Surgical approach to penile reconstruction for shaft skin excision from circumcision

We read with great interest the article titled “Surgical approach to penile reconstruction for shaft skin excision from circumcision” by Thomas G W Harris”. [1] The authors presented a very interesting case series of devastating complications following circumcision proposing two different reconstructive methods: skin grafts with or without preliminary tissue expander. We congratulate the authors for their article, and we completely agree with them for the chosen reconstructive strategy, but we have some elements to discuss. The state of the art shows different methods for reconstruction of the penile shaft such as: skin grafts, local and free flaps. Although the simplicity of the method, skin grafts should not be the first reconstruction option because of the higher risk of retraction, poor tissue elasticity limiting extensibility during erection, and less resistance to sexual intercourse. Since the bulky nature of free flaps, if any, might represent some difficulties during penetration and poor aesthetical outcomes producing unnatural appearance, local flaps remain the gold standard for penile reconstruction. Basing on like-to-like principles, the scrotum seems to be the most suitable tissue for shaft repair, including color, thickness, pliability, elasticity and consistency, able to provide a large amount of tissue and obtaining satisfactory outcomes in terms of aesthetic and functional result, avoiding also mismatch disorder. The multi-origin vascular system providing the scrotum is supported on each side by four different vessels: the anterior and lateral scrotal artery, the lateral branch of posterior scrotal artery, and the septal scrotal artery. These vessels running through Dartos fascia render the scrotal Dartos-myo-cutaneous flap an axial flap, allowing safely a single surgical operation avoiding discomfort related to a second procedure and the vascular network of the scrotum allows a large amount of tissue harvesting in a single step. [2,3,4,5,6] The scrotum provides a very large amount of thin and stretchy tissue permitting a satisfactory coverage of ta large recipient damaged area, allowing, at the same time an easy donor site primary intention closure. The skin quality of the scrotum results suitable during erection due to its elasticity and appropriate during sexual intercourse because of its thickness. (Fig. 1).