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Pedicled Penile / Preputial Skin Flap

Pedicled penile and preputial skin flaps are the most commonly used flaps in genitourinary reconstruction, all built on the excellent vascularity of the dartos fascia, which serves as the vascular carrier for every penile-skin flap design.[1][2] The family encompasses several named techniques — Quartey / Duckett transverse preputial island, longitudinal / oblique preputial island, double-face preputial island, Orandi dorsal onlay, McAninch circular fasciocutaneous, circumpenile fasciocutaneous, and the dartos fascial flap — all sharing the dartos-based supply but differing in geometry, transfer direction, and primary indication.

These flaps provide hairless, thin, pliable tissue suitable for urethral reconstruction, hypospadias repair, penile resurfacing, gender-affirming vaginoplasty, and feminizing genitoplasty. As Joshi et al. (2022) summarized for the Urologic Clinics of North America: "Penile flaps are the commonest. Overall, the winner is the dartos."[1]

Vascular Anatomy — The Foundation​

All pedicled penile / preputial flaps depend on the cutaneous blood supply of the penis.[5] The territory was definitively mapped by Grossman et al. (1989) in a cadaveric injection study:[2]

  • The cutaneous supply of the penile shaft derives solely from a pair of axial arteries running in the dartos layer — branches of the superficial external pudendal arteries
  • Additional deep perforating arteries from the dorsal penile and corporal vessels supply the glans and subcoronal region
  • The preputial skin receives blood supply from terminal branches of the dorsal penile artery (preputial branches at the coronal sulcus) plus the dartos axial vessels.[2][3][4]

Kureel et al. (2013) characterized the dartos vascular anatomy with MRI and CT angiography, confirming that parallel to the ventral midline, axial-pattern vessels to the skin-dartos complex are constant, with additional preputial supply from terminal penile arteries.[3]

The inferior external pudendal artery has a mean diameter of ~0.94 mm at the base of the penis with anastomoses across the midline. Preputial skin receives additional perforator supply from the dorsal artery, without visible anastomosis between those perforators and the inferior external pudendal artery — a key safety point for preputial-island design.[4]

The dartos is therefore the true pedicle of all these flaps; the skin is along for the ride. Suprafascial dissection that leaves the dartos behind compromises the entire flap family.

Flap Configurations​

1. Transverse preputial island flap (TPIF) — Duckett / Quartey​

The most widely used configuration, originally described by Duckett (1980) for hypospadias and by Quartey (1983) for urethral stricture:[6][7]

  • Transverse island of inner preputial skin harvested with its dartos fascial pedicle intact
  • Pedicle based on the superficial external pudendal vessels in the dartos
  • Skin island is hairless and can reach from the external meatus to the prostatic urethra[6]
  • Used as onlay (preserving the urethral plate) or tubularized into a neourethra[7][8]

2. Longitudinal / oblique preputial island flap​

A modification described by Chen et al. (1993) that includes both inner and outer surfaces of the prepuce:[9]

  • Longitudinal or oblique orientation allows incorporation of a larger skin paddle
  • Both inner and outer preputial surfaces can be used to construct the neourethra
  • Fistula 8.3% and meatal stenosis 5% in 60 patients

3. Double-face preputial island flap (DFPIF)​

Uses both the inner face (for urethroplasty) and the outer face (for ventral skin coverage) simultaneously:[10]

  • Blanc 2021 — 75 boys with severe (penoscrotal / scrotal / perineal) hypospadias
  • 48% had complications requiring redo surgery (12 fistulas, 11 diverticula, 7 meatal stenosis, 3 strictures)
  • After a median of 1.8 procedures, the final success rate was 96%
  • The healthy, well-vascularized ventral skin allows safe redo surgery when needed

4. Orandi flap (longitudinal ventral penile skin flap)​

Originally described by Orandi (1968) for urethral stricture repair; a longitudinal penile-skin island on the dartos pedicle.[11][12]

  • Barbagli 2019 described a modified dorsal Orandi: the penile-skin island is dissected on its dartos pedicle, moved over the corpora cavernosa, and the urethra is sutured over the flap
  • 10 of 12 cases successful (83%); operating time only 60 minutes
  • No postoperative fistula or urethral diverticulum[11]

5. Circular fasciocutaneous penile flap (McAninch flap)​

Described by McAninch (1993) for extensive anterior urethral strictures:[13]

  • Originates on the distal penis using Buck's fascia as the major vascular conduit
  • Provides up to 15 cm of length — the longest reach of any penile-skin flap
  • Hairless, adapts to the entire anterior urethra, and works in circumcised men
  • 10-patient series with strictures 8–21 cm: no recurrence, mean Qmax 21.7 mL/s, normal erectile function

Zhao 2026 modified version in 54 patients: the circular flap is longitudinally split on the dorsal side and transferred ventrally. No stricture recurrence at 15-month follow-up; Qmax improved from 6.3 to 18.6 mL/s (p < 0.05); IIEF-5 maintained at 23.5–23.9; post-micturition dribbling 24%; mild penile torsion in 14.8%.[14]

ConfigurationRecurrence rate (McAninch original series)[13]
Onlay13%
Tubularized58%

Onlay is strongly preferred whenever the urethral plate can be preserved.

6. Circumpenile flap (for circumcised patients)​

When the prepuce is unavailable, the remaining penile shaft skin can be harvested as a fasciocutaneous flap on its dartos pedicle:[15]

  • Srivastava 2012 — 93.3% success at 1 year and 86.7% at 3 years in circumcised patients — comparable to or better than preputial flaps
  • A critical option for patients with unsuitable oral mucosa who are also circumcised

7. Dartos fascial flap (no skin)​

The fascia alone, without a skin island — used as a waterproofing layer over the neourethra to prevent fistula. Mobilized from the penoscrotal angle, dorsal shaft, or surrounding penile fascia. Functions as the inner-layer waterproofing of virtually every modern hypospadias repair.[27][28]

Application 1 — Urethral Stricture Repair (Urethroplasty)​

The primary adult urologic application. The AUA Urethral Stricture Disease Guideline (2023) positions penile fasciocutaneous flaps alongside oral mucosal grafts:[16]

  • For long multi-segment strictures (> 10 cm): "Surgeons may reconstruct long multi-segment strictures with one-stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps, or a combination of these techniques" (Moderate Recommendation; Evidence Grade C)
  • Oral mucosa is the first choice when using grafts (Expert Opinion); penile-skin flaps remain a valid alternative when oral mucosa is unavailable or insufficient
  • Hair-bearing skin should not be used for substitution urethroplasty (Clinical Principle)

Dorsal vs. ventral onlay placement​

Bhandari 2001 compared dorsal vs. ventral placement of the preputial / penile skin onlay flap in 40 patients:[17]

  • Stricture recurrence: ventral 24% vs. dorsal 11% (NS)
  • Pseudo-diverticulum / sacculation with post-void dribble: ventral 6 patients vs. dorsal 0 (p = 0.01)
  • Conclusion: dorsal placement is anatomically and functionally more appropriate — it avoids the unsupported ventral position that leads to sacculation

Penile-skin flap vs. buccal mucosa graft — head-to-head RCTs​

StudyDesignnSuccess (flap vs. BMG)Key differences
Dubey 2007RCT5585.6% vs. 89.9% (NS)Flap: longer OR (224 vs. 162 min, p = 0.001), more skin necrosis, more post-void dribbling (34% vs. 15%, p = 0.001), lower satisfaction (65% vs. 89%, p = 0.001)[18]
PeeBuSt (Tyagi 2022)RCT10089% vs. 91% (NS)No differences in Qmax, IPSS, USS-PROM, IIEF, MSHQ-EJD at 18 months[19]
Alrefaey 2025RCT9893.2% vs. 97.9% (NS)No differences in any functional parameter; comparable satisfaction (90.9% vs. 93.8%); equivalent Kaplan-Meier stricture-free survival (HR 1.19, p = 0.275)[20]

The newer trials show equivalent outcomes between penile skin flaps and buccal mucosa grafts, suggesting that with refined technique, flaps achieve results comparable to the contemporary graft standard. Despite equivalent efficacy, current practice has shifted toward BMG: a 2024 SGUR survey found 99% prefer buccal mucosa as the primary graft site, and BMG was favored over fasciocutaneous flap regardless of circumcision status (95% with circumcision, 84% without). For panurethral strictures, 90% preferred multiple BMGs over combined graft / flap.[21]

Combined graft + flap technique​

For complex strictures with damaged urethral plates, combining a dorsal BMG with a ventral penile-skin flap leverages both:[12][22]

  • Karapanos 2024 — 12 patients with narrow penile strictures (median 5 cm). Dorsal BMG + ventral Orandi PSF with preserved native urethral plate and corpus spongiosum. 91.7% success at 38-month follow-up; no sacculation or diverticula; post-void dribbling 41.7%.
  • Anadani 2025 — case report: 5 cm recurrent stricture with prior failed urethroplasty; combined dorsal BMG + ventral penile-skin flap achieved well-patent urethra at 3 months.

Application 2 — Hypospadias Repair​

Preputial island flaps are the cornerstone of flap-based hypospadias repair, particularly for proximal hypospadias where the urethral plate is inadequate or must be transected.

Onlay vs. tubularized preputial island flap​

Wiener 1997 compared the two configurations in 132 patients (single surgeon, 11-year experience):[8]

  • Overall complications: tubularized 36% vs. onlay 31% (NS)
  • Fistula rates similar (14% vs. 17%), but tubularized fistulas were larger and required more complex repair (p = 0.015)
  • Diverticula: tubularized 9 patients vs. onlay 0 (p = 0.016)
  • Conclusion: onlay is preferred when the urethral plate can be preserved — fewer diverticula and simpler fistula management

Ghali 1999 — 418-patient comparative series​

The largest single-surgeon comparative experience (12 years):[7]

  • 216 Mathieu, 148 Duckett (tubularized TPIF), 42 onlay preputial, 12 Mustardé
  • Overall complications 22%; final success after a mean of 1.4 procedures: 95%
  • Duckett's tubularized repair had significantly higher complications (fistulae, strictures, meatal stenosis, tubular abnormalities) than onlay procedures
  • Onlay preputial island flap was more widely applicable than Mathieu and lower complications than Duckett

Long-term outcomes of TPIF — Wang 2019 (largest series)​

Wang 2019 — 320 patients, 15-year experience, mean follow-up 40.2 months:[23]

  • Complications in 39.1%: fistulas 16.6%, strictures 9.7%, diverticula 12.8%
  • 20.8% of complications presented after ≥ 1 year, and 12.8% after ≥ 5 years
  • Stricture was present in 31.7% of those with diverticula (p < 0.05)

Staged TPIF for proximal hypospadias with severe chordee​

  • Chen 2016 — staged TPIF vs. Byars two-stage in 87 children: fistula 4.8% vs. 23.2% (p < 0.05) favoring staged TPIF.[24]
  • Wang 2023 — 152 patients across three techniques: staged TPIF had the lowest complication rate 11.1% vs. TPIF + Duplay 40.0% and modified Koyanagi 50.0% (p < 0.05). Neourethral length > 4.55 cm was the single predictor of complications.[25]
  • Ali 2022 — modified two-stage inner preputial flap in 31 patients with proximal hypospadias and chordee: 77.4% success, fistula 9.7%, diverticulum 6.5%, meatal stenosis 3.2%.[26]

Pedicled dartos flap as adjunct waterproofing​

The dartos flap (fascia without skin) is the modern fistula-prevention layer:[27][28]

  • Churchill 1996 — dartos flap from the penoscrotal angle as an extra layer of closure in repeat hypospadias surgery: 100% fistula-free in 6 patients with excellent cosmesis.
  • Liang 2016 — pedicled dartos flap around the urethral orifice combined with TPIF in 46 mid-shaft hypospadias cases: fistula rate 2.2%.

Application 3 — Penile Resurfacing​

Burns​

Fuller 2014 described the inner-prepuce flap for penile scald burns in 3 pediatric patients:[29]

  • Inner preputial skin is commonly spared in scald burns (protected by the foreskin)
  • Transferred as a flap on dartos to resurface full-thickness burns of the penile shaft
  • Provides a gliding and stretchable surface unique to the penis — properties that skin grafts cannot replicate
  • Similar color, texture, and composition to penile shaft skin

Buried penis and post-Fournier's coverage​

The same dartos-based principles support penile-shaft resurfacing after Fournier's gangrene, in buried-penis repair, and after oncologic resection — see those technique pages for site-specific framing.

Application 4 — Gender-Affirming Surgery​

Penile and preputial skin flaps are foundational to male-to-female vaginoplasty:[30][31][32]

  • Penile skin inversion vaginoplasty is the gold-standard technique. Penile skin is used to line the neovaginal canal via inversion
  • The glans-penis–preputial / penile-skin flap technique uses the glans with varied amounts of penile skin to construct the clitoral hood, clitoral frenulum, and labia minora[31]
  • Neovaginal dimensions are limited by available penile skin; scrotal-skin grafts or sigmoid-colon vaginoplasty supplement when penile skin is insufficient
  • Perovic 2000 — 89 patients using a pedicled island tube skin flap from penile skin combined with a vascularized urethral flap for neovagina. 87% good cosmetic and functional results at mean 4.6 years; one major complication (rectovaginal fistula).[32]

See Feminizing Procedures (GAS) for the full vaginoplasty workflow.

Application 5 — Feminizing Genitoplasty (DSD)​

Savanelli 2008 — mucosal layer of preputial skin to provide extra length to penile flaps for vaginal-introitus and labia-minora reconstruction in 14 children with congenital adrenal hyperplasia (Prader III–V):[33]

  • Preputial mucosal flap is well-suited to reconstruction of the vestibule and distal vagina
  • Mean vaginal caliber 10 Hegar (range 6–14)
  • Very satisfactory cosmetic appearance of external genitalia

Complications — by Configuration​

ComplicationOnlay flapTubularized flapCircular flap
Urethrocutaneous fistula8–17%14–16.6%0% (Zhao 2026)
Urethral stricture4.7–11%9.7–10.8%0% (Zhao 2026)
Urethral diverticulum0–2.3%2.7–12.8%0% (Zhao 2026)
Post-void dribbling15–34%24–42%24.1%
Penile skin necrosisRareRare0%
Penile torsion5–7%Rare14.8% (mild)
Meatal stenosis3.2–5%5–7%0%

Patterns:

  • Tubularized flaps consistently have higher diverticulum rates than onlay flaps because the unsupported tubularized segment dilates over time.[8][17][23]
  • Post-void dribbling is the most common functional complaint across all configurations — more common with ventral placement and tubularized designs.[12][17][18]
  • Late complications are common: 20.8% of complications in the Wang 320-patient series presented after ≥ 1 year and 12.8% after ≥ 5 years — long-term follow-up is essential.[23]

Current Role and Guideline Positioning​

The role of penile / preputial skin flaps has evolved over the past two decades:

  • Urethral stricture surgery — buccal mucosa grafts have largely supplanted penile-skin flaps as first-line tissue, with 99% of reconstructive urologists now preferring BMG.[21] However, penile fasciocutaneous flaps remain AUA-endorsed alternatives (2023, Moderate Recommendation, Grade C) and are particularly valuable when:[16]
    • Oral mucosa is unavailable or insufficient (prior harvest, oral pathology, lichen planus)
    • The urethral plate is severely damaged (combined graft + flap technique)
    • Long-segment or panurethral strictures require more tissue than bilateral buccal harvests can provide
    • The patient is circumcised but has adequate penile-shaft skin (circumpenile flap)[15]
  • Hypospadias — preputial island flaps remain a primary technique for proximal hypospadias, with the trend toward onlay configurations (preserving the urethral plate) over tubularized designs and toward staged approaches for severe cases with chordee.[7][25] The dartos fascial flap is now considered an essential adjunct for fistula prevention in virtually all hypospadias repairs.[27][28]
  • Gender-affirming surgery — penile skin inversion remains the gold standard for male-to-female vaginoplasty, with preputial / penile skin providing the neovaginal lining and contributing to labia minora and clitoral hood.[30][31]

Summary — Configurations at a Glance​

ConfigurationPedicleOrientationMax lengthPrimary applicationKey advantage
Transverse preputial island (Duckett / Quartey)Dartos (external pudendal)Transverse~6 cmHypospadias, urethral strictureHairless; versatile (onlay or tube)[6][7]
Longitudinal / oblique preputial island (Chen)DartosLongitudinal / oblique~4 cmHypospadiasUses both inner / outer prepuce[9]
Double-face preputial island (DFPIF)DartosTransverse~6 cmSevere hypospadiasSimultaneous urethroplasty + skin cover[10]
Orandi flapDartosLongitudinal (ventral)~5 cmPenile urethral strictureSimple, fast (60 min); no diverticulum[11]
Circular fasciocutaneous (McAninch)Buck's fasciaCircular15 cmLong / panurethral strictureLongest reach; works in circumcised[13][14]
Circumpenile flapDartosVariable~8 cmStricture in circumcised patientsAvailable when prepuce absent[15]
Dartos fascial flap (no skin)DartosVariableVariableWaterproofing layer (all repairs)Prevents fistula; easy to mobilize[27][28]

Limitations and Contraindications​

  • Requires intact, non-scarred penile / preputial skin
  • Limited donor availability after circumcision — preputial options unavailable (circumpenile flap is the workaround)
  • Not available in reoperative or radiation-compromised fields
  • Hair-bearing shaft skin is unsuitable for intraluminal use (hair growth, stone formation)
  • Penile torsion risk in long flaps requiring extensive skin re-draping
  • Contraindicated in lichen sclerosus (BXO) — the donor skin is itself diseased; buccal mucosa graft is preferred

Comparison with Alternatives​

DonorStrengthsWeaknesses
Penile / preputial flap (this page)Local; reliable axial vascularity; matches urethral environmentLimited availability; unsuitable in BXO / circumcised / irradiated fields
Buccal mucosa graftUniversal availability; excellent properties; no local donor constraintRequires oral donor site; no intrinsic vascular supply (graft)
SCIP flapThin pliable free tissue; concealed groin donorFree microvascular technique; learning curve
Bilateral scrotal flapLong flap potential; localHair-bearing; epilation required; cross-link to bilobed scrotal flap notes

See Also​

References​

1. Joshi PM, Bandini M, Kulkarni SB. "Common Flaps in Genitourinary Reconstruction." Urol Clin North Am. 2022;49(3):361–369. doi:10.1016/j.ucl.2022.04.001

2. Grossman JA, Caldamone A, Khouri R, Kenna DM. "Cutaneous Blood Supply of the Penis." Plast Reconstr Surg. 1989;83(2):213–216. doi:10.1097/00006534-198902000-00001

3. Kureel SN, Gupta A, Singh CS, Kumar M. "Surgical Anatomy of Penis in Exstrophy-Epispadias: A Study of Arrangement of Fascial Planes and Superficial Vessels of Surgical Significance." Urology. 2013;82(4):910–916. doi:10.1016/j.urology.2013.04.041

4. Lohasammakul S, Turbpaiboon C, Ratanalekha R, Ungprasert P, Yodrabum N. "Inferior External Pudendal Artery Anastomosis: Additional Approach to Prevent Skin Necrosis in Replanted Penis." Plast Reconstr Surg. 2018;142(4):535e–540e. doi:10.1097/PRS.0000000000004818

5. Younis A, Harding C. "Penis and Urethra: Structure and Function." Chapter 29.

6. Quartey JK. "One-Stage Penile / Preputial Cutaneous Island Flap Urethroplasty for Urethral Stricture: A Preliminary Report." J Urol. 1983;129(2):284–287. doi:10.1016/s0022-5347(17)52051-0

7. Ghali AM. "Hypospadias Repair by Skin Flaps: A Comparison of Onlay Preputial Island Flaps With Either Mathieu's Meatal-Based or Duckett's Tubularized Preputial Flaps." BJU Int. 1999;83(9):1032–1038. doi:10.1046/j.1464-410x.1999.00083.x

8. Wiener JS, Sutherland RW, Roth DR, Gonzales ET. "Comparison of Onlay and Tubularized Island Flaps of Inner Preputial Skin for the Repair of Proximal Hypospadias." J Urol. 1997;158(3 Pt 2):1172–1174. doi:10.1097/00005392-199709000-00123

9. Chen S, Wang G, Wang M. "Modified Longitudinal Preputial Island Flap Urethroplasty for Repair of Hypospadias: Results in 60 Patients." J Urol. 1993;149(4):814–816. doi:10.1016/s0022-5347(17)36216-x

10. Blanc T, Peycelon M, Siddiqui M, et al. "Double-Face Preputial Island Flap Revisited: Is It a Reliable One-Stage Repair for Severe Hypospadias?" World J Urol. 2021;39(5):1613–1624. doi:10.1007/s00345-020-03324-7

11. Barbagli G, Joshi PM, Kulkarni SB, et al. "Penile Urethroplasty Using Orandi's Dorsal Skin Flap: A New Technique." BJU Int. 2019;124(5):892–896. doi:10.1111/bju.14881

12. Karapanos L, Halbe L, Storz E, et al. "Preservation of the Native Urethral Plate and Corpus Spongiosum Combined With Buccal Mucosa Graft Plus Orandi's Penile Skin Flap as an Alternative to Staged Urethroplasty for Narrow Penile Strictures." Int J Urol. 2024;31(10):1095–1101. doi:10.1111/iju.15521

13. McAninch JW. "Reconstruction of Extensive Urethral Strictures: Circular Fasciocutaneous Penile Flap." J Urol. 1993;149(3):488–491. doi:10.1016/s0022-5347(17)36125-6

14. Zhao T, Ji F, Liu Y, Wang L, Lyu X. "Preliminary Experience and Outcomes of Modified Distal Penile Circular Fasciocutaneous Flap for the Treatment of Anterior Urethral Strictures." World J Urol. 2026;44(1):191. doi:10.1007/s00345-026-06289-1

15. Srivastava A, Vashishtha S, Singh UP, et al. "Preputial / Penile Skin Flap, as a Dorsal Onlay or Tubularized Flap: A Versatile Substitute for Complex Anterior Urethral Stricture." BJU Int. 2012;110(11 Pt C):E1101–E1108. doi:10.1111/j.1464-410X.2012.11296.x

16. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. "Urethral Stricture Disease Guideline Amendment (2023)." J Urol. 2023;210(1):64–71. doi:10.1097/JU.0000000000003482

17. Bhandari M, Dubey D, Verma BS. "Dorsal or Ventral Placement of the Preputial / Penile Skin Onlay Flap for Anterior Urethral Strictures: Does It Make a Difference?" BJU Int. 2001;88(1):39–43. doi:10.1046/j.1464-410x.2001.02257.x

18. Dubey D, Vijjan V, Kapoor R, et al. "Dorsal Onlay Buccal Mucosa Versus Penile Skin Flap Urethroplasty for Anterior Urethral Strictures: Results From a Randomized Prospective Trial." J Urol. 2007;178(6):2466–2469. doi:10.1016/j.juro.2007.08.010

19. Tyagi S, Parmar KM, Singh SK, et al. "'Pee'BuSt Trial: A Single-Centre Prospective Randomized Study Comparing Functional and Anatomic Outcomes After Augmentation Urethroplasty With Penile Skin Graft Versus Buccal Mucosa Graft for Anterior Urethral Stricture Disease." World J Urol. 2022;40(2):475–481. doi:10.1007/s00345-021-03843-x

20. Alrefaey A, Anwar MA, Abdelmagid ME, et al. "Comparative Outcomes of Penile Skin Grafts Versus Buccal Mucosal Grafts in Urethroplasty for the Treatment of Extensive Anterior Urethral Strictures." Sci Rep. 2025;15(1):29508. doi:10.1038/s41598-025-14191-w

21. Berg C, Singh A, Hu P, et al. "Current Trends in the Use of Buccal Grafts During Urethroplasty Among Society of Genitourinary Reconstructive Surgeons." Urology. 2024;191:139–143. doi:10.1016/j.urology.2024.06.019

22. Anadani A, Obaidin A, Badawi B, Lutfi MY. "One-Stage Urethroplasty Using a Combination of Buccal Mucosa Graft and Q Penile Skin Flap for a Complicated Urethral Stricture: A Challenging Case Report." Medicine (Baltimore). 2025;104(12):e41888. doi:10.1097/MD.0000000000041888

23. Wang CX, Zhang WP, Song HC. "Complications of Proximal Hypospadias Repair With Transverse Preputial Island Flap Urethroplasty: A 15-Year Experience With Long-Term Follow-Up." Asian J Androl. 2019;21(3):300–303. doi:10.4103/aja.aja_115_18

24. Chen C, Yang TQ, Chen JB, Sun N, Zhang WP. "The Effect of Staged Transverse Preputial Island Flap Urethroplasty for Proximal Hypospadias With Severe Chordee." J Urol. 2016;196(5):1536–1540. doi:10.1016/j.juro.2016.05.098

25. Wang YS, Song HC, Liu P, Fang YW, Zhang WP. "Comparison of Outcomes in Three Surgical Techniques for Proximal Hypospadias: Staged Transverse Preputial Island Flap Urethroplasty Versus Single-Stage Repairs." Asian J Androl. 2023;25(5):616–620. doi:10.4103/aja2022106

26. Ali MM, Anwar AZ. "Experience With Modified Two Stage Inner Preputial Flap for Repair of Proximal Hypospadias With Chordee: A Single Institution Study With Intermediate Follow Up." J Pediatr Surg. 2022;57(7):1404–1408. doi:10.1016/j.jpedsurg.2021.05.024

27. Churchill BM, van Savage JG, Khoury AE, McLorie GA. "The Dartos Flap as an Adjunct in Preventing Urethrocutaneous Fistulas in Repeat Hypospadias Surgery." J Urol. 1996;156(6):2047–2049.

28. Liang W, Ji C, Chen Y, et al. "Surgical Repair of Mid-Shaft Hypospadias Using a Transverse Preputial Island Flap and Pedicled Dartos Flap Around Urethral Orifice." Aesthetic Plast Surg. 2016;40(4):535–539. doi:10.1007/s00266-016-0659-0

29. Fuller SM, Roughton MC, Gottlieb LJ. "The Inner Prepuce Flap for Penile Scald Burns." J Burn Care Res. 2014;35(4):e250–e257. doi:10.1097/BCR.0000000000000055

30. Saylor L, Bernard S, Vinaja X, Loukas M, Schober J. "Anatomy of Genital Reaffirmation Surgery (Male-to-Female): Vaginoplasty Using Penile Skin Graft With Scrotal Flaps." Clin Anat. 2018;31(2):140–144. doi:10.1002/ca.23015

31. Wylie K, Knudson G, Khan SI, et al. "Serving Transgender People: Clinical Care Considerations and Service Delivery Models in Transgender Health." Lancet. 2016;388(10042):401–411. doi:10.1016/S0140-6736(16)00682-6

32. Perovic SV, Stanojevic DS, Djordjevic ML. "Vaginoplasty in Male Transsexuals Using Penile Skin and a Urethral Flap." BJU Int. 2000;86(7):843–850. doi:10.1046/j.1464-410x.2000.00934.x

33. Savanelli A, Alicchio F, Esposito C, De Marco M, Settimi A. "A Modified Approach for Feminizing Genitoplasty." World J Urol. 2008;26(5):517–520. doi:10.1007/s00345-008-0298-4