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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 24  |  Issue : 1  |  Page : 78-80

Electrical injury of external genitalia and reconstruction with gracilis muscle flap


Department of Plastic Surgery, Sushrutha Institute of Plastic Surgery, Elite Mission Hospital, Thrissur, Kerala, India

Date of Web Publication12-Dec-2016

Correspondence Address:
Jyoshid R Balan
Sushrutha Institute of Plastic Surgery, Elite Mission Hospital, Thrissur, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-653X.195539

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  Abstract 

The high-voltage electrical injury is not uncommon, but the involvement of the genitalia and the perineum is rare. Our patient is a 29-year-old female with electrical injury from a high-tension wire and had injury to the perineum, genitalia, and lower limbs with negligible involvement of the upper limbs. There was a loss of the lower half of the labia majora and she had a tissue defect on the left side of the perineum. The reconstruction was performed with the use of pedicled gracilis flap with a good outcome.

Keywords: Electrical injury, gracilis muscle flap, labia majora, perineum


How to cite this article:
Balan JR. Electrical injury of external genitalia and reconstruction with gracilis muscle flap. Indian J Burns 2016;24:78-80

How to cite this URL:
Balan JR. Electrical injury of external genitalia and reconstruction with gracilis muscle flap. Indian J Burns [serial online] 2016 [cited 2017 Sep 23];24:78-80. Available from: http://www.ijburns.com/text.asp?2016/24/1/78/195539


  Introduction Top


The impact of electrical injury varies from small burns to devastating tissue injury amounting to death. The severity of the injury depends on the voltage of the electric current and the duration of contact; higher the voltage, more is the tissue damage. The involvement of the perineum and the genitalia are not so common in electrical injury when comparing with the limbs. The involvement of vulvar and perineal burns are usually associated with extensive thermal injuries. The occurrence of isolated vulvar and perineal burns are rare since the area is anatomically well protected.[1] The involvement of the flexor creases in electrical injury is well described due to arcing of the current and it is described as “kissing burns.” There are descriptions of electrical injury involving the genitalia in literature. In this report, we present a case of high-tension electrical injury involving the genitalia and perineum. In our patient, the possible mechanism of involvement of the genitalia is involvement of the flexor crease with a moist environment making it more susceptible.


  Case Report Top


Our patient is a 29-year-old female, who sustained injury to the perineum and genitalia from high-tension wire. She had associated flash burns of both lower limbs and buttocks. She presented to our emergency department after a fortnight of the injury. Examination of the perineum revealed loss of the lower half of the labia majora with a tissue defect in the perineum on the left side [Figure 1]. She also had associated raw areas on both upper medial thighs [Figure 1]. After a few days of dressings, she was taken up for the surgery under general anesthesia. Thorough debridement of the raw areas was done, leaving defects in the left side of perineum and genitalia. We planned to reconstruct the defect with ipsilateral pedicled gracilis muscle flap since both upper medial thighs were involved in the burns. The only issue regarding using local flap in case of electrical injury is the reliability of vascular pedicle. Since the pedicle of gracilis is situated in the upper third of the thigh and away from the perineum, the involvement of the pedicle in the injury was less likely. The upper thigh raw areas were excised, through the same incision and left side gracilis muscle flap was elevated [Figure 2]a. During elevation, the vascular pedicle pulsations and the muscle viability were made sure before fully elevating the flap. The gracilis muscle flap was used to reconstruct the left side genitalia and cover the defect over the left side perineum [Figure 2]b and [Figure 2]c. The remaining raw areas were grafted along with the raw areas of the limbs [Figure 2]d. The postoperative period was uneventful with no morbidity in the form of the graft or flap loss. She was able to continue with normal sexual functions 2 months postoperatively [Figure 3].
Figure 1: Electrical injury with raw area upper thighs, involvement of genitalia with partial loss of labia majora. Left side perineum showing a defect

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Figure 2: Intra-operative picture. (a) Left side gracilis muscle flap elevated. (b) Gracilis muscle tunneled to the defect. (c) The inset of the gracilis to the lower edge of labia majora. Excision and primary closure of the raw areas over the upper thighs. (d) Split thickness grafting over the muscle flap and residual raw area

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Figure 3: Two and half months postoperative results showing well-settled flap and grafted areas

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  Discussion Top


Isolated perineal and genital burns are rare and occur associated with involvement of other areas.[2] The incidence of electrical injury to the perineum and the genitalia is <3% according to Angel et al.[3] Superficial burns can be treated conservatively while the deeper ones require graft or flap for the coverage. Early excision and grafting is a well-described entity for perineal and genital burns.[4] The usual etiology of vulvar and vaginal defects is posttumor excision. The “angel wing” perforator flap is a described method for vulvar and vaginal reconstruction.[5]

The options for reconstruction of perineum and genitalia vary from pedicled flaps to free flaps. The local and regional pedicled flaps are given priority over microvascular free flaps in case of perineal reconstruction.[6] The local fasciocutaneous flaps are usually planned in random and there is a limitation of the size of the flaps. The Singapore flap and the lotus petal flap are regional flaps based on the internal pudendal artery. These flaps give adequate tissue for the reconstruction in moderate to larger defects. In our patient, these options were not viable since the medial upper thigh was also burnt, and the etiology of the defect was electrical injury with a possible injury of the vascular pedicle. The distant pedicled flaps used for the reconstruction are taken from the thigh or the abdominal wall. The pedicled vertical rectus abdominis myocutaneous flap is a very good option for perineal reconstruction in case of defects with larger tissue requirements. The gracilis myocutaneous flap also provides a larger tissue bulk. In case of the superficial defect or minimum tissue requirement, the pedicled anterolateral thigh flap, pedicled tensor fascia lata flap, posterior thigh flap, and gracilis muscle flaps can be used.[7] In our patient, the tissue requirement was not much; hence, we preferred pedicled gracilis for the reconstruction. The added benefit of the pedicled gracilis is that the donor site is well concealed. The pedicled gracilis muscle flap has been used for urethral fistula repair following electrical injury in the past.[8] The management of high-voltage electrical injury to the perineum and electrical injury requires a multidisciplinary approach for the management,[9] and in severe cases, a diversion colostomy is also advisable.

The impact of disfigurement of the perineum and vulva has more of psychological and mental impairment in any individual. Restoration of the best possible esthesis is advisable if practical. Our patient was initially depressed due to the injury and was noticed to be very positive during the follow-up visits.


  Conclusions Top


The pedicled gracilis muscle flap is a time-tested and viable option for the perineal and vulvar reconstruction, especially for moderate tissue defects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Weiler-Mithoff EM, Hassall ME, Burd DA. Burns of the female genitalia and perineum. Burns 1996;22:390-5.  Back to cited text no. 1
    
2.
Klaassen Z, Go PH, Mansour EH, Marano MA, Petrone SJ, Houng AP, et al. Pediatric genital burns: A 15-year retrospective analysis of outcomes at a level 1 burn center. J Pediatr Surg 2011;46:1532-8.  Back to cited text no. 2
    
3.
Angel C, Shu T, French D, Orihuela E, Lukefahr J, Herndon DN. Genital and perineal burns in children: 10 years of experience at a major burn center. J Pediatr Surg 2002;37:99-103.  Back to cited text no. 3
    
4.
Edelman GC, Sweet ME, Messing EM, Helgerson RB. Treatment of severe electrical burns of the genitalia and perineum by early excision and grafting. Burns 1991;17:506-9.  Back to cited text no. 4
    
5.
Kim SW, Lee WM, Kim JT, Kim YH. Vulvar and vaginal reconstruction using the “angel wing” perforator-based island flap. Gynecol Oncol 2015;137:380-5.  Back to cited text no. 5
    
6.
Kolehmainen M, Suominen S, Tukiainen E. Pelvic, perineal and genital reconstructions. Scand J Surg 2013;102:25-31.  Back to cited text no. 6
    
7.
Mughal M, Baker RJ, Muneer A, Mosahebi A. Reconstruction of perineal defects. Ann R Coll Surg Engl 2013;95:539-44.  Back to cited text no. 7
    
8.
Sharma RK, Biswas G. Repair of a urethral fistula following electrical burns using a gracilis muscle flap. Burns 1990;16:467-70.  Back to cited text no. 8
    
9.
Tiengo C, Castagnetti M, Garolla A, Rigamonti W, Foresta C, Azzena B. High-voltage electrical burn of the genitalia, perineum, and upper extremities: The importance of a multidisciplinary approach. J Burn Care Res 2011;32:e168-71.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
Introduction
Case Report
Discussion
Conclusions
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