Penile Reconstruction
This atlas organizes reconstruction of penile skin, glans and more extensive defects after trauma, infection, inflammatory disease, congenital differences or tumor resection. Start with the General Principles, then use the technique links according to the tissue missing and the patient's functional goals. Peyronie's surgery and Gender-Affirming Surgery have separate pathways.
Assess the problem
Determine what viable skin and dartos remain, whether the urethra, glans or corpora are involved, and whether the wound is ready for reconstruction. Preserve useful native tissue and avoid a closure that restricts erection. Review sensation, voiding, sexual activity, appearance, donor morbidity and the likelihood of staged treatment.[1][2]
| Presentation | Assessment that changes the plan |
|---|---|
| Adult-acquired buried penis | Separate shaft-skin deficiency from contributory suprapubic tissue, abdominal pannus and scrotal disease; evaluate associated urinary symptoms |
| Infection or Fournier's gangrene | Control infection and complete debridement before definitive coverage; determine bed viability and any need to fill dead space |
| LS or another inflammatory skin disorder | Assess skin, meatus and urethra separately; coordinate disease treatment and reconstruction |
| Foreign-body granuloma | Establish the extent of material and diseased tissue, healthy donor options and whether immediate coverage is appropriate |
| Lymphedema or hidradenitis | Assess combined penile, scrotal and perineal involvement; tailor tissue removal and coverage |
| Tumor excision | Establish histology, oncologic extent and appropriate margins before selecting reconstruction |
| Trauma or congenital/redo defect | Assess all involved structures and previous repairs; use specialist reconstruction where necessary |
These are planning categories, not automatic instructions to use one flap or graft for each diagnosis.[1][2]
Choose coverage by tissue requirements
| Findings | Options to consider | Important tradeoff |
|---|---|---|
| Enough viable skin for closure without distortion | Primary closure, local advancement or selected Z-plasty | Avoid tension and a constricting ring |
| Superficial loss with a vascularized bed | STSG or FTSG | Donor quality, graft take, contracture, sensation and hair characteristics |
| Need for vascularized coverage or additional tissue | Suitable local, regional or free flap | Pedicle availability, donor morbidity, bulk, hair and possible staging |
| Matrix-assisted grafting being considered | Product-specific dermal matrix plus STSG | Uncertain comparative benefit, cost and product-dependent timing |
| Residual skin suitable for planned expansion | Selected staged tissue expansion | Device complications, repeated visits and reoperation burden |
No validated circumference threshold universally separates primary closure, grafting and flap reconstruction. A graft bed and the covering over exposed corpora or testes must be assessed directly. Scrotal donor skin may be hair-bearing; neither a flap nor a graft guarantees normal sensation or elasticity.[1][2][3]
Do not place Integra on a clinically infected wound. NPWT or a silicone cover does not remove this contraindication. MatriDerm and Integra are not interchangeable staged protocols: selected MatriDerm formulations have been used with simultaneous STSG, while bilayer Integra is often followed by delayed grafting.[4][5][6] Details are in Penile Skin Grafting and Penile Tissue Substitutes.
Buried-penis classification
PAS describes the penile skin/escutcheon complex, abdominal pannus and scrotal skin. In its 101-patient multicenter validation cohort, agreement between two reviewers was high (κ = 0.95) and categories correlated with the operations performed. This supports structured description; it does not prove that a PAS category dictates the best operation or predicts every outcome.[7]
Mirastschijski proposed a three-type system distinguishing an overhanging skin apron, partial invagination and complete retraction. It is another descriptive planning framework, not an interchangeable validated treatment rule. Use classifications to communicate anatomy while matching the operation to actual findings and patient goals.[8] See Buried Penis Repair.
Glans and cancer-related reconstruction
Select organ-preserving treatment when oncologically appropriate, with histologically negative margins and a feasible surveillance plan. Margin width depends on size, grade and invasion; a universal 5–10 mm prescription is inappropriate for bulky or higher-risk tumors. Glans resurfacing preserves the underlying glans; glansectomy with neoglans reconstruction addresses a different defect. Local recurrence after organ-sparing treatment requires restaging and individualized salvage.[9]
Elst's 550-patient retrospective study involved a lower-risk glans-sparing cohort and excluded lymphatic or systemic disease preceding or accompanying local recurrence. It observed 29% local recurrence and 99% five-year cancer-specific survival. That finding cannot establish harmlessness of local recurrence in every penile-cancer population. Current EAU guidance specifically distinguishes higher-risk cohorts in which local recurrence is associated with poorer survival.[10][9]
A review of 14 glansectomy studies encompassing 327 procedures found generally favorable functional outcomes but heterogeneous definitions and reporting. Pooled erectile, voiding or satisfaction percentages are not an individual guarantee or proof of equivalence between reconstructive options.[11] See Glans Reconstruction.
Interpret the technique database
The database includes established procedures and less common described techniques. Listing a technique is not a claim that it is preferred for a diagnosis or that its outcomes are equivalent to other options. For example, the EPAP hemi-scrotal flap report describes one patient; it cannot establish elimination of pain or superiority over other scrotal flaps.[12]
Plan wound and donor-site care, dressing and catheter needs, and follow-up according to the actual reconstruction. Assess healing, sensation, erection-related tethering, urinary function, recurrent disease and patient-reported outcomes over time. Graft take, flap survival and success of the complete reconstruction are different endpoints.[2][3]
Treatment Database
| Procedure | Domain | Reconstructive role |
|---|---|---|
| Buried Penis Repair (overview) | Adult-Acquired Buried Penis | Integrated assessment of shaft skin, suprapubic tissue, scrotum and associated urinary problems. |
| Panniculectomy | Adult-Acquired Buried Penis | Abdominal pannus contributing to concealment or limiting access and care. |
| Escutcheonectomy | Adult-Acquired Buried Penis | Contributory suprapubic tissue; coordinate with the actual shaft-skin requirements. |
| Penile Skin Grafting (STSG / FTSG) | Shaft Skin — Graft | Surface coverage on a suitable vascularized bed after disease or tissue loss. |
| Primary Closure ± Z-Plasty (penis on stretch) | Shaft Skin — Graft | Defects with enough viable skin for tension-free closure; selected scar release. |
| Bipedicled Anterior Scrotal Flap (Fakin) | Shaft Skin — Flap | Selected shaft defects with suitable scrotal donor tissue and vascular supply. |
| Modified Bipedicle Scrotal Tunnel Flap (Murányi) | Shaft Skin — Flap | A described scrotal tunnel technique for selected foreign-body-related shaft defects. |
| Modified Bilateral Butterfly Scrotal Flap (Yao) | Shaft Skin — Flap | A described bilateral scrotal-flap option for shaft coverage. |
| Staged Bipedicled Scrotal Flap (Pribaz / McLaughlin) | Shaft Skin — Flap | Staged coverage of selected shaft-skin deficiencies after appropriate wound preparation. |
| Ventral Slit Scrotal Flap (VSSF) | Shaft Skin — Flap | Selected buried-penis repairs with usable dorsal skin; assess the complete defect. |
| Total Anterior Scrotal Flap (Zhao) | Shaft Skin — Flap | A specialized anterior scrotal-flap option for selected shaft defects. |
| Reverse Bilateral Anterior Scrotal Artery Flap (Gao) | Shaft Skin — Flap | A specialized scrotal-flap design requiring careful vascular and donor assessment. |
| Sensate External Pudendal Artery Perforator (EPAP) Hemi-Scrotal Flap (Tsukuura) | Shaft Skin — Flap | A sensate perforator-based option described in a case report; comparative outcomes are uncertain. |
| Penile Tissue Substitutes and Adjuncts | Tissue Substitute | Optional matrix-supported grafting; tissue expansion and NPWT have separate roles. |
| ALT Free Flap — Massive Genital / Perineal Defect | Free Tissue Transfer | Selected large or composite defects requiring vascularized tissue; assess pedicled and free options. |
| SCIP Lymphatic Flap (SCIP-LFT) — Genital Elephantiasis | Free Tissue Transfer | Selected lymphedema reconstruction combining coverage with a lymphatic-tissue approach; evidence remains limited. |
| Radial Forearm Free Flap (RFFF) — Total Penile Reconstruction | Free Tissue Transfer | One option for total penile reconstruction, with donor-site, sensory and staging tradeoffs. |
| Glans Resurfacing (TGR / PGR / CSGR) | Glans / Cancer Reconstruction | Selected superficial glans disease after histologic assessment; distinct from glansectomy. |
| Glansectomy With STSG | Glans / Cancer Reconstruction | Selected invasive glans-confined cancer after oncologic assessment and counseling. |
| Glanuloplasty With Flaps (IUF / Gulino / scrotal / rectus) | Glans / Cancer Reconstruction | Specialized neoglans reconstruction options after tissue loss or resection. |
| Inverted Urethral Flap (IUF) Glanuloplasty (Belinky / Chavarriaga) | Glans / Cancer Reconstruction | Urethral-flap neoglans reconstruction when suitable, adequately perfused urethral tissue is available. |
| Gulino Everted Urethral Flap Glanuloplasty | Glans / Cancer Reconstruction | An everted urethral-flap technique; select according to the resection and available tissue. |
| Scrotal Flap Glanuloplasty (Mazza / Cheliz) | Glans / Cancer Reconstruction | A scrotal-tissue option for selected neoglans defects. |
| Rectus Abdominis Myofascial Neoglans (Shaeer) | Glans / Cancer Reconstruction | A specialized myofascial neoglans technique described in limited reconstructive experience. |
| Microsurgical Penile / Glans Replantation | Trauma / Replantation | Urgent specialist assessment after penile or glans amputation. |
| Cecil-Culp Procedure (Scrotal Dropback) | Staged / Salvage | Selected staged salvage of complex urethrocutaneous fistula and penile-skin defects. |
| Penile / Total Penis-Scrotum-Lower-Abdominal-Wall VCA (GUVCA) | Staged / Salvage | Highly selected transplantation requiring specialized evaluation and long-term immunosuppression. |
References
1. Kristinsson S, Johnson M, Ralph D. Review of penile reconstructive techniques. Int J Impot Res. 2021;33(3):243–250. doi:10.1038/s41443-020-0246-4
2. 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
3. Mendel L, Neuville P, Allepot K, et al. Bilateral pedicled scrotal flaps as an alternative to skin graft in penile shaft defects repair. Urology. 2023;176:206–212. doi:10.1016/j.urology.2023.03.025
4. US Food and Drug Administration. Integra Dermal Regeneration Template / Omnigraft: Summary of Safety and Effectiveness Data, P900033/S042. 2016. Contraindications. FDA SSED.
5. Liguori G, Papa G, Boltri M, et al. Reconstruction of penile skin loss using a combined therapy of negative-pressure wound therapy, dermal regeneration template, and split-thickness skin graft application. Int J Impot Res. 2020;33(8):854–859. doi:10.1038/s41443-020-00343-1
6. Crane J, Lloyd A, Kaul A, Sethia K, Clibbon J. Matriderm® as a biological scaffold in penile resurfacing: a single-centre case series. J Plast Reconstr Aesthet Surg. 2026;115:325–330. doi:10.1016/j.bjps.2026.02.045
7. 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
8. Mirastschijski U. Classification and treatment of the adult buried penis. Ann Plast Surg. 2018;80(6):653–659. doi:10.1097/SAP.0000000000001410
9. European Association of Urology. EAU Guidelines on Penile Cancer. 2026. Disease management, primary tumour, section 6.1. Guideline.
10. Elst L, Roussel E, Miletic M, et al. Local recurrence after glans-sparing surgery: no impact on penile cancer-specific survival. BJU Int. 2025. doi:10.1111/bju.70055
11. Pang KH, Alnajjar HM, Muneer A. Functional outcomes of glansectomy to treat localised penile cancer: a systematic review. Int J Impot Res. 2026;38(3):206–213. doi:10.1038/s41443-025-01062-1
12. Tsukuura R, Engmann T, Miyazaki T, Yamamoto T. The sensate external pudendal artery perforator (EPAP) hemi-scrotal flap for the circumferential skin defect of the penile shaft: a case report and literature review. Microsurgery. 2025;45(7):e70123. doi:10.1002/micr.70123