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Penile Skin Grafting

Penile skin grafting restores coverage after skin loss from buried penis, infection, lymphedema, trauma, inflammatory disease or tumor excision. Split-thickness (STSG) and full-thickness (FTSG) grafts are both used. The choice depends on the defect, viable recipient tissue, donor skin and the patient's goals for voiding, sensation, appearance and erection. Early graft take is only one outcome: contracture, recurrent disease and sensory change require longer follow-up.[1]

For the complete operation, see Buried Penis Repair, Penile Reconstruction, Scrotal Reconstruction and Glans Reconstruction.

Planning and indications​

SettingPlanning priority
Adult-acquired buried penisDetermine whether shaft skin is salvageable and whether suprapubic/scrotal tissue or urethral disease also needs treatment
Fournier's gangrene or other destructive infectionComplete source control and debridement; reconstruct once the wound is viable and further debridement is not required
Lymphedema, hidradenitis or foreign-body granulomaDefine disease extent and preserve viable, unaffected tissue; recipient-bed readiness determines immediate versus staged coverage
Trauma or circumcision injuryAssess skin, glans, urethra and corporal injury separately
Penile neoplasiaEstablish histology and oncologically appropriate margins before reconstruction; glans resurfacing and reconstruction after glansectomy create different recipient beds

The principles of wound preparation are supported by genital STSG experience; tumor-related selection follows the EAU penile-cancer guideline.[1][2] Buried penis is not synonymous with lichen sclerosus (LS): Daly's selected 180-patient repair/penectomy cohort reported LS in 23%; a smaller study found LS in 55% of its 22 graft recipients. These are not population prevalence estimates.[3][4]

Examine suspicious lesions and obtain appropriate biopsy or specimen histology. The 5% penile-cancer finding in Daly's selected cohort should not be presented as an incidental-cancer probability for every buried-penis skin specimen.[3]

STSG and FTSG​

FeatureSTSGFTSG
Tissue transferredEpidermis plus part of the dermisEpidermis and the full dermis
Donor woundUsually heals by re-epithelializationUsually requires primary closure; donor availability limits size
Practical advantagesCovers larger areas; established genital reconstruction experienceGreater dermal content may help limit secondary contraction in suitable wounds
TradeoffsSecondary contracture, texture and pigment changesMore demanding graft-bed requirements; donor scar and complete defatting are considerations
HairSelect donor site and thickness deliberately; absence of hair is not guaranteedDonor-dependent; avoid an unsuitable hair-bearing surface

A retrospective comparison included 39 buried-penis repairs, of which 22 received grafts: nine FTSG and 13 STSG. No statistically significant differences were detected in the reported graft groups, but this small study does not establish equivalence or one universally preferred graft.[4]

Donor selection​

Thigh STSG is a conventional option. An excised escutcheon or pannus can provide graft skin in selected buried-penis repairs, reducing the need for a separate donor wound. Assess that skin's quality and suitability rather than assuming every excised specimen is an acceptable graft. FTSG requires removal of adherent fat while preserving the dermis; retained fat can impede contact and revascularization, but it is not established as the dominant cause of every penile FTSG failure.[1][5][6][7]

In Jeng's 32-patient escutcheon-FTSG series, four patients underwent reoperation for graft failure; 28/32 avoided reoperation for that endpoint. There was one complete and two partial graft losses. All three occurred in patients with diabetes, but the reported diabetes/cardiovascular association was not statistically significant (P = .08); this does not establish a dominant independent predictor.[8]

Operative principles​

Excision and recipient-bed preparation​

Tailor excision to the pathology and viable margins. Preserve healthy skin and dartos when appropriate; routine circumferential removal down to Buck's fascia is not necessary for every defect. Avoid damaging the urethra, neurovascular structures or corporal tissue. Obtain hemostasis and a stable, vascularized surface for graft contact.[1]

For a previously infected wound, readiness is determined by infection control and tissue viability, not a universal one- or two-week delay. A graft or matrix does not replace debridement. Integra is contraindicated on clinically infected wounds.[1][9]

If a dermal matrix is selected, distinguish the product and protocol: Liguori used staged Integra followed by STSG at three weeks; Kang used single-stage MatriDerm Flex plus STSG. These small series do not justify an automatic three-week staging rule for all substitutes.[10][11] See Penile Tissue Substitutes.

Harvest, sizing and fixation​

Select STSG thickness for the donor, bed and reconstructive goal. Published genital techniques include a 0.015-inch thigh graft and 0.018-inch pannus harvest; these are technique descriptions, not a single required depth for every patient.[1][7]

Keep the graft moist and minimize trauma. Size and secure it with the penis gently stretched so the reconstruction accommodates erection without tension. Ensure close contact, fluid egress and appropriate fixation while avoiding a constricting ring. In Alwaal's technique, viable dartos was spared when possible and the penis remained stretched during dressing placement.[1]

An unmeshed sheet can be useful when appearance and expansion during erection are priorities. Meshed unexpanded 1:1 STSG is also an established technique: Black's nine-patient series reported complete early take and favorable follow-up appearance. It does not support a blanket prohibition of all meshing or prove one seam configuration prevents every contracture.[12]

Pharmacologically induced erection during sizing is a described adjunct, not a requirement. A four-patient protocol combining prostaglandin injection, NPWT and postoperative tadalafil cannot establish the independent benefit or routine safety of any component.[13]

Bolster or NPWT​

Immobilize the graft, reduce shear and fluid accumulation, and protect against urine contamination. Conventional bolsters and NPWT are both used. Avoid excessive circumferential pressure and monitor distal perfusion. Dressing interface, suction settings, catheter need and removal timing should follow the operation and local protocol rather than a fixed rule for every graft.[1]

A 2025 meta-analysis of 16 randomized skin-graft trials found an 8.3-percentage-point average take improvement with NPWT, with substantial heterogeneity. These were not penile-only trials. Likewise, the 97.6% versus 81.7% take comparison in Cao's study was an irregular/high-mobility subgroup; it is not proof that NPWT outperforms a bolster on every penis or that one pressure is optimal.[14][15]

Postoperative care​

Document graft inspection and a plan for dressing/catheter removal, hygiene, mobility and return to sexual activity. Review earlier for increasing pain, fever, discharge, bleeding, urinary obstruction or concern about perfusion. Protection from shear must be balanced with mobilization and the patient's thromboembolic risk. Resume sexual activity when the reconstruction has healed adequately and the operating team has reviewed it.

Assess sensation, erection-related pain, tethering, recurrent skin disease, urinary symptoms and graft durability after initial healing. Early take does not guarantee normal sensation: the Alwaal series described diminished light touch and delayed ejaculation in some patients.[1]

Routine daily tadalafil to prevent graft contracture is not supported by comparative evidence. A recent rehabilitation report described only two men after complex genital infections; it does not establish a standard pelvic-floor therapy regimen that prevents penile graft contracture. Persistent functional problems merit individual assessment and targeted treatment.[13][16]

Interpreting outcomes​

StudyWhat was measuredLimits
Alwaal 201552/54 adults with mixed genital diagnoses had greater than 90% graft-area takeRetrospective; variable follow-up; functional assessments were not standardized validated instruments
Gül, online 2024 / issue 2026Nine FTSG versus 13 STSG recipients within 39 buried-penis repairsSmall nonrandomized comparison; no detected difference does not establish equivalence
Plamadeala 2026204 first-time buried-penis reconstructions; 91 received grafts. Median individual stretched-length gain 3 cm; 26/204 recurrence, 55/204 complicationsOnly 68 completed functional questionnaires; outcomes describe the complete operation, not isolated graft performance

The populations, denominators and outcome definitions differ, limiting direct comparison across studies.[1][4][17]

In the 204-patient cohort, more complex repair was associated with less recurrence and more complications. Baseline differences and selection limit causal interpretation; the finding does not justify more aggressive surgery for every patient. The source also contains inconsistent subgroup percentages, so those should not be used for individualized risk prediction.[17]

Special situations​

LS and urethral disease: genital skin should not be used for LS-related urethral reconstruction; oral mucosa is the usual graft option. That recommendation concerns the urethral lining. External shaft coverage is a separate decision, using suitable unaffected donor skin and continuing surveillance for LS or suspicious lesions.[18][19][4]

Flap versus graft: choose vascularized coverage when the bed cannot support a graft, when dead space needs filling or when critical structures need additional protection. Exposed testes or corpora alone do not automatically mandate a flap: the retained covering tissues and vascularity matter. Complex irradiated or recurrent defects warrant individualized reconstructive planning.[1]

Glans reconstruction: glans resurfacing removes the glans epithelium/subepithelial tissue and resurfaces the remaining glans, often with STSG. It is distinct from forming a neoglans after glansectomy, when the graft may cover distal corporal tissue. Match grafting to the oncologic resection; do not conflate the two recipient beds.[2]

See Also​

Videos​

Penile Skin Graft
Hypospadias Specialty Center (2019)
Split-Thickness Skin Graft Harvesting
Ben Taylor MD (2020)

References​

1. Alwaal A, McAninch JW, Harris CR, Breyer BN. "Utilities of Split-Thickness Skin Grafting for Male Genital Reconstruction." Urology. 2015;86(4):835–9. doi:10.1016/j.urology.2015.07.005

2. European Association of Urology. EAU Guidelines on Penile Cancer. 2026. Disease management, section 6.1: treatment of the primary tumour. Guideline.

3. Daly WC, Klein RD, Myrga JM, Quiroga-Garza G, Rusilko PJ. "Lichen Sclerosus in Patients Undergoing Adult-Acquired Buried Penis Repair." Urology. 2025. doi:10.1016/j.urology.2025.07.061

4. 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." Int J Impot Res. 2026;38(3):259–265. doi:10.1038/s41443-024-00832-7

5. 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

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. 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

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. US Food and Drug Administration. Integra Dermal Regeneration Template / Omnigraft: Summary of Safety and Effectiveness Data, P900033/S042. 2016. Contraindications. FDA SSED.

10. Liguori G, Papa G, Boltri M, et al. "Reconstruction of Penile Skin Loss Using a Combined Therapy of NPWT, Dermal Regeneration Template, and STSG." Int J Impot Res. 2020;33(8):854–859. doi:10.1038/s41443-020-00343-1

11. Kang D, Hong SE, Kim YH. "Single-Stage Penile Resurfacing for Foreign Body Granuloma: A Simplified Negative Pressure Wound Therapy-Assisted Protocol With Dermal Substitute." Urology. 2026. doi:10.1016/j.urology.2026.04.013

12. 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

13. Iblher N, Fritsche HM, Katzenwadel A, et al. "Refinements in Reconstruction of Penile Skin Loss Using Intra-Operative Prostaglandin Injections, Postoperative Tadalafil Application and Negative Pressure Dressings." J Plast Reconstr Aesthet Surg. 2012;65(10):1377–83. doi:10.1016/j.bjps.2012.04.020

14. Lee SC, Bayan L, Sato A, et al. "Benefits of Negative Pressure Wound Therapy in Skin Grafts: A Systematic Review and Meta-Analysis of Randomised Controlled Trials." J Plast Reconstr Aesthet Surg. 2025;102:204–217. doi:10.1016/j.bjps.2025.01.036

15. Cao X, Hu Z, Zhang Y, et al. "Negative-Pressure Wound Therapy Improves Take Rate of Skin Graft in Irregular, High-Mobility Areas: A Randomized Controlled Trial." Plast Reconstr Surg. 2022;150(6):1341–1349. doi:10.1097/PRS.0000000000009704

16. Tremblay C, Edger-Lacoursière Z, Schneider G, et al. "Rehabilitation Evaluation and Treatment for Skin Graft Complications of the Genitalia." J Burn Care Res. 2026;47(3):868–878. doi:10.1093/jbcr/irag016

17. 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

18. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. "Urethral Stricture Disease Guideline Amendment (2023)." J Urol. 2023;210(1):64–71. doi:10.1097/JU.0000000000003482

19. European Association of Urology. EAU Guidelines on Urethral Strictures. 2026. Disease management in males: lichen sclerosus-related penile strictures. Guideline.