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Split-Thickness Skin Graft (STSG)

The split-thickness skin graft (STSG) — epidermis plus a partial layer of dermis harvested with a dermatome — is one of the most versatile reconstructive tools in urology, with applications spanning adult acquired buried penis (AABP) repair, Fournier's gangrene reconstruction, penile cancer surgery (glansectomy and glans resurfacing), salvage urethroplasty, genital lymphedema, and McIndoe vaginoplasty. Its thin profile, reliable take on a vascularized recipient bed, large donor-site availability, and the option of harvesting it hairless (above the level of hair follicles) make it a workhorse graft for genital reconstruction.[1][2]

See the overview article for graft-selection principles: Grafts in GU Reconstruction. For full-thickness skin grafts see FTSG.

Graft Biology and Properties​

STSG comprises epidermis + a partial layer of dermis, harvested at typical depths of 0.008–0.018 inch (0.2–0.46 mm) with an electric / air-powered dermatome.[3][4]

PropertyImplication
Higher graft take rate than FTSGThinner graft requires less revascularization from the recipient bed; survival via imbibition → inosculation → neovascularization[3]
Hairless when harvested above hair-follicle depth (≤ 0.012 inch)Critical for urethral applications — hair-bearing skin in the urethra causes calculi, recurrent UTI, obstruction[5]
Greater contraction than FTSG20–40% primary contraction; a disadvantage for penile shaft coverage where erection elasticity matters[6]
Donor site re-epithelializes in 1–2 weeksRegenerates from residual dermal appendages; allows repeat harvest from the same site[3]

Thickness classifications​

ClassificationThicknessPropertiesTypical indications
Ultra-thin≤ 0.007 inch (≤ 0.18 mm)Fastest donor healing, least scarring, most contractionLarge burns with limited donor sites[7]
Thin0.008–0.011 inch (0.2–0.28 mm)Good take, moderate contractionBurns; urethral mesh-graft urethroplasty (above hair follicles)[8]
Standard / intermediate0.012–0.020 inch (0.3–0.5 mm)Balanced take and durabilityMost genital / urologic applications[6]
Thick0.025 inch (0.64 mm)Less contraction, more durableRarely needed; no proven benefit over standard[6]

Key thickness evidence:

  • Guogienė 2018 RCT (84 patients) — 0.2 mm grafts had the greatest epithelialization scores at the recipient site at all time points, with slightly more recipient-site pain. Donor-site pain was highest with 0.4 mm grafts.[9]
  • Chacon 2020 — ultra-thin grafts (≤ 0.007 inch) showed equivalent take and functional outcomes vs thin grafts, with faster donor-site healing (p = 0.04), fewer complications (p = 0.004), and less hypertrophic scarring (p = 0.025).[7]
  • Schreiter mesh-graft urethroplasty specifically requires 0.1 mm depth (~0.004 inch), harvested above hair follicles to ensure hairlessness.[10][8]

Clinical Applications in Urology​

1. Adult acquired buried penis (AABP) — the dominant contemporary urologic indication​

AABP repair typically involves escutcheonectomy / panniculectomy, excision of diseased penile skin (often from lichen sclerosus), and STSG application to the denuded shaft.

  • Graft take 80–100% (mean ~92%) consistently across series.[11][12][13]
  • Gül 2026 STSG-vs-FTSG comparative analysis (22 patients requiring grafts) — no significant difference in complications (p = 0.397), recurrence (p = 0.375), or functional outcomes (IIEF, IPSS both improved significantly, p < 0.001).[14]
  • Lichen sclerosus is the primary cause of AABP requiring grafts in 54.6% of cases.[14]
  • A key technical innovation: harvesting STSG from the excised escutcheon / pannus itself eliminates a separate donor site and reduces morbidity.[15]
  • Outpatient repair feasible — Figler 2020, 19-pt series: graft take ≥ 95% in all patients; cellulitis 26% and minor dehiscence 16% as the most common complications.[12]
  • Higher BMI is a significant risk factor for complications (p = 0.015).[13]

2. Fournier's gangrene reconstruction​

STSG is the most commonly used reconstructive modality after debridement for Fournier's, accounting for the majority of minimally invasive reconstructions.[16]

  • Biju 2023 (10-year retrospective, Guy's & St Thomas') — most perineal / genital defects can be repaired with STSG; FTSG recommended for penile defects specifically to avoid secondary contracture and revision surgery.[17]
  • Hayon 2021 scrotal reconstruction — orchidopexy followed by meshed STSG (2:1, 18/1000 inch) with bolster dressing achieves durable results with no chronic pain at median 8-month follow-up.[18]
  • NPWT applied before and after STSG (wound-bed preparation + graft fixation) achieves 98% graft take and is increasingly standard.[19][20]

3. Penile cancer — glansectomy and glans resurfacing​

STSG is the standard graft for neoglans reconstruction after glansectomy, and for glans resurfacing in superficial penile cancer (PeIN, Ta, T1a) and lichen sclerosus.

  • NCCN Penile Cancer Guidelines recommend STSG or FTSG after wide local excision when tension-free primary closure is not feasible, and for neoglans reconstruction after glansectomy.[21]
  • Parnham 2018 (177-pt single-center series — largest published) — glansectomy with STSG: local recurrence 9.3% at median 41.4 months; cancer-specific mortality 10.7%; only 9% required reoperation for graft loss or meatal stenosis.[22]
  • Falcone 2022 (34 pts) — 1-yr recurrence-free survival 88.2%; CSS / OS 91%; glans sensation preserved in 91.2%; 88.2% satisfied with appearance; partial graft loss 17.6%; meatal stenosis 5.8%.[23]
  • Glans resurfacing for LS — STSG achieves 84% patient satisfaction with 71% resuming sexual activity. The TODGA (tie-over dressing) technique allows immediate mobilization with excellent uptake and 2-day mean LOS.[24][25]

4. Salvage urethroplasty (mesh graft and dorsal inlay)​

STSG has a historical and ongoing role in complex / salvage urethroplasty when oral mucosa is unavailable.

  • Mesh graft urethroplasty (Schreiter technique) — two-stage procedure using meshed 0.1 mm STSG harvested above hair follicles. Performed since 1977 in complex strictures with success rates up to 84%. The graft is transplanted along the opened urethra in stage 1; the neourethra is tubularized 8–12 weeks later.[10][8]
  • Single-stage dorsal-inlay STSG (Dalpiaz 2008) — 27 patients with recurrent anterior strictures and BMG contraindications (radiotherapy, leukoplakia): 93% success at mean 32-month follow-up with no intraurethral hair growth.[26]
  • Long-term concern (Furr 2021) — staged-urethroplasty series with extended follow-up (median 57 months): BMG-only repairs 96.4% long-term success vs STSG-incorporating repairs 53%. All recurrences occurred after the initial 4-month cystoscopy; median time to recurrence 78 months — underscoring the need for prolonged surveillance.[27]
  • The AUA Urethral Stricture Disease Guideline (2023) recommends oral mucosa as the preferred substitute, with the explicit caveat that hair-bearing skin should not be used. STSG harvested above hair follicles remains an acceptable alternative when oral mucosa is contraindicated.[28]

5. Genital lymphedema​

Radical excision of lymphedematous tissue followed by STSG is the standard surgical approach for refractory genital lymphedema. Alwaal 2015 (UCSF series) — 13 patients: > 90% graft take with maintained erectile function.[1]

6. Foreign-body injection granuloma​

Penile resurfacing after excision of foreign-body granuloma (vaseline, silicone, hyaluronic acid) using STSG with NPWT-assisted fixation achieves near-complete graft take in 90.9% of cases, with median satisfaction 37/45.[29]

7. Hidradenitis suppurativa​

For penile defects after wide local excision of genital HS, unmeshed STSG at 0.046 cm depth is preferred over FTSG because it is thin and non-hair-bearing. A 1–2 week delay for granulation-tissue formation before grafting is recommended given the inflammatory and nutritionally compromised wound bed.[5]

Applications in Gynecology / Urogynecology​

1. McIndoe vaginoplasty for vaginal agenesis​

The Abbé–McIndoe procedure using STSG is the most established surgical technique for vaginal canal creation in patients with vaginal agenesis (Mayer-Rokitansky-Küster-Hauser syndrome), established for over 130 years.[30][31]

  • 10 × 20 cm STSG harvested from buttock or thigh, secured to a condom-covered mold, and inserted into a surgically created canal between bladder and rectum. Mold removed at ~14 days; polyethylene obturator used during healing.[30]
  • Achieves excellent graft take with 10 cm vaginal length and adequate caliber.[30]
  • Adjuncts — fibrin tissue adhesive and VAC improve graft viability, particularly at irradiated recipient sites where sloughing rates can reach 22% with standard techniques.[32]
  • Patient compliance with vaginal obturator use for 3–6 months postoperatively is essential to prevent stenosis.[31]

2. Vulvovaginal reconstruction after cancer​

STSG is used for anatomic reconstruction after superficial vulvectomy for VIN 3 and for vaginal reconstruction after pelvic exenteration. FTSG from the groin and STSG from the scalp are both described, though most vulvovaginal defects requiring volume need flap-based reconstruction.[33]

3. Cervicovaginal reconstruction​

A combined laparoscopic-vaginal technique using STSG for congenital cervical atresia with vaginal dysgenesis has been reported in 10 patients with successful results and no cervical or vaginal stenosis.[34]

STSG vs FTSG in Genital Reconstruction​

ParameterSTSGFTSG
Graft take rateHigher (90–100%)Lower (more demanding bed)
ContractionGreater (20–40%)Less
Elasticity during erectionLess elasticMore physiologic
Hair-growth riskMinimal if harvested thin (above follicles)Site-dependent
Donor-site healingRe-epithelializes in 1–2 wkRequires primary closure
Donor-site availabilityLarge (thigh, buttock, pannus)Limited by closure
Preferred for penile shaftAcceptable; some prefer FTSG to avoid contracturePreferred by some authors
Buried penis outcomesNo significant difference vs FTSG (Gül 2026)No significant difference vs STSG

For penile shaft reconstruction specifically, some authors recommend FTSG to avoid secondary contracture impairing erection.[17] However, the only direct comparative study (Gül 2026) found no significant difference in functional or surgical outcomes between graft types for buried penis repair.[14]

Donor Sites​

Donor siteAdvantagesDisadvantagesTypical use
Anterior / lateral thighLarge area, easy accessVisible scarDefault for most genital STSG; mesh-graft urethroplasty[1][8]
Occipital scalpConcealed scar, rapid healing, hairless STSGSmall area; unfamiliar to most urologistsScrotal / genital coverage; outperforms femoral on RCT[35]
ButtockConcealed scar, good texturePositioning challengesMcIndoe vaginoplasty[30]
Excised pannus / escutcheonEliminates separate donor siteAvailable only during panniculectomyBuried penis repair[15]
Plantar foot (non-weight-bearing)Glabrous, durableSmall area; foot morbidity riskSmall lower-extremity defects
Anterior trunkAvailable when thigh unavailableIrregular contourK-wire–assisted harvest enables flat surface[36]

Kovacs 2017 RCT (108 patients) — occipital scalp significantly superior to femoral donor sites in re-epithelialization speed, pain, complications, cosmetic outcome, and Vancouver Scar Scale. Graft take was also significantly better on days 3 and 5.[35]

Donor-Site Morbidity​

Asuku 2021 systematic review (77 studies) found significant variability in STSG donor-site outcomes:[37]

  • Time to epithelialization — 4.7–35 days (mean)
  • Pain (0–10) — 1.24–6.38 on POD 3
  • Vancouver Scar Scale — 0–10.9 at 1 yr; 28% hypertrophic scarring at 8 yr in one study
  • Infection rates — generally low but ranged 0–56%

Thinner grafts heal faster and scar less — Chacon 2020 demonstrated faster donor-site healing (p = 0.04) and less hypertrophic scarring (p = 0.025) with ultra-thin (≤ 0.007 inch) vs standard-thickness grafts.[7]

Harvest Technique — Deep Dive​

The optimal STSG harvest technique involves five interdependent variables: dermatome selection, graft thickness setting, donor-site preparation (tumescence and lubrication), donor-site selection, and graft processing (sheet vs meshed). There is no universally "best" technique — tailor to the indication.

Dermatome selection​

  • Powered dermatomes (electric / air-driven) — most commonly used. Tehrani 2006 UK survey: 61% of plastic surgeons preferred powered dermatomes for graft / donor-site quality. Electric dermatomes (Zimmer, Padgett) provide consistent thickness via an adjustable depth gauge with an oscillating blade.[38]
  • Manual dermatomes (Humby, Watson knives) — 40% of surveyed surgeons preferred them. No published evidence demonstrates superiority of powered over manual dermatomes in graft quality; choice should reflect surgeon comfort and experience.[38]
  • Drum dermatomes (Reese, Padgett-Hood) — rarely used today.

Verify the blade aperture before harvest — Dargan 2025 showed dermatome blade apertures vary between individual instruments. Using a #15 scalpel blade as an objective aperture gauge: actual cut thickness permitting blade passage ranged from 2–9/1000 inch across dermatomes (ICC 0.52). The "scalpel-blade test" is a simple maneuver to objectively validate the aperture before harvest.[39]

Tumescence​

Tumescent infiltration before harvest is supported by Level I evidence. Ash 2024 SR of 9 RCTs:[40]

  • Reduced estimated blood loss (SMD −2.68; 95% CI −3.41 to −1.94; p < 0.001)
  • Reduced bleeding scores
  • No significant difference in donor-site healing time, pain, or scar quality
  • Epinephrine concentration matters — Ho 2018 RCT: adrenaline 1:250,000 produced significantly lower bleeding scores than 1:500,000 (p = 0.035), which in turn was superior to no adrenaline (p = 0.002).[41]
  • Phenylephrine (5 µg/mL) is a β-sparing alternative without hemodynamic alteration.[42]

Tumescence also creates a firm, convex surface that facilitates even dermatome passage on irregular or lax surfaces.[43]

Lubrication​

Lubrication is essential for smooth dermatome passage and uniform harvest. Beckett 2019 blinded comparative review on a porcine model:[44]

LubricantMean score (1–5)Notes
Water-based surgical lubricant4.63Best overall performance
Poloxamer 188 (Shur-Clens)3.88Discontinued
Saline3.88Surprisingly effective; cheapest option
Mineral oil3.75Traditional standard; incompatible with Meek micrografting
Glycerin2.62Worst performance
Dry (control)1.10Significantly inferior to all lubricants (p < 0.01)

A K-Y jelly + epinephrine mixture serves as both lubricant and topical hemostatic, with low cost and ready availability.[45] Applying a semipermeable membrane (e.g., Tegaderm) to the donor site before harvest prevents graft curling and minimizes harvest trauma.[46]

Step-by-step harvest​

  1. Mark the donor site — outline required dimensions (add 10–20% for contraction and trimming).
  2. Prepare the dermatome — set thickness (verify with the scalpel-blade test if uncertain), set the width guard, ensure a sharp seated blade.[39]
  3. Tumescent infiltration — inject modified tumescent solution (saline + epinephrine 1:250,000 ± lidocaine 0.1%) subcutaneously until firm and blanched. Wait 7–10 min for maximal vasoconstriction.[40][41]
  4. Lubricate — water-based surgical lubricant, mineral oil, or saline applied generously to donor skin and dermatome guard. Optionally apply Tegaderm before lubrication to prevent graft curling.[44][46]
  5. Harvest — hold the dermatome at 30–45° to the skin, apply steady even downward pressure, advance smoothly. An assistant applies counter-traction ahead of the dermatome with a tongue depressor or board. Constant speed — too fast produces an uneven graft; too slow increases buttonholing risk.[46]
  6. Hemostasis — epinephrine-soaked gauze or topical thrombin immediately after harvest. K-Y jelly + epinephrine applied as lubricant provides simultaneous hemostasis.[45]
  7. Graft processing:
    • Sheet graft (unmeshed) — best cosmesis; preferred for penile shaft, glans, and facial defects.[6]
    • Meshed graft (1.5 : 1 or 2 : 1) — allows drainage and expansion; preferred for scrotal, perineal, and large surface defects. Mesh pattern persists permanently.[6]
    • Meek micrografting — small squares for maximal expansion (up to 1 : 9) for massive burns; oil-based lubricants are incompatible with Meek.[47]

Donor-site dressing and pain management​

Sinha 2017 evidence-based recommendations:[48]

  • Subcutaneous adrenaline-lidocaine injection at harvest (strongest evidence for pain reduction)
  • Ice application in the early postoperative period
  • Topical lidocaine or bupivacaine
  • Hydrocolloid- or polyurethane-based wound dressings with fibrin sealant — promote moist wound healing and reduce pain vs gauze

Donor-site re-epithelialization typically occurs in 1–2 weeks for thin / ultra-thin grafts and up to 3 weeks for thicker grafts. Healing beyond 3 weeks increases the risk of hypertrophic scarring.[6][37]

Graft fixation at the recipient site​

  • Bolster dressing (petrolatum gauze + cotton, sutured to the recipient site) — traditional standard for penile STSG.[5]
  • NPWT (Cao 2022 RCT) — improves graft take from 90.2% → 97.2% overall (p = 0.005), with the greatest benefit in irregular, high-mobility areas (81.7% → 97.6%, p < 0.001).[49]
  • Dermal-regeneration templates (Integra, Matriderm) — for complex penile defects, a two-stage approach with NPWT followed by delayed STSG achieves excellent take and erection-compatible elasticity by 6 months.[50]

Common pitfalls​

PitfallCauseMitigation
Buttonholing (cutting through the graft)Excessive pressure, inadequate tumescence, bony prominencesTumescent infiltration; proper counter-traction
Uneven thicknessVariable speed, inconsistent pressure, lax skinK-wire subcutaneous insertion to flatten anterior trunk[36]
Graft curlingAir exposure of dermal sideTegaderm before harvest; immediate placement dermal-side-down on saline gauze
Hair growth in graftHarvest depth below hair follicleHarvest at ≤ 0.012 inch — particularly critical for urethral reconstruction[8]
Excessive bleedingInadequate vasoconstrictionTumescent solution with epinephrine 1:250,000; topical hemostatics[41][45]

Contraindications and Limitations​

  • Active infection or inadequately debrided wound bed — graft take requires a clean vascularized recipient bed.
  • Irradiated fields — sloughing rates up to 22% without adjuncts (fibrin glue, VAC).[32]
  • Penile shaft coverage (relative) — some authors prefer FTSG to avoid contracture, though comparative data show equivalent outcomes.[14][17]
  • Urethral reconstruction (relative) — long-term success with STSG (53%) is significantly inferior to BMG-only repair (96.4%); reserve for salvage.[27]
  • Hair-bearing skin in the urethra — explicitly prohibited by AUA 2023.[28]

Key Takeaways​

The split-thickness skin graft is a foundational reconstructive tool across urology and gynecology, with its broadest contemporary application in adult buried penis repair (where it achieves > 90% graft take and high patient satisfaction, with no significant difference vs FTSG)[14], Fournier's gangrene reconstruction, and penile cancer surgery (glansectomy, glans resurfacing).[22][23] In urethral reconstruction, STSG serves as a salvage option for complex strictures when buccal mucosa is contraindicated, though long-term success rates are inferior to BMG and the AUA 2023 guideline explicitly prohibits hair-bearing skin in the urethra.[27][28] In gynecology, the McIndoe vaginoplasty with STSG remains a standard surgical option for vaginal agenesis.[30] Key technical advances include NPWT-assisted graft fixation (90.2% → 97.2% take, with greatest benefit in irregular areas)[49], harvest from the excised pannus to eliminate a separate donor site[15], dermal regeneration templates for complex penile defects[50], and the use of occipital scalp as a superior donor site to femur in dermatosurgery RCT data.[35]

See Also​

References​

1. Alwaal A, McAninch JW, Harris CR, Breyer BN. Utilities of split-thickness skin grafting for male genital reconstruction. Urology. 2015;86(4):835–9. doi:10.1016/j.urology.2015.07.005

2. Bickell M, Beilan J, Wallen J, Wiegand L, Carrion R. Advances in surgical reconstructive techniques in the management of penile, urethral, and scrotal cancer. Urol Clin North Am. 2016;43(4):545–59. doi:10.1016/j.ucl.2016.06.015

3. Younis AS, Abdelmonem IM, Gadullah M, et al. Hydrogel dressings for donor sites of split-thickness skin grafts. Cochrane Database Syst Rev. 2023;8:CD013570. doi:10.1002/14651858.CD013570.pub2

4. Greenhalgh DG. Management of burns. N Engl J Med. 2019;380(24):2349–59. doi:10.1056/NEJMra1807442

5. Hamad J, McCormick BJ, Sayed CJ, et al. Multidisciplinary update on genital hidradenitis suppurativa: a review. JAMA Surg. 2020;155(10):970–7. doi:10.1001/jamasurg.2020.2611

6. Greenhalgh DG. Management of burns. N Engl J Med. 2019;380(24):2349–59. doi:10.1056/NEJMra1807442

7. Chacon MA, Haas J, Hansen TC, Mushin OP, Bell DE. Thin and ultra-thin split-thickness skin grafts are safe and efficacious in the burn population. J Burn Care Res. 2020;41(4):849–52. doi:10.1093/jbcr/irz208

8. Reichert M, Aragona M, Soukkar A, Olianas R. Mesh graft urethroplasty — still a safe and promising technique in mostly unpromising complex urethral strictures. J Clin Med. 2022;11(20):5989. doi:10.3390/jcm11205989

9. Guogienė I, Kievišas M, Grigaitė A, Braziulis K, Rimdeika R. Split-thickness skin grafting: early outcomes of a clinical trial using different graft thickness. J Wound Care. 2018;27(1):5–13. doi:10.12968/jowc.2018.27.1.5

10. Schreiter F, Noll F. Mesh graft urethroplasty using split thickness skin graft or foreskin. J Urol. 1989;142(5):1223–6. doi:10.1016/s0022-5347(17)39036-5

11. Strother MC, Skokan AJ, Sterling ME, Butler PD, Kovell RC. Adult buried penis repair with escutcheonectomy and split-thickness skin grafting. J Sex Med. 2018;15(8):1198–204. doi:10.1016/j.jsxm.2018.05.009

12. Figler BD, Gan ZS, Mohan CS, Zhang Y, Filippou P. Outpatient panniculectomy and skin graft for adult buried penis. Urology. 2020;143:255–6. doi:10.1016/j.urology.2020.04.129

13. Erpelding SG, Hopkins M, Dugan A, Liau JY, Gupta S. Outpatient surgical management for acquired buried penis. Urology. 2019;123:247–51. doi:10.1016/j.urology.2018.10.002

14. Gül M, Plamadeala N, Falcone M, et al. No difference between split-thickness and full-thickness skin grafts for surgical repair in adult acquired buried penis regarding surgical and functional outcomes: a comparative retrospective analysis. Int J Impot Res. 2026;38(3):259–65. doi:10.1038/s41443-024-00832-7

15. Fuller TW, Theisen K, Rusilko P. Surgical management of adult acquired buried penis: escutcheonectomy, scrotectomy, and penile split-thickness skin graft. Urology. 2017;108:237–8. doi:10.1016/j.urology.2017.05.053

16. Susini P, Marcaccini G, Efica J, et al. Fournier's gangrene surgical reconstruction: a systematic review. J Clin Med. 2024;13(14):4085. doi:10.3390/jcm13144085

17. Biju NE, Sadiq M, Raj S, et al. Fournier's gangrene reconstruction: a 10-year retrospective analysis of practice at Guy's and St Thomas's NHS Foundation Trust. J Plast Reconstr Aesthet Surg. 2023;80:13–5. doi:10.1016/j.bjps.2023.02.030

18. Hayon S, Demzik A, Ehlers M, et al. Orchidopexy and split-thickness skin graft for scrotal defects after necrotizing fasciitis. Urology. 2021;152:196. doi:10.1016/j.urology.2021.02.007

19. Ye J, Xie T, Wu M, Ni P, Lu S. Negative pressure wound therapy applied before and after split-thickness skin graft helps healing of Fournier gangrene: a case report (CARE-compliant). Medicine (Baltimore). 2015;94(5):e426. doi:10.1097/MD.0000000000000426

20. Zhao JC, Xian CJ, Yu JA, Shi K. Reconstruction of infected and denuded scrotum and penis by combined application of negative pressure wound therapy and split-thickness skin grafting. Int Wound J. 2013;10(4):407–10. doi:10.1111/j.1742-481X.2012.00997.x

21. National Comprehensive Cancer Network. Penile Cancer (NCCN Clinical Practice Guidelines in Oncology). Updated 2025-11-12.

22. Parnham AS, Albersen M, Sahdev V, et al. Glansectomy and split-thickness skin graft for penile cancer. Eur Urol. 2018;73(2):284–9. doi:10.1016/j.eururo.2016.09.048

23. Falcone M, Preto M, Blecher G, et al. The outcomes of glansectomy and split thickness skin graft reconstruction for invasive penile cancer confined to glans. Urology. 2022;165:250–5. doi:10.1016/j.urology.2022.01.010

24. Malone PR, Thomas JS, Blick C. A tie-over dressing for graft application in distal penectomy and glans resurfacing: the TODGA technique. BJU Int. 2011;107(5):836–40. doi:10.1111/j.1464-410X.2010.09576.x

25. Garaffa G, Shabbir M, Christopher N, Minhas S, Ralph DJ. The surgical management of lichen sclerosus of the glans penis: our experience and review of the literature. J Sex Med. 2011;8(4):1246–53. doi:10.1111/j.1743-6109.2010.02165.x

26. Dalpiaz O, Kerschbaumer A, Pelzer A, et al. Single-stage dorsal inlay split-skin graft for salvage anterior urethral reconstruction. BJU Int. 2008;101(12):1565–70. doi:10.1111/j.1464-410X.2007.07436.x

27. Furr JR, Wisenbaugh ES, Gelman J. Long-term outcomes for 2-stage urethroplasty: an analysis of risk factors for urethral stricture recurrence. World J Urol. 2021;39(10):3903–11. doi:10.1007/s00345-021-03676-8

28. 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

29. Kang D, Hong SE, Kim YH. Single-stage penile resurfacing for foreign body granuloma: a simplified NPWT-assisted protocol with dermal substitute. Urology. 2026;published online. doi:10.1016/j.urology.2026.04.013

30. Linder BJ, Gebhart JB. McIndoe neovagina creation for the management of vaginal agenesis. Int Urogynecol J. 2021;32(2):453–5. doi:10.1007/s00192-020-04425-y

31. Lesavoy MA. Vaginal reconstruction. Urol Clin North Am. 1985;12(2):369–79.

32. Dainty LA, Bosco JJ, McBroom JW, et al. Novel techniques to improve split-thickness skin graft viability during vulvo-vaginal reconstruction. Gynecol Oncol. 2005;97(3):949–52. doi:10.1016/j.ygyno.2005.03.021

33. Höckel M, Dornhöfer N. Vulvovaginal reconstruction for neoplastic disease. Lancet Oncol. 2008;9(6):559–68. doi:10.1016/S1470-2045(08)70147-5

34. Zhang X, Han T, Ding J, Hua K. Split thickness skin graft for cervicovaginal reconstruction in congenital atresia of cervix. Fertil Steril. 2015;104(4):e9. doi:10.1016/j.fertnstert.2015.07.002

35. Kovacs M, Karsai S, Podda M. Superiority of occipital donor sites for split-thickness skin grafting in dermatosurgery: results of a prospective randomized controlled study. J Dtsch Dermatol Ges. 2017;15(10):990–7. doi:10.1111/ddg.13337

36. Yontar Y, Coruh A, Severcan M. K-wire assisted split-thickness skin graft harvesting from the anterior trunk. Burns. 2016;42(1):222–9. doi:10.1016/j.burns.2015.09.012

37. Asuku M, Yu TC, Yan Q, et al. Split-thickness skin graft donor-site morbidity: a systematic literature review. Burns. 2021;47(7):1525–46. doi:10.1016/j.burns.2021.02.014

38. Tehrani H, Lindford A, Logan AM. Hand knife versus powered dermatome: current opinions, practices, and evidence. Ann Plast Surg. 2006;57(1):77–9. doi:10.1097/01.sap.0000214902.79193.4e

39. Dargan DP, Gottlieb LJ, Vrouwe SQ. Assessment of the scalpel blade as an objective tool for measuring dermatome cut thickness. J Burn Care Res. 2025;iraf067. doi:10.1093/jbcr/iraf067

40. Ash A, Brune M, Willson TD, Colbert SH, Klifto KM. Tumescent technique for split-thickness skin graft donor sites: a systematic review of randomized controlled trials. J Plast Reconstr Aesthet Surg. 2024;90:292–304. doi:10.1016/j.bjps.2024.01.009

41. Ho CWG, Kok YO, Chong SJ. Photographic evaluation of different adrenaline-containing tumescent solutions on skin graft donor site bleeding: a prospective randomised trial. Burns. 2018;44(8):2018–25. doi:10.1016/j.burns.2018.03.003

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