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Escutcheonectomy

Escutcheonectomy is the surgical excision of the suprapubic fat pad (escutcheon) — the hair-bearing, adipose-rich tissue overlying the pubic symphysis that, in obese patients, engulfs and conceals the penile shaft.[1][2] It is a cornerstone component of adult-acquired buried penis (AABP) repair, performed in approximately 55% of AABP cases across multi-institutional cohorts,[3] and is also performed as a stand-alone or adjunctive procedure for suprapubic fat-pad excision at the time of inflatable penile prosthesis (IPP) placement and selected male-aesthetic indications.

For the integrated AABP workflow, see Buried Penis Repair. For the graft technique that almost always follows, see Penile Skin Grafting. For the related but anatomically distinct excision of the overhanging abdominal apron, see Panniculectomy. This page focuses on the escutcheonectomy itself — anatomy, indication, technique, and outcomes.

Anatomy​

The escutcheon is the suprapubic soft-tissue complex — skin, subcutaneous fat, and underlying fascia — that overlies the pubic bone. In morbid obesity this tissue hypertrophies and descends inferiorly, burying the penile shaft within a deep skin fold.

FeatureEscutcheonPannus
LocationLocalized over pubic symphysisOverhanging abdominal apron above the escutcheon
ProcedureEscutcheonectomyPanniculectomy
AABP frequency~ 55% of repairs[3]7–28% of repairs[4]
Santucci stageStage 4Stage 5

Indications​

1. AABP — PAS axis P (escutcheon-contributory)​

In the PAS classification system:[3]

  • P2a — contributory escutcheon with sufficient penile skin (21% of patients) → escutcheonectomy alone may suffice
  • P2c — contributory escutcheon with insufficient penile skin (27% — the most common subtype) → escutcheonectomy + skin graft

Performed in virtually all obese patients undergoing AABP repair when the suprapubic fat pad is contributory.[2][5]

2. Suprapubic fat-pad excision at IPP placement​

Concurrent excision of the suprapubic fat pad at the time of inflatable penile prosthesis placement in obese patients with concealed penis — improves exposed length, cosmesis, and self-image without compromising the IPP outcomes.[6]

3. Selected male-aesthetic indications​

In male-cosmetic genital surgery, a limited escutcheonectomy may be combined with suprapubic lipectomy or suspensory-ligament division to expose buried length in non-AABP patients with bothersome prepubic adiposity. See Male Cosmetic Genital Surgery.

Surgical Technique​

Incision design​

  • Transverse curvilinear incision in the suprapubic region — superior border at approximately the level of the ASIS bilaterally; inferior border curving down to ~ 1 cm above the penile base[7][6]
  • Modified trapezoid incision for cases requiring concurrent panniculectomy[8]
  • Designed to allow en bloc excision of the entire suprapubic fat pad while preserving adequate skin for tension-free closure

Excision​

  • Dissection carried through subcutaneous tissue down to anterior rectus / lower-abdominal fascia[2][6]
  • Excise skin + subcutaneous fat + the fibrous tissue tethering the penile base en bloc
  • Preserve spermatic cords and neurovascular structures
  • The penile shaft is fully liberated during this dissection
  • Specimen sent to pathology — penile cancer identified in ~ 5% of AABP-repair specimens[9]

Penile degloving and skin management​

After escutcheonectomy, the penis is fully degloved and all diseased shaft skin (LS, scarring, chronic dermatitis) is circumferentially excised. The shaft is then assessed for adequate coverage — if deficient, a skin graft is applied (see Penile Skin Grafting).

Closure and anchoring​

  • Multilayer closure — deep fascial sutures, subcutaneous sutures, skin closure[6]
  • Anchoring sutures — penopubic dermis to rectus fascia or pubic periosteum with permanent or long-lasting absorbable suture; prevents re-retraction of the penile base[7][10]
  • Closed-suction drains in the escutcheonectomy bed[6][8]

Escutcheon Specimen as Skin Graft Donor​

A defining innovation in AABP repair is using the excised escutcheon specimen as the graft donor, eliminating the need for a separate thigh donor site.[9]

STSG harvest (Strother / Kovell)​

  1. Specimen placed skin-side up on a flat back table, stretched taut
  2. Dermatome harvests STSG at 12–18 / 1000 inch in 2-inch sections[1][2][11]
  3. Take rate 80–100% (mean ~ 92%)

FTSG harvest (Monn / Mellon)​

  1. Skin sharp-dissected off the underlying fat of the specimen
  2. Meticulous defatting of the deep dermal surface — residual fat is the dominant cause of FTSG failure
  3. Take 87% complete success in 32 patients with concurrent LS (Jeng 2026); all graft losses occurred in patients with diabetes[12][13]

FTSG advantages over STSG: better cosmesis, durability, less contracture. STSG advantages: technically easier, lower hair burden.

See Penile Skin Grafting for full harvest, bolster, and postoperative-care detail.

Why Isolated Escutcheonectomy Fails​

Early AABP approaches attempted isolated escutcheonectomy (fat-pad resection alone without addressing diseased penile skin or scrotal pathology). These produced high reburying rates because they fail to address the underlying penile-skin disease, cicatricial tethering, and scrotal contribution to concealment. Modern consensus: escutcheonectomy should be combined with penile-skin excision, skin grafting, and scrotoplasty as needed for durable repair.[1][9][2]

Outcomes​

OutcomeData
Durable unburying96–100% when combined with STSG / scrotoplasty[10][2][3]
STSG take rate (escutcheon-harvested)80–100% (mean ~ 92%)
FTSG take rate (escutcheon-harvested)87–100%
Overall complications50–56%, mostly Clavien I–II[4][14]
Wound dehiscence31%
Wound infection30–41%
Revision rate3.9%
Mean OR time (with scrotoplasty + STSG)312 ± 59 min[2]
Mean EBL304 ± 133 cc
Length of stay (complex)5.3 ± 1.1 days; same-day discharge feasible in selected cases[15]

Complications​

  • Wound dehiscence (~ 31%) — suprapubic closure line; high-BMI cohorts; conservative care[14]
  • Wound infection (30–41%) — warm moist suprapubic fold[12][14]
  • Hematoma / seroma in the escutcheonectomy bed — mitigated by closed-suction drains and quilting sutures
  • Abdominal wound complications in 2 / 5 in the original Santucci series, all resolved with daily dressing changes[2]
  • Skin-graft loss — uncommon, but diabetes is the dominant predictor (all losses in the Jeng FTSG series occurred in diabetics)[12]

Preoperative Considerations​

  • BMI optimization — BMI ≥ 40 → 12.7× recurrence odds; each +1 BMI → +11% complication odds[14]
  • Frailty (mFI ≥ 2) → 6.4× complication risk[14]
  • Diabetes control — dominant graft-loss predictor[12]
  • Tobacco cessation ≥ 4–6 weeks
  • PAS-classification photography preoperatively for planning and inter-institution communication[3]

Outpatient Feasibility​

Escutcheonectomy + penile STSG can be performed outpatient or extended-stay in appropriately selected patients. Erpelding series: 62.5% same-day discharge, all Clavien II, 100% STSG take.[15] More complex cases involving concurrent panniculectomy and extensive scrotoplasty typically require 3–5 days of hospitalization.[2]

Key Takeaways​

  • Escutcheonectomy is essential to AABP repair in obese patients but must never be performed in isolation — combine with penile-skin management, scrotoplasty, and anchoring fixation
  • The excised escutcheon serves a dual purpose — pathologic tissue removed and simultaneously repurposed as the STSG or FTSG donor
  • Anchoring the penopubic dermis to rectus fascia / pubic periosteum prevents re-retraction
  • Wound complications are expected and generally manageable; preoperative BMI, diabetes, and frailty optimization significantly impact outcomes

Cross-references​

References​

1. 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

2. 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

3. 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

4. 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

5. Jun MS, Gallegos MA, Santucci RA. "Contemporary Management of Adult-Acquired Buried Penis." BJU Int. 2018;122(4):713–715. doi:10.1111/bju.14230

6. Baumgarten AS, Beilan JA, Shah BB, et al. "Suprapubic Fat Pad Excision With Simultaneous Placement of Inflatable Penile Prosthesis." J Sex Med. 2019;16(2):333–337. doi:10.1016/j.jsxm.2018.12.005

7. Alter GJ, Ehrlich RM. "A New Technique for Correction of the Hidden Penis in Children and Adults." J Urol. 1999;161(2):455–9.

8. Hesse MA, Israel JS, Shulzhenko NO, et al. "The Surgical Treatment of Adult Acquired Buried Penis Syndrome: A New Classification System." Aesthet Surg J. 2019;39(9):979–988. doi:10.1093/asj/sjy325

9. 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

10. Voznesensky MA, Lawrence WT, Keith JN, Erickson BA. "Patient-Reported Social, Psychological, and Urologic Outcomes After Adult Buried Penis Repair." Urology. 2017;103:240–244. doi:10.1016/j.urology.2016.12.043

11. 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

12. 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

13. 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

14. 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

15. 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