[Reprinted from The Philadelphia Medical Journal, November 5,1898.1 
RESTITUTION OF SKIN BY PLASTIC OPERATION IN 
CASES OF EXTENSIVE TRAUMATIC SURFACE- 
DEFECTS OF THE SCROTUM AND PENIS. 
By N. SENN, M.D., Ph.D., LL.D., 
Professor of the Practice of Surgery and Clinical Surgery in Rush Medical Col- 
lege ; Professor of Surgery in the Chicago Polyclinic; Attending Sur- 
geon to the Presbyterian Hospital; Surgeon-in-Chief to 
St. Joseph’s Hospital. 
of Chicago. 
Surgeons have for a long time been made aware of 
the fact that extensive skin-defects of the scrotum 
caused by injury or disease are usually repaired in a 
comparatively short time by granulation, cicatrization, 
and epidermization. In cases of gangrene of the scro- 
tum resulting in denudation of both testicles, the ex- 
posed organs are, in the course of a few weeks, furnished 
with a new coating without operative intervention, by 
the formation of a contracting scar, which, by making 
traction upon the surrounding skin, approximates the 
margins of the granulating surface from all sides, so 
that when the process of healing is completed the new 
scrotum is largely composed of normal skin obtained 
from the neighborhood by cicatricial contraction. 
Bruns attributed to the scrotal tissues a maximum 
recuperative power in explanation of the speedy and 
satisfactory healing of extensive skin-defects. Koche/, 
on the other hand, denies any such special properties 
inherent in the tissues of the scrotum, and asserts that 
wounds of the scrotum heal in the same manner, and 
the healing process requires the same length of time, 
as the repair of surface-wounds in any other part of 
the body. He explains the apparently more rapid healing of scrotal wounds by the displacement of the 
adjacent loose skin by the contracting scar, an opinion 
that has since become satisfactorily substantiated by 
extensive and careful clinical observations. 
Skin-grafting by Reverdin’s or Thiersch’s method has 
been resorted to and has been strongly advised by 
some surgeons to expedite the healing of large granu- 
lating wounds of the scrotum, but it is doubtful if the 
results obtained with the aid of this modern surgi- 
cal resource are any better than those following spon- 
taneous healing of such wounds. The skin-grafts are, 
at best, only an imperfect substitute for normal elastic 
skin, and their presence must, necessarily, interfere 
with the desired displacement of the adjacent skin by 
the contracting scar. 
Nothing has been done in the way of primary'plastic 
operations in restoring extensive traumatic skin-defects 
of the scrotum and penis. Surgeons have relied on the 
healing of such wounds by granulation in all cases in 
which, owing to the size of the wounds, suturing was 
out of the question. The location of such wounds ren- 
ders it almost impossible to secure and maintain an 
aseptic condition long enough for the completion of 
the healing process. The denuded and exposed parts 
are exposed to the dangers incident to infection, and 
healing seldom takes place without suppuration, and 
often weeks and months are required before the injured 
parts are protected by new and displaced skin. 
Considering that the external genital organs are sur- 
rounded on all sides by an abundance of loose skin, 
well adapted for plastic operations, it is somewhat 
strange that surgeons have not taken advantage of this 
favorable anatomic environment and resorted to plastic 
procedures in restoring recent extensive traumatic skin- 
defects of the scrotum and penis. In the case that 
forms the subject of this paper such an effort was made, and the result was so satisfactory that I have deemed 
it of sufficient importance to bring it to the attention 
of the profession. In this instance the entire scrotum, 
one testicle, and the whole cutaneous sheath of the 
penis were torn away in a machinery-accident: 
The patient, a German laborer, 33 years of age, in good 
health, was injured October 11, 1897, and was admitted to St. 
Joseph’s Hospital a few hours after the accident occurred. 
Fig. 1.—Extent of wound and appearance of parts before operation. 
He was employed in a bicycle-factory, and when the injury 
was sustained lie was standing on a ladder, adjusting a belt 
on a pulley from the headline-shaft to a stamping-press. His 
clothes were caught by the revolving shaft, and, with the ex- 
ception of his shoes and stockings, were torn from his body. 
He fell from the ladder down to the floor, a distance of ten 
feet, and at once discovered the extent of injury to the ex- 
ternal genital organs. He attempted to arrest the bleeding, 
which Was quite free, by washing the wound with cold water 
obtained from a sink. A physician was called, who dressed 
the wound and sent the patient to the hospital. On examination at the hospital the entire skin covering 
the external genital organs, as well as the left testicle, was 
found torn away with the clothing. The parts lost are now 
in possession of the physician who first dressed the wound. 
Figure 1 represents the extent of the injury and the appear- 
ance of the parts before the operation. The loss of skin ex- 
tended nearly over the entire region of the mons veneris. 
The left spermatic cord and vessels were torn off near the 
Fig. 2.—Appearance of parts after first operation ; dotted lines showing 
incisions of second operation. 
external inguinal ring. The left inguinal canal was torn 
open nearly in its entire length. Hemorrhage from the sper- 
matic artery had been arrested by applying hemostatic 
forceps. 
The patient was pale, but did not suffer from any severe symptoms of shock. He was at once placid-under the full 
influence of ether, when the wound anffi surrounding 
skin were thoroughly disinfected. The left spermatic vessels 
were ligated with catgut and the inguinal canal was sutured 
with the same material. Formalin-iodoform catgut was used 
both for ligatures and sutures. The right testicle, spermatic 
cord, and accompanying vessels were found loose and de- 
tached from the underlying tissues as far as the external in- 
guinal ring; the tunica vaginalis was intact; pulsation of 
the spermatic artery was distinct. I decided to cover 
the wound by undermining and mobilizing the adja- 
cent skin. The testicle was brought in proper position and 
was covered with skin by undermining the margins of the 
wound and suturing it in a vertical direction as far as the 
root of the penis. 
The skin above was undermined in an upward direction 
sufficiently to secure room for the denuded penis, when a 
transverse incision was made sufficiently large to bring the 
glans penis out, and the mucous membrane of the corona 
glandis was sutured to the skin with fine catgut and horse- 
hair sutures. The remainder of the wound was then closed 
transversely, as shown in Figure 2. Drainage was secured 
from the lower angle of the vertical to the left angle of the 
transverse wound by inserting a strip of iodoform-gauze. 
With the exception of the drainage-openings the wound was 
sealed with iodoform-collodion, over which the ordinary anti- 
septic dressing was applied and held in place by means of 
strips of adhesive plaster. 
The operation was not followed by any untoward symptoms. 
The patient emptied his bladder without any difficulty, being 
directed to lie on his side during the evacuation. With the 
exception of a small place about the left angle of the trans- 
verse incision, the entire wound healed by primary intention. 
On October 25th, two weeks after the first operation, a 
second plastic operation was performed, for tire purpose of 
releasing the penis from its abnormal position and providing 
for it a complete cutaneous sheath from the skin of the ab- 
domen. The operation was carried out under full ether-an- 
esthesia. The dotted lines in Figure 2 show the number and 
direction of the incisions. The incision above the glans 
penis secured a flap to cover the dorsum of the organ. The 
lateral incisions furnished a flap to cover at least two-thirds 
of the circumference of the penis. The dorsal Hap received 
an ample blood-supply from its new attachments with the 
base of the glans penis. After liberating the penis and 
bringing it into its natural position the dorsal flap was sutured 
on each side to the lower flap, which had become attached 
in the center to the whole length of the undersurface of the 
penis. (Figure 3.) The large wound above the penis was 
covered with two triangular flaps, which were sutured 
together in the median line, and when in position were; attached to the lateral incision and base of the penis by 
means of tension-sutures of silk and coaptation-sutures of 
silkworm-gut and horsehair. The dressing was the same as 
after the first operation, with the exception that the penis 
was dressed separately and with special care, to prevent 
harmful circular pressure. Primary union failed to take 
place at the root of the penis on the left side, where the apex 
of the triangular (lap sloughed, leaving a limited granulating 
Fig. 3.—Penis liberated and covered completely with skin from the abdomen. 
Wound above closed with two triangular flaps. 
defect, which healed in a most satisfactory way in the course 
of three weeks. In spite of frequent and severe erections, 
the wounds on the side of the penis healed almost through- 
out by primary intention. The patient left the hospital 
two months after his admission, highly pleased with the 
immediate and remote results of the two plastic operations.