotoplasty can be considered to remove excess skin in order to restore normal appearance of their scrotum and penis length, which can improve a man's confidence. In both conditions, the scrotoplasty procedure involves making an incision in the fused part between the penis and scrotum and then reconstructing the scrotum.[2]

Female-to-Male Transition

Some trans men and intersex or non-binary people who were assigned female at birth may choose to have gender-affirming surgeries to create male genitals from existing tissue, as part of their female-to-male transition.[3] There are two types of gender-affirming surgeries for the creation of a penis, metoidioplasty and phalloplasty. In both of these surgeries, a scrotoplasty can be considered as an additional surgery to add testicular implants.[4] Metoidioplasty involves modification of the clitoris into a penis. Generally, the clitoris is hormonally enlarged with testosterone, making it possible for it to be straightened and lengthened into a penis. Outcomes of this surgery include the ability to urinate while standing and retain sexual stimulation.[4] Phalloplasty is the other type of surgery to create a penis, but utilizes skin from other areas of the body besides existing genitals. The most common part of the body used in this surgery is the forearm and has the same outcomes as a metoidioplasty.[5] The addition of a scrotoplasty with implants is an optional procedure for individuals to choose based on their goals with their transition. Deciding if a scrotum meets their needs in their transition is a consideration for adding a scrotoplasty procedure.[4][5]

Fournier's Gangrene, Trauma, and Cancer

There are various categories of injuries to the scrotum that result in the loss of scrotal skin tissue. Scrotoplasty in these conditions is needed to remove necrotic skin and reconstruct the scrotum.

The first category of scrotal injury includes Fournier's Gangrene, which is a necrotic infection of the soft tissue around the genital. This infection is commonly caused by a poly microbic flora in the individuals who has co-morbidities such as immunocompromised conditions, diabetes mellitus, colorectal infection. To stop the necrotizing fasciitis from spreading, the treatment requires an aggressive surgical debridement which often results in the loss of the scrotal skin. After the patient is stable and cleared from the infection, scrotal reconstruction is needed to restore its function the scrotum.[6]

The second category of scrotal injury includes trauma to the scrotum, such as from burns, machinery accidents, traffic accidents, firearm accidents, and surgical accidents.[7] People who experience these injuries may require scrotoplasty if they lose more than 50% of their skin.[2][8] Reconstructing scrotal skin can be accomplished by using skin grafts from other areas of the body. Tissue expansion, a procedure in which the skin is stretched to regenerate new cells, can also be an option in order to restore scrotal skin loss.

Cancer that affects the scrotum and requires removal of tissue may also require scrotoplasty to repair the scrotum.[9]

Excess Skin

There are many reasons that can cause scrotal sagging such as natural aging, varicocele, and hydrocele. Scrotoplasty, in particular scrotal lift, is an option to remove excess loose scrotal skin, tighten, and reduce the size of the scrotum in order to reduce discomfort and improve appearance.

Procedure

Pre-Operation

Candidates must avoid any nicotine products, which can potentially affect wound healings and perioperative complications, for 3 months prior to the surgery.[10] People must also be screened for other contraindications, including obesity with specific adipose distribution. Diabetes can also lead to wound complications such as wound separation or wound disruption.[11] Other contraindications exist for specific types of phalloplasty. For instance, a body mass index (BMI) of greater than 35 kg/m2 is contraindicated for radial forearm free flap (RFFF) phalloplasty. A metoidioplasty or anterolateral thigh (ALT) phalloplasty is only recommended for people with an ideal body weight.[10]

For gender-affirming scrotoplasty, people should have already been receiving hormone therapy for over 1 year with established mental and primary health care. Some transmasculine people have already undergone double mastectomy and hysterectomy. Scrotoplasty for transmasculine individuals is usually done with other gender-related genitourinary surgery (GRGUS), which consists of various procedures with variable personal desires for metoidioplasty, phalloplasty, vaginectomy, and urethroplasty.[10] A comprehensive history and physical assessment of the physical sites are taken during consultation to identify the candidates' surgical goals, which then help determine which procedures are needed.

Operation

Depending on the purpose of scrotoplasty, whether the patients need to remove excess scrotal skin, reconstruct the scrotum due to scrotal skin loss, or create a new scrotum, the scrotoplasty types will vary.

There are various scrotoplasty techniques for the buried penis and penoscrotal web. The surgeon can perform the simplest technique by making a horizontal incision and closing along the longitudinal axis. However, the methods that give patients higher satisfaction are the single or double Z-plasty or V-Y advancement flap because they also can increase the penile length.[12]

The scrotoplasty procedure requires skin grafting to reconstruct the scrotum for scrotal skin loss. Full-thickness skin grafts (FTSGs) and split-thickness skin grafts STSG [13] are two types of skin graft can be used for reconstruction.[14][14] The suprapubic skin and the anterior thigh are the most common donor sites.

The novo scrotoplasty is one stage of female-to-male transition, performed together with phalloplasty, which creates the penis. When a trans man or transmasculine person has a scrotoplasty, the labia majora (the big lips of the vulva) are dissected to form hollow cavities and united into an approximation of a scrotal sack.[15] If there is not enough skin to make a scrotum, then the surgeon may need to make tissue expansion before the operation by putting expanders under the skin. Over the course of a few months, more salt water (saline) will be occasionally added to the expanders through a port on the outside. This helps the skin expand and grow more skin. Each expansion procedure is done in an outpatient hospital visit. The patient does not have to stay overnight in the hospital, but will have to stay near the hospital, and return several times. Later, between 6 and 12 months after the first novo scroto-phalloplasty, silicone prosthetic testicles can be put in. These can be inserted through small cuts to fill the new scrotum. At this point, the new scrotum no longer needs expanders. Then the skin is closed up around the artificial testicles.[16][17] The artificial testicles only give a shape and do not create semen, sperm, or hormones.

Post-Operation

In general, post-operative hospital stays for people undergoing scrotoplasty range from days to weeks, corresponding to the complexity of the procedure.[18] For instance, gender-affirming scrotoplasty, especially when done with other procedures, takes longer to recover than other types of scrotoplasty.[19]

Usually after the procedure, people may wear a support garment to limit the movement of the surgical sites to limit the risk of complications. In addition, a flexible tube for draining urine from the urinary bladder (urinary catheter) is placed and held in place until the genitals heal. Swelling of the scrotal areas is normal and can last up to months.

Individuals with buried penis undergoing a scrotal lift can be discharged on the same day as procedure, and are not allowed to engage in sexual activities for many weeks.[20] People can ambulate or must rest in bed during recovery, depending on the surgeon's decision. A blood thinner (anticoagulant) is considered for people with risk factors for deep vein thrombosis.[20]

Most cases of gender-affirming scrotoplasty are done with Hoebeke's technique where the majority of people are satisfied with shape, size, and position of their newly constructed scrotum and consider getting prosthetic testicles and erectile inflatable devices .[21][22] Initially, a secondary surgery was carried out to insert 2 silicone prosthetic testicles into the newly constructed scrotum between 6-12 months following the initial scrotoplasty. An erectile inflatable device was then implanted during a tertiary surgery at least 12 months from the initial scrotoplasty.[23] Later one, this technique was modified in which 1 silicone prosthetic testicle and an erectile inflatable device were implanted during the same surgery between 6-12 months after the initial scrotoplasty.[23]

Complications

People who are candidates for scrotoplasty need to be educated on the associated risks and complications before the procedure. There have been advancements in the surgical techniques. However, the risk of recurrent condition still exists. In addition, the cosmetic results might not be satisfactory to some people after surgery.[24] Another factor to consider is the loss of sensation in the scrotal area due to the nature of the procedure which can involve removal of genital tissues.[24]

Complications to scrotoplasty among transmasculine individuals primarily deal with testicular implants. If they are too big, there is chance that the implants could feel uncomfortable, or be a cause of chronic pain.[25] Another complication is that the implant could erode the skin of the scrotum. This can cause infection, or an abnormal connection between two body parts (a fistula) where the implant may work its way outside the body.[25] People with a history of smoking are at increased risk of infections and prosthetic explantation.[26]

Other complications are those that are typical for any surgery, such as blood loss or problems with anesthesia.

Cost

A scrotoplasty for a trans man or transmasculine person typically costs around US$3,000 to $5,000.[25] These costs can be covered by health insurance, though the patient must communicate a great deal with their insurance in order to make certain that it will.

See also

References

  1. ^ a b Zaccaro C, Subirà D, López-Diez I, Manfredi C, Ascensios-Vargas JP, Moncada-Iribarren I (May 2022). "History and future perspectives of male aesthetic genital surgery". International Journal of Impotence Research. 34 (4): 327–331. doi:10.1038/s41443-022-00580-6. PMID 35538312. S2CID 248574391.
  2. ^ a b c Lucas JW, Lester KM, Chen A, Simhan J (August 2017). "Scrotal reconstruction and testicular prosthetics". Translational Andrology and Urology. 6 (4): 710–721. doi:10.21037/tau.2017.07.06. PMC 5583055. PMID 28904904.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  3. ^ Frey JD, Poudrier G, Chiodo MV, Hazen A (March 2017). "An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient: A Review of the Literature". Plastic and Reconstructive Surgery. 139 (3): 728–737. doi:10.1097/PRS.0000000000003062. PMID 28234856.
  4. ^ a b c Djordjevic ML, Stojanovic B, Bizic M (June 2019). "Metoidioplasty: techniques and outcomes". Translational Andrology and Urology. 8 (3): 248–253. doi:10.21037/tau.2019.06.12. PMC 6626308. PMID 31380231.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  5. ^ a b Heston AL, Esmonde NO, Dugi DD, Berli JU (June 2019). "Phalloplasty: techniques and outcomes". Translational Andrology and Urology. 8 (3): 254–265. doi:10.21037/tau.2019.05.05. PMC 6626313. PMID 31380232.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  6. ^ Schifano N, Castiglione F, Cakir OO, Montorsi F, Garaffa G (May 2022). "Reconstructive surgery of the scrotum: a systematic review". International Journal of Impotence Research. 34 (4): 359–368. doi:10.1038/s41443-021-00468-x. PMID 34635818. S2CID 238586767.
  7. ^ McGeady JB, Breyer BN (August 2013). "Current epidemiology of genitourinary trauma". The Urologic Clinics of North America. 40 (3): 323–334. doi:10.1016/j.ucl.2013.04.001. PMC 4016766. PMID 23905930.
  8. ^ Baky Fahmy MA, ed. (2022). Normal and Abnormal Scrotum. Springer Nature Switzerland AG. doi:10.1007/978-3-030-83305-3. ISBN 978-3-030-83304-6. S2CID 244716445.
  9. ^ Por YC, Tan BK, Hong SW, Chia SJ, Cheng CW, Foo CL, Tan KC (August 2003). "Use of the scrotal remnant as a tissue-expanding musculocutaneous flap for scrotal reconstruction in Paget's disease". Annals of Plastic Surgery. 51 (2): 155–160. doi:10.1097/01.SAP.0000058501.64655.31. PMID 12897518. S2CID 9488906.
  10. ^ a b c Chen ML, Reyblat P, Poh MM, Chi AC (June 2019). "Overview of surgical techniques in gender-affirming genital surgery". Translational Andrology and Urology. 8 (3): 191–208. doi:10.21037/tau.2019.06.19. PMC 6626317. PMID 31380226.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  11. ^ Gupta NK, Sulaver R, Welliver C, Kottwitz M, Frederick L, Dynda D, Köhler TS (April 2019). "Scrotoplasty at Time of Penile Implant is at High Risk for Dehiscence in Diabetics". The Journal of Sexual Medicine. 16 (4): 602–608. doi:10.1016/j.jsxm.2019.02.001. PMID 30852109. S2CID 73726378.
  12. ^ Alter GJ, Salgado CJ, Chim H (August 2011). "Aesthetic surgery of the male genitalia". Seminars in Plastic Surgery. 25 (3): 189–195. doi:10.1055/s-0031-1281488. PMC 3312189. PMID 22851910.
  13. ^ Chen JC, Jain SA (2010-01-01). "Chapter 104 - Principles of Skin Grafts". In Weinzweig J (ed.). Plastic Surgery Secrets Plus (Second ed.). Philadelphia: Mosby. pp. 677–683. doi:10.1016/b978-0-323-03470-8.00104-6. ISBN 978-0-323-03470-8. Retrieved 1 August 2022.
  14. ^ a b Garaffa G, Gentile V, Antonini G, Tsafrakidis P, Raheem AA, Ralph DJ (September 2013). "Penile reconstruction in the male". Arab Journal of Urology. 11 (3): 267–271. doi:10.1016/j.aju.2013.04.003. PMC 4443016. PMID 26558091.
  15. ^ Selvaggi G, Hoebeke P, Ceulemans P, Hamdi M, Van Landuyt K, Blondeel P, et al. (June 2009). "Scrotal reconstruction in female-to-male transsexuals: a novel scrotoplasty". Plastic and Reconstructive Surgery. 123 (6): 1710–1718. doi:10.1097/PRS.0b013e3181a659fe. PMID 19483569.
  16. ^ Sengezer M, Sadove RC (October 1993). "Scrotal construction by expansion of labia majora in biological female transsexuals". Annals of Plastic Surgery. 31 (4): 372–376. doi:10.1097/00000637-199310000-00016. PMID 8239440.
  17. ^ Sutcliffe PA, Dixon S, Akehurst RL, Wilkinson A, Shippam A, White S, et al. (March 2009). "Evaluation of surgical procedures for sex reassignment: a systematic review". Journal of Plastic, Reconstructive & Aesthetic Surgery. 62 (3): 294–306. doi:10.1016/j.bjps.2007.12.009. PMID 18222742.
  18. ^ "Scrotoplasty: What It Is, Procedure, Risks & Benefits". Cleveland Clinic. Retrieved 1 August 2022.
  19. ^ "Scrotoplasty: Procedure, Risks, Recovery, Pictures, and More". Healthline. 2021-01-12. Retrieved 1 August 2022.
  20. ^ a b Smith-Harrison LI, Piotrowski J, Machen GL, Guise A (January 2020). "Acquired Buried Penis in Adults: A Review of Surgical Management". Sexual Medicine Reviews. 8 (1): 150–157. doi:10.1016/j.sxmr.2019.02.008. PMID 31101591.
  21. ^ Pigot, Garry L. S.; Al-Tamimi, Muhammed; Ronkes, Brechje; van der Sluis, Tim M.; Özer, Müjde; Smit, Jan Maerten; Buncamper, Marlon E.; Mullender, Margriet G.; Bouman, Mark-Bram; van der Sluis, Wouter B. (2019-10). "Surgical Outcomes of Neoscrotal Augmentation with Testicular Prostheses in Transgender Men". The Journal of Sexual Medicine. 16 (10): 1664–1671. doi:10.1016/j.jsxm.2019.07.020. ISSN 1743-6109. PMID 31501057. {{cite journal}}: Check date values in: |date= (help)
  22. ^ Selvaggi, Gennaro; Hoebeke, Piet; Ceulemans, Peter; Hamdi, Moustapha; Van Landuyt, Koen; Blondeel, Phillip; De Cuypere, Griet; Monstrey, Stan (2009-06). "Scrotal Reconstruction in Female-to-Male Transsexuals: A Novel Scrotoplasty:". Plastic and Reconstructive Surgery. 123 (6): 1710–1718. doi:10.1097/PRS.0b013e3181a659fe. ISSN 0032-1052. {{cite journal}}: Check date values in: |date= (help)
  23. ^ a b Selvaggi, Gennaro; Hoebeke, Piet; Ceulemans, Peter; Hamdi, Moustapha; Van Landuyt, Koen; Blondeel, Phillip; De Cuypere, Griet; Monstrey, Stan (2009-06). "Scrotal Reconstruction in Female-to-Male Transsexuals: A Novel Scrotoplasty:". Plastic and Reconstructive Surgery. 123 (6): 1710–1718. doi:10.1097/PRS.0b013e3181a659fe. ISSN 0032-1052. {{cite journal}}: Check date values in: |date= (help)
  24. ^ a b Pestana IA, Greenfield JM, Walsh M, Donatucci CF, Erdmann D (October 2009). "Management of "buried" penis in adulthood: an overview". Plastic and Reconstructive Surgery. 124 (4): 1186–1195. doi:10.1097/PRS.0b013e3181b5a37f. PMID 19935302. S2CID 36775257.
  25. ^ a b c Erickson-Schroth L, ed. (2014). Trans Bodies, Trans Selves: A Resource for the Transgender Community. Oxford University Press. p. 282.
  26. ^ Pigot, Garry L. S.; Al-Tamimi, Muhammed; Ronkes, Brechje; van der Sluis, Tim M.; Özer, Müjde; Smit, Jan Maerten; Buncamper, Marlon E.; Mullender, Margriet G.; Bouman, Mark-Bram; van der Sluis, Wouter B. (October 2019). "Surgical Outcomes of Neoscrotal Augmentation with Testicular Prostheses in Transgender Men". The Journal of Sexual Medicine. 16 (10): 1664–1671. doi:10.1016/j.jsxm.2019.07.020. ISSN 1743-6109. PMID 31501057.

Further reading

  • Por YC, Tan BK, Hong SW, Chia SJ, Cheng CW, Foo CL, Tan KC (August 2003). "Use of the scrotal remnant as a tissue-expanding musculocutaneous flap for scrotal reconstruction in Paget's disease". Annals of Plastic Surgery. 51 (2): 155–160. doi:10.1097/01.SAP.0000058501.64655.31. PMID 12897518. S2CID 9488906.
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