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Pedicled Penile / Preputial Skin Flap

Penile and preputial skin flaps transfer skin with a preserved vascular pedicle. They can provide a urethral patch, replace a selected segment, or cover a penile defect. A free penile or preputial graft is detached from its donor blood supply and has different requirements and evidence.[1][2]

For adult urethroplasty, EAU 2026 recommends a graft above a flap when both are equally indicated and advises flaps for a poorly vascularized urethral bed .[2] AUA 2023 states that surgeons may reconstruct long multi-segment strictures with oral mucosal grafts, penile fasciocutaneous flaps or a combination , and that oral mucosa should be the first choice when a graft is used .[17] Selection depends on the urethral plate, donor skin, prior operations, stricture cause and available oral mucosa. Neither a flap nor a graft makes a compromised reconstruction risk-free.[2]

Vascular Anatomy​

The skin-dartos complex carries the superficial penile cutaneous circulation. Grossman's 12-cadaver injection study identified paired axial vessels in the dartos supplying shaft skin, with deeper perforators contributing to the glans and subcoronal region.[3][4][5] Later work describes external pudendal contributions and additional preputial supply; the small imaging study by Kureel specifically concerned six patients with exstrophy or epispadias.[3][4][5]

McAninch terminology needs care. The original 1993 description calls Buck's fascia the vascular conduit. Carney and McAninch subsequently distinguish Buck's supporting fascia from the dartos vascular pedicle carried toward the skin island. The practical principle is preservation of the superficial vascular fascial attachments, with correct separation of the skin and deeper fascial planes. This is not a flap based on deliberate division of the deep dorsal penile arterial supply.[6][7][8]

Protect both the flap and the remaining penile skin: avoid stripping the vascular attachments, pedicle torsion, constriction and tension. Confirm that the selected skin is hair-free; ventral shaft skin near the raphe can bear hair. Previous circumcision limits preputial options but does not automatically exclude a distal shaft-skin flap.[2][7]

Configurations​

ConfigurationTissue and useImportant distinction
Transverse preputial/distal penile island — Duckett/Quartey familySkin island on a vascular fascial pedicle; onlay or selected tubularized repair. Quartey's 1983 report described a transverse distal penile or preputial island supplied axially by the superficial external pudendal vessels as hairless and able to reach from the external meatus to the prostatic urethra as a patch or tube; urethroscopy nevertheless found three fine hairs in two of ten new urethras at 5 weeks to 6 monthsPediatric hypospadias and adult stricture series are different populations; reach depends on the actual pedicle and defect[9][10]
Longitudinal/oblique preputial islandInner and outer preputial surfaces incorporated into the reconstructionChen's report of 60 children (mean repair length 3.1 cm) described a specific hypospadias modification with fistula in 8.3% and meatal stenosis in 5%; it can be combined with a midline scrotal-skin tube for scrotal or perineal hypospadias[11]
Double-face preputial islandInner surface for urethra, outer surface for ventral skin coverageCan preserve coverage for subsequent repair, but substantial reoperation remains possible[12]
OrandiLongitudinal ventral penile skin islandThe dorsal-onlay modification is distinct from the original ventral configuration[13][8]
McAninch circular fasciocutaneousDistal circumferential skin island opened into a longitudinal stripOften provides about 13–15 cm; selected circumcised patients remain candidates; longer defects may require another tissue transfer. McAninch's 1993 report of 10 patients (strictures 8–21 cm) had no recurrence at a mean of 14.4 months, with two defects bridged by a supplemental graft[6][7]
Circumpenile shaft flapNon-hair-bearing shaft skin when prepuce is unavailableFeasibility depends on residual skin and perfusion, not circumcision status alone. In Srivastava's retrospective series the circumpenile dorsal onlay group (circumcised patients) had primary success of 93.3% at 1 year and 86.7% at 3 years[14]
Dartos flap without skinVascularized fascial coverage over a urethral repairAn interposition/coverage layer, not a skin-lined substitute urethra[15][16]

Adult Urethral Reconstruction​

Indications and tissue selection​

A penile flap may be appropriate for a long or complex anterior stricture, a poorly vascularized recipient bed, or a reconstruction needing more than one tissue type. Adequate healthy donor skin and a viable pedicle are needed. A previously operated recipient bed may be a reason to consider a vascularized flap; previous surgery is not itself an absolute prohibition. Prior surgery or irradiation of the donor tissue or pedicle requires a separate viability assessment.[2][7]

Avoid genital skin for LS-associated urethral strictures. AUA 2023 states that surgeons should not use genital skin for reconstruction in lichen sclerosus-proven stricture , and EAU strongly recommends against genital skin in augmentation penile urethroplasty in men with LS-related strictures. Use non-hair-bearing tissue for intraluminal reconstruction. When oral mucosa is suitable and a graft can work, current guidelines generally favor oral grafting. These rules concern urethral reconstruction; external skin coverage is a different application.[17][2]

Onlay versus tube​

An onlay preserves usable native urethral plate. In the 1998 McAninch and Morey 66-patient cohort, recurrence occurred in 7/54 onlay repairs (13%) and 7/12 tubularized repairs (58%), with mean follow-up of 41 months.[18] The overall initial success was 52/66; the higher 95% eventual success included subsequent procedures.[18] Mean stricture length was 9.08 cm. These are observational results affected by case selection. Neurovascular lower-extremity complications developed in 4 patients after prolonged high lithotomy positioning, and Carney and McAninch advise limiting time in the exaggerated lithotomy position.[18][7] In Kim's 29-patient series of circular flap urethroplasty, overall success without additional urethral instrumentation was 20/29 (68.9%) at a median of 19 months; the authors' separate 23/29 (79.3%) flap-site stricture-free figure counts only the six recurrences at the flap, not success after additional procedures. Recurrence was mostly at the flap junction, and post-micturition dribbling was the most common complication.[8]

Those figures are not from the original 1993 ten-patient report, which had no recurrence at mean 14.4 months and used supplemental grafts in two of the longest defects.[6] A later retrospective 124-patient circular-flap series excluding lichen sclerosus estimated overall stricture-free survival of 84% at five years and 79% at ten years (median follow-up 7.3 years); these were Kaplan–Meier estimates.[36]

If a complete tube is required in one stage, a vascularized flap and a tubularized free graft are not interchangeable. EAU advises against a free graft fashioned as a complete tube in a single-stage repair.[2]

Dorsal versus ventral placement​

Pedicle orientation and reach. Matching the pedicle base to the recipient level is part of flap selection. A dorsally based penile skin island is described as reliable for shaft-level transfer but as requiring extensive mobilization for perineal reach, making it difficult to carry to the proximal bulbous or membranous urethra. A broad ventrally based dartos pedicle, with its lateral vascular connections preserved, is described as more efficient for anterior reconstruction and as capable of reaching the proximal urethra when needed. Scrotal skin on tunica dartos can reach the bulbar urethra but is less efficient for the proximal anterior urethra and does not reach the penile shaft.[35] The EAU recommends a graft when flap and graft are equally indicated .[2]

Bhandari's nonrandomized 40-patient comparison reported sacculation or pseudodiverticulum with dribbling in 6/21 ventral versus 0/19 dorsal repairs. The published abstract's ventral recurrence count and percentage are inconsistent, so they should not be used as a precise comparative estimate. Bhandari’s comparison supports attention to flap support in the studied repairs.[19]

Barbagli's dorsal Orandi modification succeeded in 10/12 cases, without fistula or diverticulum in that small series. This is feasibility evidence, not a guarantee of zero complications or a standard 60-minute operation.[13]

Flap versus buccal graft: keep the comparisons separate​

Dubey 2007 randomized 55 patients to a dorsal penile-skin flap or dorsal buccal mucosa graft. Reported success was 85.6% versus 89.9%, without a significant difference. Flap surgery took longer (224 versus 162 minutes), 6 flap patients had superficial penile skin necrosis, 1 had extensive skin loss requiring grafting (overlap with the six not specified), and 2 had torsion, troublesome post-void dribbling occurred in 34.1% versus 14.8%, and 65% versus 89% would recommend the procedure.[20]

A 2023 review identified 13 studies totaling 1,216 patients and included 12 in its meta-analysis. Pooled success did not differ significantly between oral mucosa graft and penile skin flap (OR 1.41, 95% CI 0.96–2.07); exploratory analyses of larger studies and studies with longer follow-up favored oral mucosa.[34] PeeBuSt and Alrefaey 2025 compare free penile-skin grafts with buccal grafts.[21][22] They are discussed on the graft page.[21][22]

The GURS survey reflects practice preference: 134 of 350 invited members responded; 99% of those respondents preferred buccal mucosa as their primary graft site. For penile urethroplasty, BMG was preferred to a flap by 95% for circumcised and 84% for uncircumcised patients.[23]

Combined graft and flap​

A dorsal BMG with a ventral penile flap may be used for selected narrow or deficient plates. Karapanos's 12-patient series reported 11/12 success at median 38 months, with three transient fistulas and dribbling in five patients.[24] This is a specialist option supported by limited observational evidence.[24][2]

Contemporary circular-flap reports​

Zhao's 2026 retrospective series of 54 patients reported no recurrence at average 15 months, but dribbling in 13/54 and mild torsion in 8/54.[25] Short follow-up and absence of a comparison group prevent claims of superiority or a zero long-term failure rate.[25][2]

Hypospadias​

The decision to preserve or transect the urethral plate, the residual curvature after straightening, tissue availability and the patient's previous repairs determine whether an onlay, tubularized flap or staged approach is appropriate. For severe proximal hypospadias requiring urethral-plate transection, EAU guidance describes two- or multistage repair as increasingly preferred because reported recurrent ventral curvature is lower; long-term complication rates vary. EAU strongly recommends long-term follow-up after hypospadias repair.[16] For neourethral coverage, EAU guidance says tunica vaginalis may yield better results than dartos fascia and describes a double-layer technique when dartos is used.[16] No coverage layer guarantees prevention of a fistula.[16]

Ghali's single-surgeon series of 418 primary repairs (Mathieu 216, Duckett 148, onlay preputial island 42, Mustardé 12) reported a 22% initial complication rate and 95% final success after a mean of 1.4 procedures. Complications were more frequent with a proximal meatus, severe chordee or urethral-plate transection, and Duckett tubularization had more complications than onlay repair.[10]

StudyPopulation and designFinding and limitation
Wiener 1997132 repairs, retrospective single-surgeon comparisonDiverticula occurred in 9/74 tubularized versus 0/58 onlay repairs; overall complication rates were 36% versus 31% and fistula rates 14% versus 17%, but tubularized fistulas tended to be larger and harder to repair. Mean follow-up 20.3 months. Selection and anatomy differ between groups[26]
Blanc 202175 severe cases, double-face flap series36/75 required redo surgery; final success after additional procedures was 96%.[12]
Wang 2019320 Duckett repairs, retrospective seriesReported complications in 125/320 (39.1%); mean follow-up 40.2 months, with only 39 patients followed beyond five years. Late presentation occurred.[27]
Wang 2023152 primary proximal cases with ventral curvature ≥30° after degloving, nonrandomized comparisonComplications occurred in 11.1% with staged TPIF versus 40.0% with TPIF plus Duplay and 50.0% with modified Koyanagi (81 staged TPIF, 55 TPIF plus Duplay, and 16 modified Koyanagi patients). Staged TPIF had fewer reported complications, but shorter follow-up, surgeon selection and exclusion of first-stage complications from the overall rate favor that comparison. The internally derived 4.55-cm cutoff is not a validated treatment threshold[28]

Churchill's dartos flap (fibroadipose tissue with a pedicle at the penoscrotal angle) was used in 8 children: 6 with repeat hypospadias had no fistula (mean follow-up 1 year), and 1 fistula occurred after staged repair for anterior urethral valves.[15] Liang's pedicled dartos flap around the urethral orifice with a transverse preputial island flap had 1 anastomotic fistula in 46 mid-shaft repairs (2.2%).[29] Historical six-patient dartos-coverage and other small technique reports illustrate feasibility. Preserve penile-skin perfusion while obtaining a suitable coverage layer.[15][29][16]

Resurfacing and Other Genital Reconstruction​

Preserved inner preputial skin can cover selected shaft defects. Fuller's three-patient burn report describes this option when the inner prepuce is spared. See buried penis repair and Fournier's gangrene for condition-specific reconstruction.[30]

Penile skin is also used in penile-inversion vaginoplasty, with additional grafts or other lining options when necessary. Perovic's series of 89 patients used a pedicled penile-skin island tube with a vascularized urethral flap: 77 (87%) had good cosmetic and functional results and one had a major complication (rectovaginal fistula from rectal injury).[32] Skin lining and a sensate glans-based clitoral flap are distinct structures with different vascular requirements. See feminizing procedures.[31][32]

Savanelli's report used preputial mucosa for vestibule and distal vagina reconstruction (reported vaginal caliber 10 Hegar, range 6–14) and explicitly acknowledged that follow-up had not reached sexual and reproductive outcomes.[33]

Complications and Counseling​

Discuss recurrent stenosis, fistula, sacculation or diverticulum, postvoid dribbling, skin or flap ischemia, altered sensation, torsion or curvature and possible further procedures. EAU 2026 summarizes reported penile skin flap complications as skin necrosis 0–3.8%, fistula 0–7%, penile deformity 0–7%, post-void dribbling 0–79% and sacculation 0–16.5%, with patency 74.2–100%, and notes that no direct comparative series of the flap types exist.[2] It also recommends against hair-bearing perineal or scrotal flaps unless no other option is feasible . Rates depend on the indication, flap configuration, failure definition and length of follow-up. Adult circular-flap and pediatric hypospadias percentages come from different, nonrandomized cohorts.[2][8][18]

Assess perfusion, donor closure, support of the reconstructed lumen and pedicle orientation. For adult penile or flap-substitution urethroplasty, EAU 2026 recommends at least one year of follow-up and a risk-adjusted schedule .[37] Its proposed standard-risk pathway uses uroflowmetry and patient-reported assessments, including sexual function, at 3, 12 and 24 months and five years, with anatomic assessment at 3, 12 and 24 months. Assess cosmetic concerns and consider longer surveillance after penile reconstruction.[37]

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. EAU. Urethral Strictures: Tissue Transfer. 2026, sections 9.1–9.3.

3. 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

4. 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

5. 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

6. 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

7. Carney KJ, McAninch JW. Penile circular fasciocutaneous flaps to reconstruct complex anterior urethral strictures. Urol Clin North Am. 2002;29:397–409. doi:10.1016/S0094-0143(02)00046-0.

8. Kim KR, Suh JG, Paick JS, Kim SW. Surgical outcome of urethroplasty using penile circular fasciocutaneous flap for anterior urethral stricture. World J Mens Health. 2014;32:87–92. doi:10.5534/wjmh.2014.32.2.87.

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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. doi:10.1016/S0022-5347(01)65432-6.

16. EAU. Paediatric Urology: Hypospadias. Current surgical coverage and long-term follow-up recommendations.

17. 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

18. McAninch JW, Morey AF. Penile circular fasciocutaneous skin flap in 1-stage reconstruction of complex anterior urethral strictures. J Urol. 1998;159:1209–1213. doi:10.1016/S0022-5347(01)63558-4.

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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. PMID: 9258164

27. 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

28. 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

29. 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

30. 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

31. 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

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

34. Song L, Zhang R, Lu C, Chen Y. "Factors to Consider in Augmentation Urethroplasty with Oral Mucosa Graft or Penile Skin Flap for Anterior Urethral Stricture: A Systematic Review and Meta-analysis." Eur Urol Open Sci. 2023;50:113–122. doi:10.1016/j.euros.2023.02.010

35. Jordan GH, Rourke KF. The Use of Flaps in Urethral Reconstructive Surgery. In: Schreiter F, Jordan GH, eds. Urethral Reconstructive Surgery. Springer; 2006:129–136. doi:10.1007/3-540-29385-x_16

36. Whitson JM, McAninch JW, Elliott SP, Alsikafi NF. "Long-term efficacy of distal penile circular fasciocutaneous flaps for single stage reconstruction of complex anterior urethral stricture disease." J Urol. 2008;179(6):2259–2264. doi:10.1016/j.juro.2008.01.087

37. European Association of Urology. Urethral Strictures: Follow Up. EAU Guidelines. 2026;sections 11.6–11.7.