Midline raphe scroti artery flap for penile shaft reconstruction

Abstract

Aim: To investigate a novel method for penile shaft reconstruction.
Methods: Penile tissue loss is caused by injury, infections, obesity or cancer resection. Reconstructive techniques comprise skin grafts with the risk of scarring and tissue rigidity. To develop an alternative reconstructive procedure, the pertinent vascular anatomy was studied on fresh cadavers instilled with red latex, which permitted the design of the midline raphe scrotal artery flap (MiRA). After anatomical proof-of-feasibility, penile reconstruction was performed in adult patients with classic buried penis or after cancer resection.
Results: Anatomical studies revealed a novel finding of two scrotal septa, each with the terminal branch of the internal pudendal artery. Pedicled on both arteries, a neurovascular island flap could be harvested. In the presence of excess scrotal tissue, the entire circumference of the penile shaft could be covered by this flap. Patients with penile skin defects and excess scrotal tissue were eligible for flap harvest. The flap was raised either as an extended island flap pedicled on both septal arteries for complete penile shaft coverage, or as a VY-flap for partial reconstruction; the donor site was closed primarily. Post-operative complications included swelling or partial wound dehiscence. There were no flap losses or perfusion problems. Patients reported full sensitivity to the penile shaft skin and sufficient skin elasticity for erection.
Conclusion: The MiRA flap is a technically safe neurovascular flap suitable for the reconstruction of partial or full defects of the penile shaft, such as after type III buried penis surgery, and provides sufficiently elastic and sensitive skin for functional penile reconstruction.

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Original Article Open Access
Mirastschijski et al. Plast Aesthet Res 2020;7:45
DOI: 10.20517/2347-9264.2020.44Plastic and
Aesthetic Research
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Midline raphe scroti artery ap for penile shaft
reconstruction
Ursula Mirastschijski1,2, Carla Schwenke3, Igor Schwab4, Andreas Buchhorn5, Andreas Schmiedl5
1Mira-Beau gender esthetics, Berlin 10777, Germany.
2Wound Repair Unit, CBIB, Faculty of Biology and Chemistry, University of Bremen, Bremen 28359, Germany.
3Department of Urology, Josef-Hospital, Delmenhorst 27753, Germany.
4Department of Plastic, Reconstructive and Aesthetic Surgery, Klinikum Bremen-Mitte, Bremen 28205, Germany.
5Institute of Anatomy, Hannover Medical School, Hannover 30625, Germany.
Correspondence to: Prof. Dr. Ursula Mirastschijski, Wound Repair Unit, CBIB, Faculty of Biology and Chemistry, University of
Bremen, Leobener Str./NW2, Bremen 28359, Germany. E-mail: mirastsc@uni-bremen.de
How to cite this article: Mirastschijski U, Schwenke C, Schwab I, Buchhorn A , Schmiedl A. Midline raphe scroti artery flap for
penile shaf t reconstruction.
Plast Aesthet Res
2020;7:45. http://dx.doi.org/10.20517/2347-9264.2020.44
Received: 20 Mar 2020 Fir
s
t Decision: 20 Jul 2020 Revised: 26 Jul 2020 Accepted: 4 Aug 2020 Published: 21 Aug 2020
Academic Editor: Marlon E. Buncamper Copy Editor: Cai-Hong Wang Production Editor: Jing Yu
Abstract
Aim: To investigate a novel method for penile shaft reconstruction.
Methods: Penile tissue loss is caused by injury, infections, obesity or cancer resection. Reconstructive techniques
comprise skin grafts with the risk of scarring and tissue rigidity. To develop an alternative reconstructive procedure,
the pertinent vascular anatomy was studied on fresh cadavers instilled with red latex, which permitted the design
of the midline raphe scrotal artery flap (MiRA). After anatomical proof-of-feasibility, penile reconstruction was
performed in adult patients with classic buried penis or after cancer resection.
Results: Anatomical studies revealed a novel finding of two scrotal septa, each with the terminal branch of the
internal pudendal artery. Pedicled on both arteries, a neurovascular island flap could be harvested. In the presence
of excess scrotal tissue, the entire circumference of the penile shaft could be covered by this flap. Patients
with penile skin defects and excess scrotal tissue were eligible for flap harvest. The flap was raised either as an
extended island flap pedicled on both septal arteries for complete penile shaft coverage, or as a VY-flap for partial
reconstruction; the donor site was closed primarily. Post-operative complications included swelling or partial
wound dehiscence. There were no flap losses or perfusion problems. Patients reported full sensitivity to the penile
shaft skin and sufficient skin elasticity for erection.

Page 2 of 13 Mirastschijski et al. Plast Aest het Res 2020;7:45 I http://dx.doi.org/10.20517/2347-9264.2020.44
Conclusion: The MiRA flap is a technically safe neurovascular flap suitable for the reconstruction of partial or full
defects of the penile shaft, such as after type III buried penis surgery, and provides sufficiently elastic and sensitive
skin for functional penile reconstruction.
Keywords:
Scrotal anatomy, septal artery, penile shaft coverage, penile reconstruction, buried penis, scrotal island
flap, midline raphe scrotal artery flap
INTRODUCTION
e penile skin is unique in that it has usually no hair and no subcutaneous fat layer. It is highly elastic
and exible, allowing for around a 2-fold increase in penile length and a 1.5-fold increase in girth during
erection[1]. Hence, reconstruction of the penile envelope is dicult when most parts of the skin are lost.
Common causes for penile defects include infections such as Fournier’s gangrene[2], inflammatory
reactions with tissue induration and granuloma formation aer injection of various substances[3], tumour
resections[4], trauma (e.g., burns[5], combat[6] or other related accidents[7]) or penile invagination into the
pre-pubic fat apron in highly obese men[8]. With the rising incidence of morbid obesity, this phenomenon,
also called buried penis, is increasingly seen in men with resulting impairment of micturition and sexual
intercourse[9].
Full- or split-thickness skin grafts are the current gold standard for the reconstruction of penile skin
defects[10-12]. Draw-backs of this technically simple and straightforward procedure are the tendency for
scarring and the rigidity of the skin gra once it has taken. Penile deviation or pain during erection with
loss of penile length are commonly reported. Another reconstructive possibility is the use of scrotal skin.
Despite the similarity of scrotal and penile skin - both are devoid of a subcutaneous fat layer and highly
elastic - the reach of scrotal skin aps is limited to the base of the penile sha without the possibility of
covering the entire shaft length[13]. Hence, temporary burying of the penis in the scrotum with delayed
release, or local aps for defects at the penile base are currently practised as well[14,15].
e concept of plastic-reconstructive surgery is based on intimate anatomical knowledge of tissue structure
and perfusion. e course of vessels enables the design of pedicled or free aps to reach distant defects for
closure. Despite its primitive function as a testicular bag, the scrotal sac has a pivotal role in maintenance of
a man’s reproductivity. e delicate regulation of temperature by the scrotum is orchestrated by an interplay
of vessel width, muscle and skin contraction. As a consequence, vessels from dierent sources enter the
scrotal sac to build a dense network. It is a well-known fact that branches from the external pudendal
artery, also called rami scrotales laterales and anteriores, provide blood to the lateral and ventral scrotal
skin, respectively. The internal pudendal artery sends branches to the dorsal part of the scrotum (rami
scrotales posteriores), interacting closely with the branches of the external pudendal artery. Until recently,
there was no information on arterial perfusion of the scrotal septum[16].
In order to nd novel surgical means to reconstruct the penile sha, scrotal and penile anatomy and vessel
distribution were anatomically studied on deceased body donors instilled with red ink into pelvic vessels
first. After demonstration of the vascular anatomy of a scrotal island flap based on the arteries of both
scrotal septa, patients with penile sha defects were reconstructed with the novel neurovascular midline
raphe scrotal artery ap (MiRA) island ap.

Mirastschijski et al. Plast Aes thet Res 2020;7:45 I http://dx.doi.org/10.20517/2347-9264.2020.44 Page 3 of 13
METHODS
Anatomical studies
Initially, dissection studies were performed on cadavers at Hannover Medical School. Perfusion xation
was carried out via the femoral artery with a solution containing 2.7% paraformaldehyde (n = 4). Because
the scrotal sac is positioned in the lower, dorsal parts of the supine laying body, a lot of liquid was found
in the tissue which made vessel studies dicult. Furthermore, this xation technique turned the normally
soft and flexible genital tissue into a stiff matrix with rigid skin such that flap studies were impossible.
Consequently, for ap surgery, fresh cadavers within 24 h of death were chosen. Male pelvic parts of fresh
cadavers including the genitals (n = 4) were instilled with red silicone dye S 10 (KSK02A15.0 BIODUR® S
10; Biodur® Products GmbH, Heidelberg, Germany). Before vessel injection, the dye was mixed with the
hardener S 6 (KSH03A1.0 BIODUR® Härter S 6) in a ratio of 100:5. e abdominal aorta was dissected
and incised above the bifurcation. An anterograde tube was then inserted into the abdominal aorta above
the bifurcation into both common iliac arteries. Using a 500 mL perfusion syringe, the colour suspension
was pressed through the tube into the aorta by hand. e femoral artery was clamped below the exit of the
profunda femoris artery. About 500 mL was injected. e solution was distributed over the internal iliac
artery into the internal pudendal artery and over the external iliac artery into the external pudendal artery.
Aer one-day of hardening, preparation of the vessels was started. Pictures were taken with a Nikon D5100
and a Nikon D800E camera.
For studies of the genital vasculature, the main vessels were prepared and branches to the scrotal sac
and penis were followed. Of note, the testicular vasculature (funiculus spermaticus) was not dissected
or investigated. First, the external pudendal artery was dissected at its origin in the groin or upper
medial thigh and its course followed until the point of branching at the lateral aspect of the scrotal skin.
Interestingly, there were variations with regard to its origin: directly from the femoral artery (n = 3), from
the profound femoral artery (n = 2) and from the inferior epigastric artery (n = 1). Two donors had femoral
artery surgery previously such that anatomical studies of the thigh vessels were impossible due to severe
scarring and the presence of vascular implants.
For flap anatomy, incision markings were positioned as shown in Figure 1A-C, parallel to the midline
scrotal raphe. After incision, the scrotal fasciae were dissected carefully starting from the most caudal
point of the ap [Figure 1D-F]. e septum was visualized. Due to the prominent visibility of the septal
vessels, with the terminal branch running from the dorsal aspect of the septum like an arch to the ventral
plane of the scrotum, a second vessel was noticed with the same course but in a different plane. After
further dissection, it became clear that the scrotal midline is separated beneath the raphe by two septa each
containing one terminal branch of the internal pudendal artery on each side. Considering the embryology
and the fact that the scrotal sac is formed by the fusion of two embryonal swellings, this observation is
not the least surprising but rather, a logical consequence of embryological development. We could also
demonstrate a dual septum with separate vessels which were communicating with each other. Next, the
ap was pedicled on both septa and septal arteries, and lateral branches communicating with the central
branches were dissected, retaining those branches that inserted directly into the ap. e septa at the dorsal
aspect of the scrotum were released up to its cranial root and until sucient mobility of the ap for penile
sha coverage was achieved. e ap was wrapped around the penile sha and closed at its dorsal aspect
[Figure 1G-I]. Because scrotal tissue is highly elastic, and due to pre-existing excessive cutaneous tissue,
the donor site was closed primarily aer orchidopexy [Figure 1H and I]. Because the ap and its vascular
pedicle were designed around the scrotal midline, which is also called raphe, the ap was named the MiRA
ap.
The novel finding of the scrotal anatomy with presence of two scrotal septa including an arch forming
terminal branch of the internal pudendal artery is shown in detail in Figure 2. Since the scrotum is

Page 4 of 13 Mirastschijski et al. Plast Aest het Res 2020;7:45 I http://dx.doi.org/10.20517/2347-9264.2020.44
Figure 1. Representative images of anatomical studies on fresh cadaversare presented. A-C: pre-operative anatomical markings of the
external genital region with a circumcised penis, excessive scrotal tissue and peno-scrotal webbing (B, arrow); D-F: flap mobilization
and measurements of approximately 11 cm in length (E) and 7 cm in width (F); G-I: penile defect coverage (G) and donor site closure (H,
I) are demonstrated
A
D
G
B
E
H
C
F
I

Mirastschijski et al. Plast Aes thet Res 2020;7:45 I http://dx.doi.org/10.20517/2347-9264.2020.44 Page 5 of 13
Figure 2. Septal anatomy with demonstration of the dual presence of scrotal septa including an arch forming terminal branch of the
internal pudendal artery that is running from the dorsal to the ventral aspect of the septum. A: lateral view with the flap folded behind
the septa. Arrows depicting the septal artery of each septum; B: close-up of A with the septal arteries (thick arrows) and anastomoses
with lateral scrotal branches derived from the external pudendal artery (thin arrows); C: septal artery with anastomoses to the lateral
border of the flap; D: close-up of the left septum with upper arrow depicting the septal artery. Lower arrow pointing to the artery of
the right septum that is visible shining through the tissue layer of the left septum; E: graphical overview of the vascular anatomy of
the scrotum. The scrotum is vascularized by the anterior, lateral and posterior branches of different arteries. The main vessels of the
scrotum are the internal and external pudendal artery. After leaving the Alcock channel (ischiorectal fascia, blue long arrow), the
internal pudendal vessels (1) divide into the rectal (not shown) and perineal artery (2). The dorsal scrotal branches (3) originate from
the perineal artery which continues in the midline as the septal artery (4, red arrow). Further branches of each internal pudendal artery
are the central arteries - providing the ipsilateral cavernosal bodies (5) and the corpus spongiosum (6) - and the dorsal penile artery (7).
The anterior (8) and lateral (9) scrotal branches derive from the external pudendal artery originating from the femoral artery. Of note,
the pudendal nerve (10, green arrow) accompanies the internal pudendal artery and its branches throughout the scrotum and penis
A D
E
B C

Page 6 of 13 Mirastschijski et al. Plast Aest het Res 2020;7:45 I http://dx.doi.org/10.20517/2347-9264.2020.44
vascularized by the anterior, lateral and posterior branches of dierent arteries, a schematic overview of the
vascular perfusion is shown in Figure 2E.
Patient selection for reconstructive surgery
Male patients (n = 5) with genital defects aer tumour or with classic buried penis type III according to the
previously published classication[9] were selected for penile sha reconstruction with the novel MiRA ap.
Aer thorough discussion and informed consent was obtained, elective reconstructive penile surgery took
place at the Department of Plastic, Reconstructive and Aesthetic Surgery or the Department of Urology
at Klinikum Bremen-Mitte, Bremen, Germany, in the years 2016 and 2017. e prerequisite for choosing
patients suited for this type of surgery was: (1) a penile sha defect of the entire penile length; (2) sucient
scrotal tissue and; and (3) written consent for the operation and photo-documentation.
e mean follow-up was around 7 months. e post-operative follow-up of patients 1 to 3 was uneventful
except for initial swelling and minor wound dehiscence. Patient 4 needed partial flap removal due to
recurrent LSC which had formed beneath the neo-preputium of the ap. Patient 5 received out-patient care
for penile cancer with his urologist and was lost from follow-up. For more detailed information see Table 1.
Surgical technique MiRA flap
Preoperatively, incision lines were marked on patients in the upright and supine position [Figure 3A]. e
midline of the scrotal sac, the raphe scroti, is the central part of the ap because it depicts the insertion
point of the scrotal septa and the position of the supplying vessels, i.e., the end branches of the internal
pudendal artery. Incision lines are marked bilaterally from the midline/the raphe scroti with a V- or
W-shape at its distal mobilization point. A scrotal examination was performed to conrm the presence of
both testes in the scrotal sac and absence of inguinal hernias. Furthermore, the presence of excess scrotal
tissue, also called peno-scrotal-webbing, was marked for ap harvest. Diagnosis of the stage of the adult
buried penis was performed according to the adult buried penis classification[17]. Prior to surgery, the
genital area was shaved. Patients were placed supine, washed with medical soap and disinfected. First,
diseased tissue was excised, e.g., sclerotic Lichen sclerosus skin lesions or in one case, a penile carcinoma
of the glans. All excised tissue was submitted for histopathological analysis. Patients presenting with adult
buried penis were treated according to the previously published algorithm[17]. In short, aer liposuction,
the pre-pubic fat apron was excised. e buried penis was retrieved and the area for ap reconstruction
measured with a ruler. The size of the MiRA flap was designed accordingly [Figure 3B and C]. After
Patient
number Diagnosis Co-morbidities Previous genital
operations Age (years)* BMI (kg/m2)Follow up
(months)
1 Buried penis Grade III Diabetes type II,
hypertension
benign prostatic
hyperplasia
Circumcision 74 35.1 6
2 Buried penis Grade III Diabetes type II,
hypertension, morbid
obesity
Circumcision 63 40.5 12
3 Buried penis Grade III Diabetes type II,
hypertension
Circumcision, recurrent
phimosis
63 38.5 6
4 Buried penis Grade III hypertension,
hyperuricemia, morbid
obesity
Circumcision due
to LSC**, recurrent
phimosis
56 50.7 12
5 Penile cancer Compensated
cardiac insufficiency,
hypertension
Cancer resection
(Buschke-Lowenstein-
Tumor)
80 n.d. 0
Table 1. Demographic data of patients included in the study
*at the time of operation; **LSC: Lichen sclerosus et atrophicus; BMI: body mass index; n.d.: no data. Classification of the buried penis
according to Mirastschijski[9] 2018

Mirastschijski et al. Plast Aes thet Res 2020;7:45 I http://dx.doi.org/10.20517/2347-9264.2020.44 Page 7 of 13
incision, the flap was raised on both septal arteries preserving both septa underneath the island flap
[Figure 3D-F]. Vascular branches anastomosing with lateral vessels were sealed using LigaClips®. The
flap was mobilized, freeing both septa from its caudal fixation in the scrotum up to the cranial fixation
point at the penile base so that it could be easily wrapped around the entire penile sha. Closure of the
scrotal sac was performed after bilateral orchidopexy, thorough hemostasis and drain placement. Due
to excessive and elastic scrotal tissue, the donor site defect was closed primarily aer mobilization of the
wound edges with subcutaneous absorbable single knots and intradermal running sutures aer inserting a
Penrose drain [Figure 3G-H]. e prepubic wound was closed according to plastic-surgical standards with
fascial anchoring sutures aer Baroudi and Ferreira[18] to avoid seroma formation and recurrence of penile
retraction into the prepubic tissue. For penile sha reconstruction, the MiRA scroti island ap, pedicled
Figure 3. The surgical technique of the midline raphe scrotal artery flap is presented. A: preoperative markings; B: flap harvest and
positioning around the penile shaft with complete coverage; C-F: the terminal branch of the pudendal artery runs in an arch-formed
way from the dorsal plane of the septum to the ventral side. The black arrow depicts the artery (D-F), the white arrow depicts the
concomitant nerve (E); G, H: postoperative result after wound closure. Visualization of the septal artery by diaphanoscopy in F
A D
G
B
E
H
C
F

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on both septal arteries, was wrapped around the penile shaft and closed with subcutaneous resorbable
(e.g., 3.0 Vicryl) and cutaneous non-absorbable (e.g., 3.0 Ethilon) single knots sutures. Because of post-
operative swelling, single knot sutures are preferred to avoid wound dehiscence. e reconstructed penis
is then dressed using a fatty gauze to protect the skin of the ap. A stabilizing sponge is positioned around
the penile sha and secured with staplers at the penile base and with sutures (3.0 Prolene, blunt needle) to
the glans. Aside from stabilizing the ap to the penile sha, the sponge inhibits excessive post-operative
swelling and lymphedema as well.
RESULTS
Five patients were included in the study after providing informed consent to the operation and to
anonymous publication of their photographs. Demographic data of the patients is listed in Table 1. Mean
post-operative follow-up was around 7 months. e surgical method was performed in each of the patients
without any complications. In each patient, the scrotal septum consisted of two membranes as found in
the anatomical study. In each septum, an arch-shaped terminal branch of the internal pudendal artery was
identied exactly underneath the scrotal raphe, which served as a surgical landmark. erefore, all island
aps were supplied by a dual arterial system. In all cases, excessive scrotal tissue was present to provide
sucient material for the island ap. In four cases of patients with adult buried penis, the complete penile
sha was graed with the MiRA ap. Figure 4 depicts an example of a patient with buried penis grade III
[Figure 4A and B]. Initial swelling was reduced aer 4 weeks post-operatively [Figure 4 C and D]. Aer one
year, the patient was very satised with the result including the neo-foreskin [Figure 4E and F]. No recurrence
of the buried penis was noticed in any of the monitored cases. In one case, a partial ventral sha defect was
covered with the ap aer excision of a carcinoma of the glans that had grown into the ventral skin [Figure 5].
The surgical procedure was performed by two independent surgeons. Post-operative complications
included a moderate hematoma (n = 1) without the need for intervention and lymphedematous swelling
which is very common for the genitalia. In two cases, a wound dehiscence occurred followed by secondary
suture aer reduction of the swelling. Long-term results included lymphedematous swelling that resolved
aer six to eight weeks and the recurrence of pre-existing Lichen sclerosus et atrophicus in one patient
with the need to excise part of the ap which had formed a neo-foreskin covering the glans completely.
Patients were highly satised and reported immediate sensation to the penile sha aer the operation, and
of enhanced erectile activity - which might have derived from the penile anchoring sutures.
DISCUSSION
Penile sha reconstructive surgery had been hitherto limited to skin gras with loss of tissue elasticity and
sensitivity or to part-time burying the penis into scrotal tissue. Local aps were restricted to the penile base
with insucient tissue to cover the complete length of the sha. Here, we present a double artery pedicled
midline scrotal island ap with complete cutaneous and sensitive restoration of the penile sha.
e current gold standard for surgical penile sha reconstruction are full-[17] or split-thickness skin gras[12]
with the disadvantages of post-operative shrinkage[10], scarring and loss of elasticity and, as a consequence,
reduced penile excursion which can impair erection and sexual intercourse. Major drawbacks of skin
gras are the complete loss of sensitivity to the penile sha and partial reduction of the penile length in
cases of gra shrinkage. e ultimate goal of our study was to nd a surgical technique for full functional
restoration of the penile sha while at the same time remaining a simple surgical procedure suitable for
patients with critical co-morbidities.
e use of scrotal tissue for penile sha reconstruction is not novel. Scrotal skin is similar to penile skin
in that it does not contain a subcutaneous fat layer and has a higher amount of elastic fibers than that
found in non-genital skin[19]. In contrast to penile skin, it is thicker and contains hair and sebaceous

Mirastschijski et al. Plast Aes thet Res 2020;7:45 I http://dx.doi.org/10.20517/2347-9264.2020.44 Page 9 of 13
glands. Several techniques were described to use scrotal skin for penile reconstruction, e.g., a scrotal dartos
ap[20], advancement aps[13,21] or a ventral slit scrotal ap[22]. e drawback of local advancement aps is
the limited reach with coverage of the penile base and parts of the penile sha but not the entire length of
the penis. e current urological golden standard for complete penile coverage is temporal burying of the
penile sha in the scrotal sac[14,23]. Aer 3 weeks, the ap is revascularized through penile vessels which
permit retrieval of the penis with full sha coverage by scrotal skin. Because the scrotal skin is completely
released, no nervous continuity is provided and, as a consequence, there is no sensitivity to the sha.
Anatomical studies on fresh cadavers were the prerequisite for the design of the novel ap presented in
this study. e male genital anatomy is poorly delineated specically with regard to scrotal vessels. Here,
we describe for the rst time the existence of two scrotal septa, each equipped with the terminal branch of
the internal pudendal artery that runs from the dorsal wall of the scrotum within the septum to the ventral
wall and anastomoses with lateral branches deriving from the external pudendal artery. Carrera et al.[16]
described in 2009 the central perfusion of the scrotal sac by two terminal branches of the internal pudendal
Figure 4. Pre- and postoperative example of a patient with buried penis type III and penile reconstruction with the MiRA island flap. A,
B: preoperative view with completely invaginated penile shaft of a classic type III buried penis patient; C, D: postoperative result after 4
weeks; E, F: stable result after one year without recurrence of the buried penis and with neo-foreskin
A
D
B
E
C
F

Page 10 of 13 Mirastschijski et al. Plast Aesthe t Res 2020;7:45 I http://dx.doi.org/10.20517/2347-9264.2020.44
Figure 5. The MiRA flap is suitable for partial penile reconstruction in a patient presenting with a Buschke-Lowenstein tumor that
extended onto the ventral side of the penile shaft. A, B: preoperative setting; C, D: tumor resection including total glansectomy; E-H:
intraoperative view with flap harvest (E, F) and closure of the donor site (G, H); I, J: postoperative result with partial preservation of the
penile shaft enabling micturition in the upright position
A
D
G
I J
B
E
H
C
F

Mirastschijski et al. Plast Aesth et Res 2020;7:45 I http://dx.doi.org/10.20517/2347-9264.2020.44 Page 11 of 13
artery, however, they did not discern that these arteries were running in parallel in two separate septa. A
study by Angspatt et al.[24] showed that the anterior scrotal artery supplies 62.5%-100% (mean 75.9%) of the
scrotal skin in the anteroposterior dimension and 66%-100% (mean 88%) in the superoinferior dimension.
e main blood supply runs through the branches of the external pudendal artery. e remaining tissue
was supplied by the posterior scrotal artery. Seemingly, the dominant vascular system perfusing the scrotal
tissue derives from the external pudendal artery with the anterior and lateral scrotal branches. e internal
pudendal artery provides branches to the dorsal part of the scrotum and the septum.
During embryonal development, the external genitalia in both sexes originate from the genital tubercles
and swellings. Under the influence of male or female hormones, genital swellings differentiate into the
scrotum (dihydrotestosterone) or labia majora (estrogen)[25]. In females, the process continues with
separation of the genital swellings that surround the vaginal vestibulum; in the male embryo, both genital
swellings fuse in the midline to become the scrotal sac[25]. e scrotal septum depicts the fusion line of both
genital swellings, and it is not surprising that it consists of two thin membranes with identical anatomical
structure. Genital development is indeed common knowledge, however, the existence of two scrotal septa
including a mirroring vasculature has not been described so far.
An island ap with dual arterial blood supply implies a safe surgical technique for penile sha coverage. Both
occlusion or disruption of the blood supply via one vessel will not jeopardize ap survival due to redundant
blood supply by the twin artery. Our assumption is based on angiosome studies by Angspatt et al.[24]
and previous reports on the anatomy of the posterior scrotal artery[26]. e septal scrotal artery is a branch
of the posterior scrotal artery deriving from the perineal artery [Figure 2E]. In our anatomical studies, we
could not clearly detect such angiosomes. Because the posterior scrotal artery anastomoses with branches
of the lateral scrotal artery, it is conceivable that the angiosome may include the skin area around the raphe
scroti along the septum scroti.
Interestingly, there are two further reports on scrotal island flaps with pedicles different from ours.
Karim et al.[27] used a dorsal scrotal island flap supplied by the dorsal scrotal vessels for perianal defect
coverage. Fakin et al.[28] reconstructed patients with penile granuloma with a ventral scrotal ap pedicled on
the deep external pudendal artery. Abundant bilateral cutaneous perfusion from dierent vascular sources
with highly elastic and excessive tissue renders the scrotum an ideal donor area for reconstructive surgery.
To avoid testicular torsion or ascension due to diminished volume of the scrotal sac aer skin and septal
resection, bilateral orchidopexy is recommended and should be routinely performed.
Nerves concomitant to the septal arteries provide cutaneous sensation over the ventral aspect of the
scrotum in proximity to the midline where the ap is harvested. is unexpected nding was reported by
our patients who were puzzled to locate the sensation of the neo-penile skin to the scrotal sac [Table 2].
In fact, the brain’s plasticity enables even elderly patients to learn the new location of the skin within a
few weeks, a well-known feature from reconstructive hand surgery[29]. In larger patient cohorts, objective
measurement tools such as the Semmes Weinstein test for sensitivity analysis are recommended to evaluate
clinical ndings in a standardized way.
A general drawback of island flaps is the cessation of lymphatic drainage due to complete cutaneous
excision with loss of lymphatic continuity [Table 2]. Consequently, a prolonged lymphedema is noticed
until new lymphatic vessels have developed. To minimize swelling and the risk of wound dehiscence,
a protective and stabilizing dressing is positioned circumferentially around the penis with fixation
to the perineum and glans. After removal, manual lymphatic drainage and compression therapy are
recommended. e highly elastic scrotal skin provides sucient tissue to cover the entire penile sha and
can form a neo-prepuce as well. In case of patients with Lichen sclerosus et atrophicus (balanitis xerotica

Page 12 of 13 Mirastschijski et al. Plast Aesthe t Res 2020;7:45 I http://dx.doi.org/10.20517/2347-9264.2020.44
obliterans), a recurrence of the disease was noticed due to restoration of the moist and predisposing milieu
for this skin disease. In this particular case, a revision with partial excision of the novel ap was indicated
and the defect was covered with a skin gra.
In conclusion, the novel neurovascular MiRA island flap is well suited to reconstruct the entire penile
sha aer tissue loss with restoration of a fully sensitive cutaneous envelope. Due to its abundant vascular
perfusion via two septal arteries, it is a safe and easily performed surgical technique for a wide range of
tissue defects of the male genitalia.
DECLARATIONS
Authors’ contributions
Invention of the ap, surgical design in anatomical studies: Mirastschijski U
Surgical procedures in patients: Mirastschijski U, Schwenke C
Made substantial contributions to the conception and design of the study, performed data analysis,
interpretation and acquisition, provided administrative, technical and material support, writing the
manuscript, corrections and advice: Mirastschijski U, Schwenke C, Schwab I, Buchhorn A, Schmiedl A
Availability of data and materials
Not applicable.
Financial support and sponsorship
None.
Conflicts of interest
All authors declared that there are no conicts of interest.
Ethical approval and consent to participate
An informed consent to participate in the study was obtained from each patient. For variation of standard
surgical procedures, no ethical approval is needed.
Consent for publication
A written informed consent for anonymous publication of photographs was obtained from each patient.
Copyright
© e Author(s) 2020.
Pros Cons
Simple surgical technique,
sufficient perfusion due to the presence of two arteries,
intact sensibility due to the presence of cutaneous nerves
Penile lymphedema,
wound dehiscence
Highly elastic tissue well-suited for size changes during erection Postoperative compression therapy
Restoration of micturition
Rehabilitation of sexual function
Bulkiness,
presence of hair
Prevention of recurrent buried penis
Reduction of excessive scrotal tissue
Scrotal size reduction,
orchidopexy
Neo-foreskin Contra-indication: LSC**
Recurrence due to neo-foreskin
Table 2. Summary of outcomes with midline raphe scroti artery island ap
**LSC: Lichen sclerosus et atrophicus

Mirastschijski et al. Plast Aesth et Res 2020;7:45 I http://dx.doi.org/10.20517/2347-9264.2020.44 Page 13 of 13
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