Flap reconstruction following Fournier's gangrene: A systematic review of techniques and outcomes

Fournier's gangrene is a life-threatening necrotizing soft tissue infection of the perineal and genital regions that often results in extensive tissue loss and complex reconstructive challenges. While initial management relies on aggressive debridement and source control, the subsequent reconstruction of perineoscrotal defects is critical to restore function, protect exposed structures, and preserve aesthetic and psychological well-being. Flap-based techniques, including fasciocutaneous and musculocutaneous options, are increasingly favored over skin grafts or secondary healing, particularly in the setting of exposed testes, urethra, or bone. We conducted a systematic review of 107 studies published between 1967 and 2024, encompassing 619 patients and 625 flaps, to comprehensively evaluate the types, indications, and outcomes of flap reconstruction following Fournier's gangrene. Medial thigh, pudendal thigh, anterolateral thigh (ALT), and gracilis muscle flaps emerged as the most commonly utilized, with regional flaps overwhelmingly preferred over free tissue transfer. The primary indications included coverage of exposed vital structures (52 %), functional restoration (39 %), and cosmesis (4 %). Despite the high-risk nature of the patient population, complication rates were low, with flap loss reported in only 1.6 % of cases. Functional and aesthetic outcomes were generally satisfactory, though standardized reporting tools were rarely used. Our findings highlight the apparent reliability, versatility, and safety of regional flaps in Fournier's gangrene reconstruction and underscore the need for greater standardization in outcome assessment and flap selection algorithms. This review serves as the most comprehensive synthesis to date and provides an evidence-based foundation for flap reconstruction decision-making in this devastating condition.