Penile Reconstruction
This page hosts the Decision Framework and Treatment Database for penile reconstruction in the non-gender-affirming context — shaft skin, glans, adult-acquired buried penis (AABP), cancer-related penile-sparing surgery, lichen sclerosus, foreign-body injection, lymphedema, hidradenitis suppurativa, trauma, and congenital anomaly. Peyronie's correction lives at 04j Peyronie's Disease; gender-affirming phalloplasty / metoidioplasty lives at 04k Gender-Affirming Surgery; penile augmentation (PDD / SPS) lives in the Small Penis Syndrome clinical-conditions article.
For technique-level detail, see the existing visible articles in this section: Buried Penis Repair, Penile Skin / Shaft Reconstruction, Glans Reconstruction / Glansplasty, and the Cecil-Culp Procedure.
Decision Framework
Penile shaft skin presents reconstructive challenges that differ from any other body site: it is non-hair-bearing, thin, must accommodate erection without tethering, and is frequently circumferentially deficient (lichen sclerosus, obesity-driven buried penis, Fournier's gangrene, foreign-body silicone injection, oncologic excision, circumcision injury). The closure must allow sufficient elasticity for tumescence, and any primary closure should be performed with the penis on stretch to prevent acquired curvature.[1][2] The contemporary anchors are the Kristinsson 2021 Int J Impot Res review of penile reconstructive techniques, the Alwaal 2015 UCSF n = 54 STSG series (graft take > 90%, normal voiding, preserved erection), the Mendel 2023 and McLaughlin 2024 bipedicled-scrotal-flap series, the Tsukuura 2025 sensate EPAP hemi-scrotal perforator flap, the Liguori 2020 Integra + NPWT + STSG series, the Crane 2026 Matriderm + STSG single-stage series (n = 36 / 92.1% take), the Mirastschijski 2018 and Schlaepfer 2023 / Flynn 2022 PAS classifications for AABP, and the EAU-ASCO 2023 (Brouwer) + NCCN 2025 + Pang 2026 glansectomy SR + Baumgarten 2018 multicenter penile-sparing-surgery 1,188-patient cohort for cancer-related reconstruction.[3][4][5][6][7][8][9][10][11][12][13]
Assess Etiology and Defect Characteristics
| Etiology | Typical Defect Pattern | Key Considerations |
|---|---|---|
| Adult-acquired buried penis (AABP) — most common indication | Circumferential skin loss after excision of diseased / scarred skin + escutcheonectomy | BMI optimization; lichen-sclerosus-obesity-stricture cycle; PAS classification (Schlaepfer 2023) drives operative plan |
| Fournier's gangrene | Variable, often circumferential with exposed corpora ± testes | Staged: serial debridement → granulation / NPWT → reconstruction; flap preferred when corpora exposed |
| Lichen sclerosus | Circumferential; often with concurrent urethral stricture | Staged urethroplasty may be required; BMG urethroplasty if stricture; high reoperation rate |
| Foreign-body injection (silicone, paraffin) | Circumferential after radical excision of granulomas | Bipedicled scrotal flap is preferred; high satisfaction (4.37/5; Fakin 2017) |
| Genital lymphedema / elephantiasis | Circumferential after excision of lymphedematous tissue | Combine excision + lymphatic reconstruction (SCIP-LFT) to prevent recurrence (Yamamoto 2022) |
| Hidradenitis suppurativa | Variable; often combined with perineal / scrotal defects | Ludolph 2016 dermal-template + VAC + STSG framework |
| Penile cancer (organ-sparing) | Glans-only / partial shaft / circumferential | EAU-ASCO 2023: 5–10 mm margins suffice; glans resurfacing / glansectomy / WLE + graft |
| Circumcision injury (overzealous Mogen-clamp excision) | Circumferential, may include partial glans loss | Tissue expansion preferred when sufficient residual skin (Harris 2023 pediatric) |
| Trauma (degloving, avulsion, burn) | Variable, partial to circumferential | Replantation if available; otherwise STSG vs flap by wound bed |
| Congenital (exstrophy-epispadias, hypospadias) | Ventral or circumferential paucity | Tissue expansion; FTSG; staged with concurrent urethroplasty (Harris 2020 / Harris 2023) |
Match Defect Characteristics to Technique
| Defect | Wound Bed | First-Line | Alternative(s) | Avoid |
|---|---|---|---|---|
| Small (<30% circumference) | Clean | Primary closure on stretch ± Z-plasty (release linear contracture, redistribute tension vectors) | Local advancement flap | Closing under tension (causes acquired curvature on tumescence) |
| Moderate (30–50% circumference) | Clean | FTSG (groin / hip-crease donor) or scrotal flap | STSG | FTSG in compromised wound bed |
| Large circumferential | Clean, well-vascularized | STSG (first-line; thigh donor; unmeshed for cosmesis) | Bipedicled anterior scrotal flap | Closure under tension |
| Large circumferential | Contaminated / compromised (post-Fournier's, post-radiation) | Staged: NPWT → ADM (Integra or Matriderm) → delayed STSG (Liguori 2020; Crane 2026) | Pedicled flap | Single-stage STSG on contaminated bed |
| Large circumferential | Sufficient residual skin | Tissue expansion (preferred in pediatric / congenital where donor-site morbidity is the dominant concern) | STSG / FTSG | Tissue expansion when no residual skin |
| Massive defect with exposed corpora / testes | Any | Pedicled scrotal flap (bipedicled / butterfly / EPAP hemi-scrotal) | Pedicled SCIP, gracilis, or VRAM for very large defects | STSG alone over exposed corpora |
| AABP — PAS-stratified | See classification below | Determined by Schlaepfer 2023 PAS subtype (P0–P2c × A0–A2 × S0/S1) | Mirastschijski 2018 typing as alternative framework | Operating without PAS classification |
Graft vs Flap vs Substitute Sub-Comparison
| Feature | STSG | FTSG | Bipedicled Scrotal Flap | ADM (Integra / Matriderm) + STSG | Tissue Expansion |
|---|---|---|---|---|---|
| Donor site | Thigh, buttock, abdomen | Groin / hip-crease, escutcheon (resected during AABP) | Anterior scrotum (single donor) | None (off-the-shelf scaffold) | None (uses residual penile skin) |
| Graft take rate | >90% (Alwaal 2015 n = 54) | ~70–90% | Vascularized — flap survival >90% | Matriderm 92.1% (Crane 2026 n = 36) | n/a |
| Elasticity / erection accommodation | Moderate | Better than STSG | Excellent (closely matches native skin) | Improved over STSG-alone | Best |
| Hair-bearing | No | Variable (donor-dependent) | No | No | No |
| Compromised-bed performance | Poor | Worse than STSG | Good (vascularized) | Best — staged approach handles contamination | n/a |
| Stages required | Single | Single | Single (modified butterfly) or two | Two (NPWT → ADM → STSG) | Two (placement → expansion) |
| Best evidence | Alwaal 2015 UCSF n = 54 (multi-etiology); Gül 2026 STSG-vs-FTSG no-difference | Jeng 2026 escutcheon FTSG for AABP+LS (n = 32); diabetes is the dominant graft-loss risk | Fakin 2017 siliconoma n = 43 (4.37/5 satisfaction); McLaughlin 2024 bipedicle | Liguori 2020 (n = 6, complete take, 6-mo elasticity); Crane 2026 Matriderm (n = 36) | Harris 2020 exstrophy n = 50 (96% overall success); Harris 2023 hypospadias n = 24 (87.5% success; 37.5% expander extrusion) |
Glans-Specific Decision Matrix
| Clinical Scenario | First-Line | Alternative | Avoid |
|---|---|---|---|
| PeIN / Ta carcinoma in situ; superficial glans disease | Glans resurfacing with STSG or FTSG after superficial excision | Topical 5-FU / imiquimod (non-operative) | Wide partial penectomy when organ-sparing is feasible |
| Invasive distal glans disease (T1–T2 limited to glans) | Total glansectomy + neoglans reconstruction (STSG or FTSG over cavernosal bed) — Pang 2026 SR: 91.1% preserved erectile function, 75.6% standing voiding, 86.3% appearance satisfaction | Partial glansectomy | Partial penectomy when glansectomy + neoglans achieves equivalent oncologic control |
| Distal-shaft tumor (limited) | Wide local excision + STSG / FTSG with 5–10 mm margins (Brouwer 2023 EAU-ASCO; traditional 2-cm margin no longer required) | Partial penectomy | 2-cm margins (over-resection without oncologic benefit) |
| Locally recurrent disease after organ-sparing | Repeat WLE + grafting if margin-negative resection is feasible — local recurrence does not affect cancer-specific survival (Elst 2025 BJU; 5-yr CSS 99%) | Partial penectomy | Treating local recurrence as automatic indication for amputation |
| Lichen sclerosus involving glans | Glans resurfacing with STSG — 90% report complete resolution of pain / pruritus | Topical high-potency steroids | Untreated symptomatic LS (progresses to obliterative meatal stenosis) |
| Distal glans loss (post-traumatic / circumcision) | Neoglans reconstruction with STSG / FTSG / local advancement | Buccal-mucosa graft for combined glans + meatal reconstruction | Tubularized repairs that recreate the high-failure-rate features of distal hypospadias |
| Total / subtotal penile loss | Phalloplasty (RFFF / ALT / pedicled abdominal) — see Foundations — Flaps in GU Reconstruction | Cecil-Culp staged repair when phalloplasty unavailable | STSG-only repair of circumferential proximal-shaft defects |
Adult-Acquired Buried Penis Classification
Two validated systems coexist; Schlaepfer 2023 PAS is the contemporary anchor for surgical planning.[14][15][16]
Mirastschijski (3 types):
- Type 1 — Pseudo-BP: penis covered under lax skin without retraction → apronectomy + prepubic lift sufficient.
- Type 2 — Intermediate: partial penile invagination → prepubic apronectomy + anchoring sutures.
- Type 3 — Classical BP: complete retraction into prepubic fat, often with stenotic scar → scar excision + fat reduction + shaft extraction + anchoring sutures + penile-skin reconstruction.
Schlaepfer 2023 PAS (TURNS Network — κ = 0.95 interrater reliability):
- P (penile skin / escutcheon) — P0 (normal) / P1 (contributory escutcheon only) / P2a (escutcheon + sufficient penile skin) / P2b (escutcheon + partially insufficient skin) / P2c (escutcheon + insufficient skin — most common at 27%).
- A (abdominal pannus) — A0 (no pannus, 41%) / A1 (noncontributory) / A2 (contributory).
- S (scrotal skin) — S0 (normal, 71%) / S1 (abnormal).
Concurrent procedures by PAS-frequency (Schlaepfer 2023; Tausch 2016):[14][16]
- Escutcheonectomy in 55% of AABP cases
- Scrotoplasty / scrotectomy in 48%
- Panniculectomy in 7% (severe abdominal lipodystrophy)
Stepwise Treatment Algorithm
- Assess wound bed — clean, contaminated, or compromised drives single-stage vs staged approach.
- Determine extent — circumference percentage drives primary-closure vs graft vs flap vs free-flap decision.
- Choose graft vs flap by Step 3 sub-comparison; ADM bridges contaminated beds; tissue expansion when residual skin allows.
- Plan concurrent procedures — escutcheonectomy / scrotoplasty / panniculectomy / urethroplasty.
- Postoperative protocol — petrolatum-gauze + cotton-gauze + dry-gauze bolster sutured to penis × 5–7 days; NPWT for staged ADM cases; urinary catheter through graft healing; counsel on expected wound dehiscence (up to 88% in high-BMI AABP cohorts; managed with local wound care).[2][17]
- Long-term surveillance — for oncologic cases, strict follow-up (local recurrence 21–29% after organ-sparing surgery; CSS unaffected); for AABP, weight-loss support to reduce reburying (12% reburying rate at long-term follow-up).[12][13][18]
Treatment Database
| Procedure | Domain | Notes |
|---|---|---|
| Buried Penis Repair (escutcheonectomy + STSG ± panniculectomy + scrotoplasty) | Adult-Acquired Buried Penis | Most common indication. Schlaepfer 2023 PAS classification (P/A/S) drives operative plan. Tausch 2016 stratification: escutcheonectomy 55%, scrotoplasty/scrotectomy 48%, panniculectomy 7%. Best paired with weight loss. Mirastschijski 2018 Type 1–3 alternative typing. |
| Escutcheon-Derived Full-Thickness Skin Graft (FTSG) for AABP + LS | Adult-Acquired Buried Penis | Jeng 2026 *Urology* n=32 escutcheon FTSG for AABP with concurrent lichen sclerosus. Overall complication 56%; surgical failure / reoperation 13%. Diabetes is the dominant graft-loss risk factor. Useful when escutcheon tissue is being resected anyway during escutcheonectomy. |
| Split-Thickness Skin Graft (STSG) — Penile Shaft | Shaft Skin — Graft | First-line for large circumferential defects. Alwaal 2015 UCSF n=54: graft take >90% across Fournier's / lymphedema / buried penis / siliconoma / HS / tumor; preserved erection, normal voiding, good cosmesis. Thigh donor (typical thickness 0.012–0.018"); unmeshed preferred for cosmesis. Gül 2026: no significant difference between STSG and FTSG for AABP. |
| Full-Thickness Skin Graft (FTSG) — Penile Shaft | Shaft Skin — Graft | Greater elasticity, less contracture, better color match than STSG. Donor sites: groin / hip-crease (most common); escutcheon tissue (resected during AABP). Hair-bearing risk depending on donor. Pediatric circumcision-injury preference (Harris 2023 — 10/12 pts). Higher metabolic demand → lower take rate in compromised wound beds. |
| Primary Closure ± Z-Plasty (penis on stretch) | Shaft Skin — Graft | Small defects (<30% circumference). Penis must be on stretch during closure to prevent acquired curvature on tumescence. Z-plasty releases linear scar contracture and redistributes tension vectors. |
| Bipedicled Anterior Scrotal Flap | Shaft Skin — Flap | Most widely described flap for penile shaft resurfacing. McLaughlin 2024 PRS bipedicle (n=8 satisfactory, 2 minor complications). Mendel 2023 Urology n=22: median EHS 3.5/4; global satisfaction 8/10; 31.8% dehiscence, 13.6% infection, 27.3% late skin retraction; 27.3% required late revision. Pigmented sensate tissue closely matches native penile skin. |
| Bipedicled Anterior Scrotal Flap — Siliconoma Indication | Shaft Skin — Flap | Fakin 2017 J Urol n=43 (silicone-injection siliconoma): satisfaction 4.37/5; all patients reported postoperative erection and intercourse ability; minor complications only (partial necrosis 9%, hematoma 12%, wound disruption 19%). Preferred for siliconoma over STSG (which scars unfavorably). |
| Modified Bilateral Scrotal Flap ("Butterfly") | Shaft Skin — Flap | Yao 2022 *J Vis Exp* n=7. Bilateral flaps from each side of scrotal midline, pedicled on anterior scrotal artery, rotated to cover shaft defect in single stage. Significant penile-length increase (flaccid + erect) reported. 2 minor flap necroses managed with wound care. |
| Sensate External Pudendal Artery Perforator (EPAP) Hemi-Scrotal Flap | Shaft Skin — Flap | Tsukuura 2025 *Microsurgery*. Hemi-scrotal flap on isolated EPA perforator with anterior-scrotal-nerve preservation (sensate). Wider rotation arc, tension-free inset, preserved contralateral EPA, inconspicuous donor scar. Good color match + sensation at 7 mo; no short-term complications. |
| Adjacent-Tissue Transfer / Advancement Flaps | Shaft Skin — Flap | Used in complex AABP with severe abdominal lipodystrophy when scrotal tissue is insufficient (Tausch 2016 PAS classification framework). Penoscrotal-skin anchoring to proximal shaft (phalloplasty) when uncovered penile skin is viable. |
| Integra (ADM) + NPWT + Delayed STSG | Tissue Substitute | Two-stage. Stage 1: ADM + NPWT for neodermis regeneration (~3 weeks). Stage 2: unmeshed STSG over integrated neodermis. Liguori 2020 *Int J Impot Res* n=6 (lymphedema / skin deficiency): complete take at 7 d; sufficient elasticity for normal erection mechanics at 6 mo; no major complications. Alternative to free-tissue transfer. |
| Matriderm + STSG (Single-Stage) | Tissue Substitute | Crane 2026 *J Plast Reconstr Aesthet Surg* n=36 / 38 operations. Successful graft uptake **92.1%**; good-to-excellent cosmesis 74.4%; functional improvement 97%; psychological improvement 75%. Single-stage advantage over Integra two-stage approach. |
| Dermal Template + VAC + STSG (Fournier's / HS framework) | Tissue Substitute | Ludolph 2016 *Int Wound J*. Combined dermal-template + negative-pressure-wound-therapy + STSG for severe defects after Fournier's gangrene or hidradenitis suppurativa. Useful when contamination history precludes single-stage repair. |
| Tissue Expansion (TE) | Tissue Expansion | Subcutaneous expanders in residual penile shaft skin generate additional local tissue. Preferred for primary reconstruction when sufficient residual skin exists (avoids donor-site morbidity). Harris 2020 exstrophy-epispadias n=50: TE used in 27 pts; primary success 70%; overall success 96%. Harris 2023 hypospadias n=24: 87.5% overall success; 37.5% expander extrusion. |
| ALT Free Flap — Massive Genital / Perineal Defect | Free Tissue Transfer | Reserved for massive defects after Fournier's gangrene or oncologic resection where pedicled options are insufficient. Alammar 2026 *Burns* SR Fournier's flap reconstruction. See Foundations — ALT Flap for harvest detail. |
| SCIP Lymphatic Flap (SCIP-LFT) — Genital Elephantiasis | Free Tissue Transfer | Yamamoto 2022 *J Plast Reconstr Aesthet Surg*. Combines tissue coverage with lymphatic reconstruction to prevent recurrence after radical reduction of male genital elephantiasis. No lymphedema recurrence at mean 22.7 mo. |
| Radial Forearm Free Flap (RFFF) — Total Penile Reconstruction | Free Tissue Transfer | Best option for total penile reconstruction (neophallus) in non-GAS contexts (post-traumatic total loss, oncologic amputation). Highest function / sensation / cosmesis among free-flap options. Disfiguring forearm scar. See Foundations — RFFF for harvest detail. |
| Glans Resurfacing (STSG / FTSG over denuded glans) | Glans / Cancer Reconstruction | For PeIN / Ta carcinoma in situ or distal LS. Superficial excision of glans epithelium followed by skin graft. Local recurrence 0–10%; 90% of LS patients report complete pain/pruritus resolution. |
| Total Glansectomy + Neoglans Reconstruction | Glans / Cancer Reconstruction | For invasive distal glans disease (T1–T2 limited to glans). STSG or FTSG applied to exposed cavernosal bed. Pang 2026 *Int J Impot Res* SR: partial graft loss 6.1%; meatal stenosis 8.1%; preserved erectile function **91.1%**; sexually active 62.5%; standing voiding 75.6%; glans sensation maintained 83.7%; appearance satisfaction 86.3%. |
| Wide Local Excision + STSG / FTSG (shaft tumor) | Glans / Cancer Reconstruction | Brouwer 2023 EAU-ASCO: 5–10 mm margins are sufficient (traditional 2-cm margin no longer required). Baumgarten 2018 multicenter n=1,188: 5-yr local-recurrence-free survival **73.6%**; margin status is the only significant predictor on multivariate analysis. Elst 2025 BJU: local recurrence after organ-sparing surgery does NOT affect cancer-specific survival (5-yr CSS 99%). |
| Meatoplasty / Meatotomy Adjunct | Glans / Cancer Reconstruction | Meatal stenosis 8.1% post-glansectomy (Pang 2026). Stepwise: dilation → meatotomy → formal meatoplasty (BMG inlay or Y-V) for refractory cases. |
| Cecil-Culp Procedure (Scrotal Dropback) | Staged / Salvage | Two-stage penile-in-scrotum marsupialization. Modern niche uses: recurrent UCF after failed hypospadias repair (Ehle 100% success), penile trauma with extensive skin loss, salvage when BMG is not viable. |
| Staged Skin Replacement after Lichen Sclerosus | Staged / Salvage | Refractory pan-penile lichen sclerosus often requires staged excision + STSG + delayed urethroplasty. Concurrent BMG urethroplasty deferred until skin has matured 3–6 mo. High reoperation rate; surveillance for distal-meatal disease. |
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. Pestana IA, Greenfield JM, Walsh M, Donatucci CF, Erdmann D. Management of "buried" penis in adulthood: an overview. Plast Reconstr Surg. 2009;124(4):1186–1195. doi:10.1097/PRS.0b013e3181b5a37f
3. 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
4. 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
5. McLaughlin MM, Abbassi B, Pribaz JJ. Bipedicled scrotal flap for penile resurfacing. Plast Reconstr Surg. 2024;153(4):935–942. doi:10.1097/PRS.0000000000010811
6. 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
7. 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
8. 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
9. Mirastschijski U. Classification and treatment of the adult buried penis. Ann Plast Surg. 2018;80(6):653–659. doi:10.1097/SAP.0000000000001410
10. Brouwer OR, Albersen M, Parnham A, et al. European Association of Urology–American Society of Clinical Oncology collaborative guideline on penile cancer: 2023 update. Eur Urol. 2023;83(6):548–560. doi:10.1016/j.eururo.2023.02.027
11. National Comprehensive Cancer Network. Penile cancer (NCCN Clinical Practice Guidelines). Updated 2025-11-12.
12. 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
13. Baumgarten A, Chipollini J, Yan S, et al. Penile-sparing surgery for penile cancer: a multicenter international retrospective cohort. J Urol. 2018;199(5):1233–1237. doi:10.1016/j.juro.2017.10.045
14. 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
15. Flynn KJ, Vanni AJ, Breyer BN, Erickson BA. Adult-acquired buried penis classification and surgical management. Urol Clin North Am. 2022;49(3):479–493. doi:10.1016/j.ucl.2022.04.009
16. Tausch TJ, Tachibana I, Siegel JA, et al. Classification system for individualized treatment of adult buried-penis syndrome. Plast Reconstr Surg. 2016;138(3):703–711. doi:10.1097/PRS.0000000000002519
17. Corder B, Googe B, Velazquez A, Sullivan J, Arnold P. Surgical management of acquired buried penis and scrotal lymphedema: a retrospective review. J Plast Reconstr Aesthet Surg. 2023;85:18–23. doi:10.1016/j.bjps.2023.06.021
18. 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