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Skin Grafting of the Scrotum

Split-thickness skin grafting (STSG) can provide thin coverage for extensive superficial scrotal skin loss when healthy tissue cannot be closed comfortably. Choose it according to the viable recipient bed and defect, not a fixed 50% threshold. Total skin loss and exposed testes do not automatically require a flap.[1][2]

This page covers graft-specific choices. See the scrotal reconstruction overview, STSG principles and FTSG principles for the broader reconstruction and donor-site decisions.

When grafting is suitable​

Grafting may follow controlled Fournier's gangrene, trauma, excision of genital lymphedema or hidradenitis, oncological resection, or removal of injected foreign material. The wound must have adequate perfusion, source control and a plan to prevent collections and shear. Deep dead space or a recipient surface that cannot support a graft may instead require vascularized flap coverage.[1][2]

For cancer, margins and reconstructive timing follow the oncological plan. In lymphedema, coverage follows appropriately selected excision and does not itself guarantee correction of the underlying lymphatic disorder. Morey's nine-patient series reported satisfactory outcomes without observed recurrence, but cannot establish a lifelong cure rate.[3]

Recipient bed and testicular position​

FindingImplication
Healthy preserved dartos or other vascularized soft tissuePreserve useful tissue; dartos is not intrinsically a poor graft bed
Viable spermatic coverings or appropriately prepared granulationMay support grafting after assessment of the actual vascularity and stability
Exposed testesEvaluate the covering layers and recipient surface; exposure alone does not mandate a flap
Absent tunica vaginalisNot a universally accepted absolute contraindication; assess the actual bed, depth and protection of the testis
Necrotic, inadequately debrided or poorly perfused surfaceAddress the cause or choose another reconstruction before applying a graft

The tunica vaginalis is a testicular covering, not a substitute name for every tissue around the spermatic cord. Avoid stripping viable layers simply to reach a named surface, and do not graft directly onto a poorly vascularized surface merely because its anatomical label appears in a protocol.[1][2]

Orchidopexy is not mandatory for every graft. Apposition or fixation may help selected defects, but unnecessary cord dissection, coiling, compression or forced superior repositioning adds risk. Hayon's ten-patient post-necrotizing-fasciitis series describes a particular orchidopexy-plus-graft approach, with median eight-month follow-up; it does not establish the only safe way to graft the scrotum.[4][1]

Graft choice and donor site​

STSG is commonly used because it provides broad, thin coverage. Thickness and meshing depend on the recipient bed, desired contour, drainage and available donor skin. Hayon's reported protocol used 0.018 inch (about 0.46 mm), 2:1 meshing and a five-to-seven-day bolster. These are study-specific parameters, not a universal prescription.[4]

FTSG can be used selectively, but much of the comparative literature concerns penile resurfacing in adult acquired buried penis, rather than scrotal coverage. Gül's retrospective cohort included only 22 grafted patients (9 FTSG, 13 STSG); a nonsignificant difference does not establish equivalence. Do not assume FTSG is required to preserve erections or that results from penile skin grafts predict scrotal outcomes.[5]

A thigh STSG donor is common; other sites depend on available skin, hair, thickness, prior scars and patient preference. Harvested escutcheon FTSG belongs chiefly to selected penile reconstruction and requires healthy donor skin. A scalp-donor case report does not establish a preferred donor or expected take rate for Fournier wounds.[2][6][7]

Operative sequence​

  1. Establish readiness. Debride nonviable tissue, control the source of infection and assess the patient and recipient bed. Grafting does not require a fixed one-to-two-week interval after the last debridement.
  2. Define the coverage and position. Preserve useful coverings, protect the cords and testes, and plan any selected apposition or fixation without tension.
  3. Harvest and prepare the graft. Choose thickness, dimensions and meshing for the defect; avoid excess tension and maintain orientation.
  4. Apply to a viable bed. Obtain close contact, secure edges as appropriate, control bleeding and prevent fluid pockets and shear.
  5. Protect the reconstruction. Select a bolster or appropriately applied NPWT and a tailored activity plan. Dressing pressure must not compromise perfusion or compress exposed critical structures.
  6. Plan reassessment. Review graft adherence, infection, collections and perfusion; adjust support, mobilization and wound care to healing rather than assuming all patients require prolonged bed rest.[2][1][4]

Fibrin sealant has been used in small combined genital-reconstruction series. It is a selected fixation adjunct, not a substitute for a viable bed or evidence that sutures/staples can always be omitted.[8]

NPWT: distinguish wound preparation from graft fixation​

Pre-grafting wound management and post-grafting fixation are different questions. Fournier case reports describe both, but do not establish a survival benefit, reliably lower bacterial burden or an expected 98% take rate. Urgent debridement and antibiotics remain the core acute treatment. The EAU Fournier section gives a weak recommendation to restrict adjuncts to trials, based on a stated search through July 2017.[7][9][10]

For skin-graft fixation across body sites, higher-level evidence is more informative:

EvidenceFinding and applicability
Cao randomized trial, 86 patientsOverall take was 97.2% with NPWT versus 90.2% with a tie-over bolster. The irregular/high-mobility subgroup had 97.6% versus 81.7% take. These are different analyses, and neither is a scrotal-specific randomized estimate.[11]
Lee 2025 meta-analysis, 16 RCTs411 NPWT patients and 401 controls; pooled take improved by 8.3 percentage points (95% CI 2.97–13.63), with substantial heterogeneity (I² = 85%). Fewer graft losses and reoperations were reported, but sites and protocols varied.[12]
Pressure subgroup findingsLee and Jiang reported favorable results around −80 mmHg. Subgroup findings across studies do not prove that −80 is the universally optimal pressure or that −125 is harmful/ineffective in every setting; adverse-event and pressure-comparison data remain limited.[12][13]

Choose device settings and protective layers according to the actual wound, perfusion, device instructions and surgical plan. The general graft-fixation evidence should not be presented as a Fournier mortality trial.

Two-stage contour revision​

Konofaos described six patients with total scrotal skin loss: initial wrap-around grafting followed by reapproximation and shaping of the grafted units. Satisfactory outcomes were reported at mean 18 months. This is an option for selected reconstruction, not controlled evidence that it is cosmetically superior to every single-stage graft or native-tissue closure.[14]

Outcomes and complications​

Alwaal's 54-patient mixed genital cohort included penile and scrotal reconstruction across several diseases; 52 patients had greater than 90% graft take. This is not a scrotal-only success rate or a formally measured 96% erectile-function preservation rate. Follow-up reported favorable function and appearance, but objective fertility and sensory outcomes were limited.[2]

Penile AABP complication data should not be relabeled as scrotal-graft risk. For example, Jeng's 32-patient escutcheon-FTSG cohort had a 56% overall complication rate and 41% wound infection rate, with median eight-month follow-up; four patients required reoperation for distinct failures. These data reflect a complex, highly comorbid penile-reconstruction population.[15]

Counsel about partial or complete loss, infection, collections, scarring or contraction, altered sensation, pain and appearance. Donor sites can also be painful or scarred. The 2023 Cochrane hydrogel review found insufficient evidence to determine overall benefit over other donor dressings; it does not establish hydrogel superiority or an ideal donor location.[2][16]

Fertility remains uncertain. A rat study showing worse histological measures after grafting is not proof of infertility in human recipients, and the absence of native dartos within a graft does not mean all deeper native thermoregulatory structures have been removed. Discuss reproductive goals and investigate persistent pain, testicular abnormalities or fertility concerns as appropriate.[17][1]

See Also​

Videos​

Split-Thickness Skin Graft Harvesting
Ben Taylor MD (2020)

References​

1. Karian LS, Chung SY, Lee ES. Reconstruction of defects after Fournier gangrene: a systematic review. Eplasty. 2015;15:e18. Full text.

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. Morey AF, Meng MV, McAninch JW. "Skin graft reconstruction of chronic genital lymphedema." Urology. 1997;50(3):423–426. doi:10.1016/S0090-4295(97)00259-8

4. Hayon S, Demzik A, Ehlers M, et al. "Orchidopexy and split-thickness skin graft for scrotal defects after necrotizing fasciitis." Urology. 2021;152:196. doi:10.1016/j.urology.2021.02.007

5. 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 regarding surgical and functional outcomes: a comparative retrospective analysis." Int J Impot Res. 2026;38(3):259–265. doi:10.1038/s41443-024-00832-7

6. 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

7. Ye J, Xie T, Wu M, Ni P, Lu S. "Negative pressure wound therapy applied before and after split-thickness skin graft helps healing of Fournier gangrene: a CARE-compliant case report." Medicine (Baltimore). 2015;94(5):e426. doi:10.1097/MD.0000000000000426

8. Tang SH, Kamat D, Santucci RA. "Modern management of adult-acquired buried penis." Urology. 2008;72(1):124–127. doi:10.1016/j.urology.2008.01.059

9. Zhao JC, Xian CJ, Yu JA, Shi K. "Reconstruction of infected and denuded scrotum and penis by combined application of negative pressure wound therapy and split-thickness skin grafting." Int Wound J. 2013;10(4):407–410. doi:10.1111/j.1742-481X.2012.00997.x

10. European Association of Urology. Urological Infections Guidelines. 2026. Section 3.13: Fournier's gangrene. Guideline.

11. 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

12. 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

13. Jiang ZY, Yu XT, Liao XC, et al. "Negative-pressure wound therapy in skin grafts: a systematic review and meta-analysis of randomized controlled trials." Burns. 2021;47(4):747–755. doi:10.1016/j.burns.2021.02.012

14. Konofaos P, Hickerson WL. "A technique for improving cosmesis after primary scrotum reconstruction with skin grafts." Ann Plast Surg. 2015;75(2):205–207. doi:10.1097/SAP.0000000000000066

15. 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:S0090-4295(26)00240-2. doi:10.1016/j.urology.2026.04.008

16. Younis AS, Abdelmonem IM, Gadullah M, et al. "Hydrogel dressings for donor sites of split-thickness skin grafts." Cochrane Database Syst Rev. 2023;8:CD013570. doi:10.1002/14651858.CD013570.pub2

17. Demir Y, Aktepe F, Kandal S, Sancaktar N, Turhan-Haktanir N. "The effect of scrotal reconstruction with skin flaps and skin grafts on testicular function." Ann Plast Surg. 2012;68(3):308–313. doi:10.1097/SAP.0b013e318214534f