Buried Penis Repair
This is the operative companion to Adult-Acquired Buried Penis. Plan reconstruction around the patient's urinary, sexual, hygiene and skin-care problems, the tissues actually contributing to concealment, and the amount of healthy skin remaining. AABP repair may combine several procedures, but every patient does not need every component.[1][2]
Plan the components
| Finding | Possible component | Planning point |
|---|---|---|
| Constricting scar or diseased penile skin | Scar release and selective skin excision | Preserve useful native skin and viable underlying tissue; determine the resulting defect |
| Contributory escutcheon | Escutcheonectomy and appropriate fixation | Distinguish suprapubic tissue from an overhanging abdominal pannus |
| Contributory abdominal pannus | Panniculectomy | Coordinate incision, perfusion, closure tension and donor-skin use |
| Diseased or redundant scrotal tissue | Scrotoplasty or selected scrotectomy | Protect the testes and spermatic cords; assess remaining coverage |
| Skin deficiency | Graft or suitable local flap | Choose by bed viability, donor quality, hair, contracture and staging needs |
| Suspected urethral disease | Urethral assessment and coordinated treatment | The type and timing of repair depend on stricture anatomy and the skin-reconstruction plan |
PAS describes the penile skin/escutcheon complex, abdominal pannus and scrotal skin. Its 101-patient validation cohort demonstrated strong agreement between reviewers and correlation with operations performed; it did not establish a mandatory treatment algorithm or prove outcome prediction.[2] Limited surgery can fail when contributory disease is left untreated, but isolated escutcheonectomy does not inevitably fail, and circumferential grafting is not required when healthy shaft skin is adequate.[3][4]
Operative sequence and safety
Exposure, release and tissue assessment
Confirm markings with the patient positioned for examination and surgery, accounting for pannus descent. Release the constricting tissues sufficiently to expose the glans, meatus and shaft. Assess each tissue layer before removing it; do not routinely strip all healthy dartos or create an unnecessary circumferential skin defect. Send abnormal excised tissue for histopathology and investigate suspicious lesions rather than assuming all concealed skin disease is benign.[1][5][6]
Daly's retrospective series included 180 patients undergoing buried-penis repair or penectomy in the setting of buried penis. LS occurred in 23% and penile cancer in 5%. This selected cohort does not establish a 5% incidental-cancer rate in every routine repair specimen. The reported 2.3-fold association concerned requiring intervention for urethral stricture (54.8% versus 23.8%), not an adjusted odds ratio for stricture prevalence or evidence that LS causes graft failure.[6]
Escutcheon and pannus surgery
Remove the suprapubic tissue that contributes to burial while planning a viable, low-tension closure. Incision design and depth vary with the tissue excess and accompanying procedures. Reconstruct the penopubic angle and secure mobile tissues to suitable deep fascia when needed. Protect the penile neurovascular structures, urethra and spermatic cords; manage dead space and drainage according to the operation.[1][3]
A panniculectomy review identified only four reports with 57 patients, supplemented by an NSQIP analysis. Concurrent panniculectomy was not independently associated with more 30-day complications in that adjusted analysis, despite greater morbidity in the unadjusted group. This observational finding does not prove that adding panniculectomy has no risk, or justify adding it when the pannus is not contributory.[7] See Escutcheonectomy and Panniculectomy.
Select shaft coverage
| Option | Role | Limitations |
|---|---|---|
| Native skin advancement or selected Z-plasty | Enough healthy mobile skin remains | No validated universal percentage-of-circumference threshold; assess on stretch |
| STSG | Broad superficial coverage on a vascularized bed | Donor-site care, graft loss, sensory change and contracture remain possible |
| FTSG | Selected defects with a suitable recipient bed and donor skin | Careful defatting and donor assessment; no established AABP superiority over STSG |
| Ventral slit scrotal flap | Selected ventral skin deficiency with suitable scrotal tissue | Hair, rugae and disease recurrence; not suitable for every circumferential defect |
| Staged reconstruction | Uncertain tissue viability, extensive inflammation or complex combined reconstruction | More procedures and longer treatment course |
STSG from the thigh and STSG or FTSG from suitable excised suprapubic tissue are described options. Reusing appropriate escutcheon or pannus skin can avoid another donor wound; it is not automatically the donor of choice when the skin is diseased, hair-bearing in an unsuitable pattern or otherwise poor quality.[8][9][5]
The small retrospective Gül comparison included 39 patients overall but only 22 graft recipients: nine FTSG and 13 STSG. Failure to detect a difference does not establish equivalence or an LS-specific preference. In Jeng's 32-patient LS/FTSG series, one patient had complete and two partial graft loss; all three had diabetes, but the reported association was not statistically significant. Neither study establishes diabetes as the dominant independent cause of FTSG loss.[10][11]
The original VSSF report involved 15 selected patients, with mean BMI 42.6 kg/m²; it was not restricted to patients without substantial obesity. Eleven were satisfied without further intervention and three had recurrent concealment. These results do not make the flap a universal substitute for grafting.[12] See Penile Skin Grafting and Ventral Slit Scrotal Flap.
Harvest, fixation and dressing
For STSG, choose the donor, thickness and meshing pattern for the actual defect and functional goals. Sheet grafts and unexpanded 1:1 meshing have both been used on the shaft. Black's nine-patient report used 0.012- or 0.016-inch grafts with transverse unexpanded slits and a ventral zigzag junction; this is a described technique, not a required configuration.[13]
For FTSG, retain epidermis and dermis while removing adherent fat carefully. Maintain graft contact with a hemostatic, viable recipient bed, prevent fluid collection and minimize shear. Fit and secure the graft with the penis extended to avoid preventable tethering, without applying a constricting dressing.[9][5]
Bolster materials, NPWT, catheter use and removal timing depend on the repair and local protocol. Figler's 19-patient outpatient technique used a bolster for 5–7 days; the 21-patient Rook series removed it at a median of four days. Rook's 100% early graft take was a median, not proof that every patient had complete take or that this dressing is superior. Routine fibrin sealant, erection suppression or a particular dressing is not established by these uncontrolled series.[14][15][16]
Coordinate urethral reconstruction
Assess voiding symptoms, the meatus and suspected stricture disease before finalizing the skin operation. When exposure prevents adequate preoperative evaluation, consent and plan for intraoperative assessment and, if necessary, temporary suprapubic drainage. Avoid forcing an instrument through a narrowing simply to complete evaluation.[1]
Fuller's retrospective cohort found strictures in 13 of 42 patients; eight of those 13 had strictures at least 6 cm long and underwent Kulkarni urethroplasty before AABP repair. That sequence is a useful option for selected long anterior strictures, not a rule for all strictures. Other expert operative experience describes selected simultaneous dorsal oral-mucosal graft urethroplasty. Plan staging with a reconstructive urologist, considering recipient-bed perfusion and the difficulty of later mobilizing grafted shaft skin.[17][1]
Recovery and risk counseling
Individualize outpatient versus inpatient care to the repair, comorbidity, mobility, support and access to wound care. Erpelding's selected 16-patient series discharged ten on the operative day and six the following day; all recorded 30- and 90-day complications were Clavien II. Figler's separate 19-patient series reported five cellulitis and three minor-dehiscence events. These small series establish feasibility in selected patients, not universal outpatient suitability or absence of thromboembolic risk.[18][14]
Optimize weight-related risk, diabetes, smoking, nutrition and functional status, and arrange appropriate perioperative thromboprophylaxis and wound support. Chestnut's 76-patient retrospective cohort associated BMI with recurrence and complications; its data-derived BMI 38 and 40 thresholds and large odds ratios are not externally validated eligibility cutoffs or individual risk estimates. Frailty was independently associated with complications in Staniorski's 103-patient high-complexity cohort. Neither study supports indefinite delay based on a single numerical threshold.[19][20]
Counsel specifically about wound breakdown, infection, hematoma, graft loss, recurrent concealment and possible revision. Minor wound problems may respond to local care, whereas progressive infection, significant ischemia, hematoma or graft failure requires reassessment.[20][11]
Outcomes: keep populations and endpoints separate
| Study | Population and endpoint | Interpretation |
|---|---|---|
| Pariser 2018 | 64 repairs; 58 achieved an unburied penis without further unburying surgery; median follow-up 209 days | 91% refers to that composite definition and follow-up, not graft take |
| Staniorski 2023 | 103 high-complexity repairs; 50% had complications, with 41% Clavien I–II; 3.9% revision for poor outcome, median follow-up 11 months | The revision rate is not a universal recurrence rate |
| Plamadeala 2026 | 204 initial repairs; 91 received grafts; median follow-up 18 months; 55 complications and 26 recurrences | Mixed procedures and retrospective selection limit causal comparisons |
Sources: Pariser,[21] Staniorski,[20] and Plamadeala.[22] In the 204-patient cohort, recurrence-free survival was estimated at 91.5% at 12 months and 83.7% at 24 months. Higher complexity was associated with more complications and lower adjusted recurrence; that does not prove that escalating surgery improves outcomes. The reported 3-cm stretched-length gain was a median, and patient-reported outcomes were available for only 68 patients. Satisfaction and functional gains therefore need their actual respondent denominators.[22]
Follow-up should assess healing, urinary function, erection-related tethering, recurrent inflammatory disease, recurrent concealment and patient goals. Pediatric congenital concealed penis requires a separate pediatric assessment; adult excision and grafting algorithms should not be applied automatically.[1][23]
See Also
- Adult-Acquired Buried Penis
- Penile Reconstruction
- Scrotal Reconstruction
- Kulkarni One-Stage Panurethral Urethroplasty
Videos
References
1. Ho TS, Gelman J. Evaluation and management of adult acquired buried penis. Transl Androl Urol. 2018;7:618–627. doi:10.21037/tau.2018.05.06.
2. Schlaepfer CH, Flynn KJ, Alsikafi NF, et al. "Clinical Validation of an Adult-Acquired Buried Penis Classification System Based on Standardized Evaluation of the Penis, Abdomen, and Scrotum." Urology. 2023;180:249–256. doi:10.1016/j.urology.2023.04.048
3. Fuller TW, Theisen K, Rusilko P. "Surgical Management of Adult Acquired Buried Penis: Escutcheonectomy, Scrotectomy, and Penile Split-Thickness Skin Graft." Urology. 2017;108:237–238. doi:10.1016/j.urology.2017.05.053
4. Mirastschijski U. "Classification and Treatment of the Adult Buried Penis." Ann Plast Surg. 2018;80(6):653–659. doi:10.1097/SAP.0000000000001410
5. Alwaal A, McAninch JW, Harris CR, Breyer BN. Utilities of split-thickness skin grafting for male genital reconstruction. Urology. 2015;86(4):835–839. doi:10.1016/j.urology.2015.07.005.
6. Daly WC, Klein RD, Myrga JM, Quiroga-Garza G, Rusilko PJ. "Lichen Sclerosus in Patients Undergoing Adult-Acquired Buried Penis Repair: A Large Cohort Review." Urology. 2025. doi:10.1016/j.urology.2025.07.061
7. Barrow B, Laspro M, Brydges HT, et al. "Technical Considerations and Outcomes for Panniculectomy in the Setting of Buried Penis Patients: A Systematic Review and Database Analysis." Ann Plast Surg. 2024;93(3):355–360. doi:10.1097/SAP.0000000000004025
8. 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):1198–1204. doi:10.1016/j.jsxm.2018.05.009
9. Monn MF, Socas J, Mellon MJ. "The Use of Full Thickness Skin Graft Phalloplasty During Adult Acquired Buried Penis Repair." Urology. 2019;129:223–227. doi:10.1016/j.urology.2019.04.007
10. 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." Int J Impot Res. 2026;38(3):259–265. doi:10.1038/s41443-024-00832-7
11. Jeng G, Massoud L, Parish C, et al. "Surgical Outcome of Full-Thickness Skin Graft Using Escutcheon Tissue for Management of Adult Acquired Buried Penis With Concurrent Lichen Sclerosus." Urology. 2026. doi:10.1016/j.urology.2026.04.008
12. Westerman ME, Tausch TJ, Zhao LC, et al. "Ventral Slit Scrotal Flap: A New Outpatient Surgical Option for Reconstruction of Adult Buried Penis Syndrome." Urology. 2015;85(6):1501–4. doi:10.1016/j.urology.2015.02.030
13. Black PC, Friedrich JB, Engrav LH, Wessells H. "Meshed Unexpanded Split-Thickness Skin Grafting for Reconstruction of Penile Skin Loss." J Urol. 2004;172(3):976–9. doi:10.1097/01.ju.0000133972.65501.44
14. Figler BD, Gan ZS, Mohan CS, Zhang Y, Filippou P. "Outpatient Panniculectomy and Skin Graft for Adult Buried Penis." Urology. 2020;143:255–256. doi:10.1016/j.urology.2020.04.129
15. Richards P, Yadav K, Coakes C, et al. "Rook to the Rescue: A Case Series on the Novel Use of Eggcrate Foam Bolsters for Skin Grafts in Penile and Genital Reconstruction." Ann Plast Surg. 2026. doi:10.1097/SAP.0000000000004649
16. Tang SH, Kamat D, Santucci RA. "Modern Management of Adult-Acquired Buried Penis." Urology. 2008;72(1):124–7. doi:10.1016/j.urology.2008.01.059
17. Fuller TW, Pekala K, Theisen KM, et al. "Prevalence and Surgical Management of Concurrent Adult Acquired Buried Penis and Urethral Stricture Disease." World J Urol. 2019;37(7):1409–1413. doi:10.1007/s00345-018-2514-1
18. Erpelding SG, Hopkins M, Dugan A, Liau JY, Gupta S. "Outpatient Surgical Management for Acquired Buried Penis." Urology. 2019;123:247–251. doi:10.1016/j.urology.2018.10.002
19. Chestnut C, Koch G, Stewart A, et al. "Increased Body Mass Index Is Associated With Recurrence and Complications Following Repair for Adult Acquired Buried Penis." J Sex Med. 2025. doi:10.1093/jsxmed/qdaf149
20. Staniorski CJ, Myrga JM, Vasan RV, Klein RD, Rusilko PJ. "Surgical Outcomes and Prediction of Complications Following High-Complexity Buried Penis Reconstruction." J Urol. 2023;210(5):782–790. doi:10.1097/JU.0000000000003669
21. Pariser JJ, Soto-Aviles OE, Miller B, Husainat M, Santucci RA. "A Simplified Adult Acquired Buried Penis Repair Classification System With an Analysis of Perioperative Complications and Urethral Stricture Disease." Urology. 2018;120:248–252. doi:10.1016/j.urology.2018.05.029
22. Plamadeala N, Lee WGD, Ruffo A, et al. "Outcomes of Adult Acquired Buried Penis (AABP) Reconstruction: A Multicentre Cohort Study." Int J Impot Res. 2026;38(4):354–362. doi:10.1038/s41443-026-01269-w
23. Zhang H, Zhao G, Feng G, et al. "A New Surgical Technique for the Treatment of Congenital Concealed Penis Based on Anatomical Finding." J Urol. 2020;204(6):1341–1348. doi:10.1097/JU.0000000000001300