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“Mulching” Integra for Glans Penis Reconstruction

Knotts, Christopher D. M.D.; Morgan, Aaron L. B.S.; Deschamps-Braly, Jordan C. M.D.; Sawan, Kamal T. M.D.; El Amm, Christian A. M.D.

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Plastic and Reconstructive Surgery: September 2010 - Volume 126 - Issue 3 - p 151e-152e
doi: 10.1097/PRS.0b013e3181e3b599
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Sir:

Penile soft-tissue defects are uncommon but present significant challenges to reconstructive surgeons in terms of erectile capacity, sensation, cosmesis, and reliability of coverage. Many techniques have been described for penile coverage, including use of remnant prepuce, scrotal skin, or local flaps,1 although skin grafting is most advocated for ease of use, minimal donor-site morbidity, and versatility.2 The bilayer skin regenerate Integra (Integra Lifesciences Corp., Plainsboro, N.J.) has also been described for resurfacing the penile shaft,3 but never for glans reconstruction.

Integra is composed of two layers, an acellular dermal matrix consisting of bovine collagen and shark chondroitin-6-sulfate applied to a thin layer of silicone, which acts as artificial epidermis. After vascular and cellular ingrowth into the dermal matrix, the silicone layer is peeled away and replaced with a split-thickness skin graft, which decreases donor-site morbidity and improves aesthetic results.4 Integra has also been used as a filler by removing the silicone layer and burying the dermal matrix layer beneath autologous tissues.5 We present a case of modifying Integra by removing the silicone laminate and sharply “mulching” the dermal matrix to fill a glans penis defect.

A 60-year-old diabetic man was referred to our plastic surgery clinic for soft-tissue coverage following Mohs' excision of penile squamous cell carcinoma. The full-thickness defect involved the glans penis and extended into the coronal sulcus, with no urethral involvement (Fig. 1). The depth and concavity of the lesion were not conducive to skin grafting alone; therefore, we elected to first correct the volume deficit with Integra and perform skin grafting afterward.

Fig. 1.
Fig. 1.:
Original full-thickness defect at the time of presentation.

At the time of surgery, a tourniquet was applied to the penis and saline was injected to achieve erection. The wound bed was prepared sharply and a sheet of Integra was modified by removing the silicone laminate and “mulching” the matrix to a putty consistency using a scalpel. The “mulch” was sculpted to recreate the glans, and the entire defect was covered with unmodified Integra. A bolster was placed and the patient discharged to home on the day after surgery.

One week postoperatively, the bolster was removed and daily moist dressings were changed by the patient. Two weeks later, the patient was returned to the operating room for placement of a full-thickness, nonmeshed skin graft taken from non–hair-bearing inguinal skin. Again, a bolster was placed and 1 week later removed to show 100 percent graft take.

At 2-month follow-up, graft contraction led to slight deviation of the urethra that did not interfere with urination (Fig. 2). The patient reported normal erectile capacity and decreased but notably present discrimination to light touch. The patient returned to sexual activity 6 weeks after skin grafting.

Fig. 2.
Fig. 2.:
Postoperative view after full-thickness skin graft showing good take and improvement in contour deformity.

Mulching the dermal matrix component of Integra is an important tool for the reconstructive surgeon faced with restoring volume loss of the glans penis. The technique allows for vascular ingrowth, reinnervation, contour correction, and a wound bed capable of accepting a skin graft for final coverage.

Christopher D. Knotts, M.D.

Aaron L. Morgan, B.S.

Jordan C. Deschamps-Braly, M.D.

Kamal T. Sawan, M.D.

Christian A. El Amm, M.D.

University of Oklahoma Health Sciences Center

OU Medicine

Oklahoma City, Okla.

DISCLOSURE

The authors have no financial interest in any of the products mentioned in this article.

REFERENCES

1.Jordan GH, Schlossberg SM, McCraw JB. Principles of wound healing and tissue transfer techniques for genitourinary reconstructive surgery. Semin Urol. 1987;5:219–227.
2.Vincent MP, Horton CE, Devine CJ Jr. An evaluation of skin grafts for reconstruction of the penis and scrotum. Clin Plast Surg. 1988;15:411–424.
3.Payne CE, Williams AM, Hart NB. Lotus petal flaps for scrotal reconstruction combined with Integra resurfacing of the penis and anterior abdominal wall following necrotising fasciitis. J Plast Reconstr Aesthet Surg. 2009;62:393–397.
4.Heimbach D, Luteman A, Burke JF, et al. Artificial dermis for major burns: A multi-center randomized clinical trial. Ann Surg. 1998;208:313–320.
5.Frame JD, Frame JE. Modifying Integra as a regeneration template in deep tissue planes. J Plast Reconstr Aesthet Surg. 2006;59:460–464.

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