The Sensate External Pudendal Artery Perforator (EPAP) Hemi-Scrotal Flap for the Circumferential Skin Defect of the Penile Shaft: A Case Report and Literature Review

Abstract

Penile skin reconstruction is traditionally performed using a skin graft and/or local pedicled flap. The scrotal flap is one of the options. However, previous techniques sacrifice the bilateral external pudendal arteries which put the skin pedicle at risk of dyspareunia and stretching. To overcome this limitation, we used the external pudendal artery perforator (EPAP) hemi-scrotal flap with isolation of the pedicle perforator to elevate the perforator flap with a wider rotation arc, easier and safer inset without tension, and sufficient coverage of the defect. A 40 years old male with schizophrenia had circumferential penile skin defect after penile replantation. The sensate EPAP hemi-scrotal flap measuring 9 × 14 cm was designed using doppler ultrasound preoperatively and harvested above the deep fascia. The external pudendal artery perforator and the anterior scrotal nerve were isolated. The shaft skin defect was covered with the sensate EPAP flap and the donor site was closed primarily. Postoperative course was uneventful without any short-term complications. Seven months after the reconstructive surgery, the transferred flap showed good color match and sensation, and the donor site was inconspicuous. Its function recovered without the sensation of pain and stretching. According to current literature the scrotal flap is a suitable donor site because of its thin, pliable, pigmented, and sensate characteristics. Beyond this current approach, we believe that harvesting the scrotal flap specifically as a perforator flap may be a superior flap for penile skin coverage. A higher rotation arc and inconspicuous donor site scar are further beneficial features of this approach.