Preventing Penile Retraction After Fournier's Gangrene: Progressive-Tension Soft-Tissue Fixation for Penile Reconstruction.

Fournier's gangrene (FG) is a rapidly progressive necrotizing soft-tissue infection associated with substantial morbidity and mortality. Extensive genital debridement may result in complex defects requiring reconstruction to restore function, body image, and quality of life. Penile reconstruction is particularly challenging because successful skin grafting requires both graft immobilization and maintenance of penile projection. We report a 58-year-old man with type II diabetes mellitus and obesity who presented with fever, genital pain, and severe systemic inflammation (C-reactive protein: 248 mg/L). Following intensive care admission, he underwent two surgical debridements. The scrotal soft tissues were completely excised, and the testes were preserved in bilateral subcutaneous anteromedial thigh pouches. After infection control, an extensive circumferential penile skin defect remained. Negative-pressure wound therapy (NPWT) was attempted; however, despite induction of an artificial erection, a reliable airtight seal could not be maintained because of abundant and highly mobile pubic tissues. To address the tendency toward proximal penile retraction, defined as displacement of the penile shaft into the surrounding mobile soft-tissue envelope, the pubic tissues were sequentially anchored circumferentially to Buck's fascia using buried 4-0 polydioxanone (PDS) sutures in a progressive-tension fashion. Fixation points were tailored intraoperatively to progressively obliterate the dead space while preserving tissue perfusion. The shaft was subsequently resurfaced with an unmeshed split-thickness skin graft harvested from the right thigh. At one month, stable graft coverage and penile projection were maintained without recurrent retraction, and the patient was able to void spontaneously without difficulty. This case highlights that circumferential penile reconstruction may require stabilization not only of the graft-to-bed interface but also of the surrounding mobile soft-tissue envelope. Progressive-tension fixation to Buck's fascia may provide a useful adjunct in selected patients in whom obesity, tissue mobility, and penile retraction complicate conventional graft stabilization.