Escutcheonectomy
Escutcheonectomy removes contributory suprapubic skin and fat overlying the pubic region. It may form part of Buried Penis Repair, but the need for grafting, scrotal surgery or Panniculectomy depends on the remaining anatomy. The escutcheon is distinct from the overhanging abdominal pannus.[1]
Select the operation
Assess the patient standing and supine, including pannus descent, suprapubic tissue, penile skin quality, glans/meatal exposure and scrotal disease. Determine how much concealment is caused by suprapubic descent versus constriction or skin deficiency. PAS can document these features; its validation established reproducibility and correlation with operations, not a requirement that every patient receive a fixed combination.[1][2]
| Finding | Implication |
|---|---|
| Contributory escutcheon with adequate healthy shaft skin | Escutcheon correction and fixation may be sufficient; do not create a graft requirement by routine skin removal |
| Contributory escutcheon with diseased or deficient shaft skin | Combine with appropriate skin treatment and coverage |
| Abdominal pannus also contributes | Consider a coordinated panniculectomy |
| Diseased scrotum or urethral stricture | Plan the associated reconstruction and its timing separately |
Limited fat-pad surgery can leave unresolved concealment when other disease is present. This does not mean that isolated escutcheonectomy always fails or that skin grafting almost always follows.[3][1]
Operative approach
Mark and expose
Individualize the incision to the tissue requiring removal, closure tension and surrounding perfusion. A transverse curvilinear design and modified patterns for associated panniculectomy are described. Published landmarks from one operation are not universal incision limits.[4][1]
Mobilize and remove the excess suprapubic tissue in the planned plane. Lower-abdominal fascial exposure may be used to support fixation. Protect the penile neurovascular structures, urethra and spermatic cords; assess the actual structures before further dissection.[4][1]
Preserve usable penile skin
Release constricting scars and remove diseased tissue when indicated. Preserve adequate viable shaft skin rather than routinely degloving and circumferentially excising it. Assess suspected LS, meatal disease and suspicious lesions, with histopathology of abnormal excised tissue. The 5% penile-cancer figure reported in Daly's selected repair-or-penectomy cohort is not a cancer rate in escutcheon specimens.[1][5]
Fixation and closure
Reconstruct the penopubic angle and secure mobile subdermal tissues to suitable deep fascia when needed. Fixation supports the repair but cannot guarantee prevention of recurrent concealment. Plan a layered, low-tension closure, hemostasis and dead-space management; drains are used according to the operation.[1][4]
Grafting when required
Suitable suprapubic tissue can provide STSG or FTSG and avoid a separate donor wound. Assess donor skin quality and hair rather than assuming excised tissue is suitable because it is available. For FTSG, preserve the dermis and carefully remove adherent fat. Graft sizing, fixation and dressing must preserve contact and permit functional shaft extension.[6][7]
The evidence does not establish superior AABP cosmesis or durability for every FTSG. Jeng's 32-patient LS series had one complete and two partial graft losses, and four patients required reoperation for a range of failures. Thus, 28/32 without that reoperation endpoint is not an 87% complete-graft-take rate. All three graft-loss patients had diabetes, but the reported association was not statistically significant and does not prove diabetes is the dominant independent cause.[8] See Penile Skin Grafting.
Concurrent penile prosthesis placement
Simultaneous suprapubic fat-pad excision and IPP placement has been described in selected patients. Baumgarten's report included only eight patients, one of whom developed prosthetic infection. The uncontrolled series cannot establish that combined surgery preserves the same infection risk as IPP alone. Selection and counseling should involve an experienced prosthetic/reconstructive team.[4] Cosmetic procedures such as suspensory-ligament division are not routine components of functional escutcheonectomy.
Outcomes and recovery
| Source | What was actually studied |
|---|---|
| Tang 2008 | Five men underwent combined reconstruction; four had escutcheonectomy. Penile graft take was 80–100% at two months; two abdominal wound complications occurred |
| Fuller 2017 | Twelve combined escutcheonectomy/scrotoplasty/STSG repairs; mean follow-up eight months, graft take mean 91.7%; mean stay 5.3 days |
| Staniorski 2023 | 103 high-complexity repairs including escutcheonectomy and penile grafting; 50% complications and 3.9% revision for poor outcome at median 11-month follow-up |
| Erpelding 2019 | Sixteen selected combined repairs; ten discharged the same day and six the next day, with all recorded 30-/90-day complications Clavien II |
These are outcomes of different combined repairs, not head-to-head comparisons or an escutcheonectomy-specific pooled success rate.[9][3][10][11]
Counsel about wound breakdown, infection, fluid collections, graft problems when grafting is used, recurrent concealment and possible revision. Optimize relevant medical and functional risks, including weight-related disease, diabetes, smoking and frailty. Staniorski's frailty association is an observational odds ratio, not an individualized probability of a complication. Tailor discharge, mobilization, thromboprophylaxis, catheter and wound follow-up to the complete operation and available support.[10][11]
See Also
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. 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
5. Daly WC, Klein RD, Myrga JM, et al. Lichen sclerosus in patients undergoing adult-acquired buried penis repair: a large cohort review. Urology. 2025. doi:10.1016/j.urology.2025.07.061.
6. 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
7. 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
8. 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
9. 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
10. 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
11. 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