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Skin Grafting of the Scrotum

When >50% of the scrotal envelope is lost and primary closure is not feasible even with aggressive mobilization, split-thickness skin grafting onto the tunica vaginalis is the workhorse for definitive coverage; full-thickness grafts are reserved mainly for penile shaft resurfacing where contracture must be minimized.[1][2][3] This page focuses on graft-specific decisions — bed selection, technique, NPWT fixation, and outcomes. The full reconstructive ladder is in Scrotal Reconstruction Techniques; donor-site harvest details are in STSG and FTSG.

Indications​

SettingBest for / indications
Fournier's gangrene / NSTIMost common indication — clean granulating bed after serial debridement when primary closure is not feasible.[3][4]
Penoscrotal lymphedemaTotal excision of lymphedematous skin + STSG neoscrotum — Morey's 9-patient series: excellent cosmesis, no recurrence.[5][6]
Adult acquired buried penis (AABP)Escutcheonectomy + scrotoplasty + penile resurfacing — STSG and FTSG show no significant difference in surgical, functional (IIEF, IPSS), or recurrence outcomes (Gül, n = 22).[7]
Hidradenitis suppurativa / wide local excisionAfter wide excision of genital HS when residual scrotal skin <50%.[1]
Genital tumors / oncologic resectionCoverage after wide excision when insufficient residual skin for primary closure.[8]
Foreign-body / filler injectionCoverage after excision of injected silicone, paraffin, or other filler.[8]
Penoscrotal avulsion / degloving / battlefield traumaDefinitive coverage when primary closure fails after tunica-vaginalis bridging.[9]

In the UCSF series (Alwaal, n = 54), etiology distribution was tissue loss / Fournier's 13, lymphedema 13, AABP 12, foreign-body 8, hidradenitis 4, tumors 4.[8]

Graft Selection — STSG vs FTSG​

STSG (workhorse for the scrotum)​

  • Thickness — 0.046 cm (18/1000 inch) — intermediate, balancing take with durability.[1][3]
  • Mesh ratio — 2:1 — drains seroma / hematoma and conforms to scrotal contour.[1][3]
  • Advantages — high take rate (>90% in 96% of patients, UCSF), technically straightforward, large surface coverage.[8]
  • Disadvantages — lacks rugation, elasticity, dartos smooth muscle, sweat glands; meshed pattern persists; thermoregulation permanently impaired.[1][10]

FTSG (selective use)​

  • Penile shaft resurfacing — preferred (or thick STSG) in potent patients to minimize contracture and preserve erectile function; resected escutcheon tissue is commonly repurposed as the donor.[11][12]
  • Scrotum — less commonly used; the large surface area makes FTSG harvest impractical. The Guys / St Thomas's 10-year experience recommends FTSG for the penis and STSG for the scrotum as the default pairing.[13]

Donor Sites​

SiteNotes
Anterior / lateral thighWorkhorse STSG donor; large yield; acceptable morbidity.[14]
ButtockGood color match; donor hidden when clothed.
ScalpRapid donor-site healing from dense follicle density; 98% take in a reported Fournier's STSG case.[15]
Upper medial arm / backAlternatives depending on habitus.
Escutcheon (suprapubic fat pad)Dedicated FTSG donor in AABP repair — repurposes resected escutcheon and avoids a separate donor.[11][12]
GroinCan supply STSG or FTSG; full-thickness defect closed primarily leaves a cosmetically superior linear scar.[16]

Recipient Bed Preparation​

BedSuitability
Tunica vaginalisOptimal — well-vascularized, smooth, stable; the standard scrotal STSG bed.[1]
Granulation tissue over tunica vaginalisExcellent — forms 1–2 weeks after debridement and is the typical bed at the time of grafting.[1][3]
Dartos fasciaPoor — smooth-muscle layer with insufficient revascularization.[1]
Tunica albugineaAvoid — graft adheres directly to the testis, producing a fixed, unnatural appearance.[1]

Orchidopexy (mandatory adjunct)​

Performed before or at the time of grafting: spermatic cords are mobilized, redundant cord is coiled under the abdominal wall, and the testes are brought together and secured at the penoscrotal junction with interrupted absorbable suture (e.g., 3-0 polyglactin). This reduces scrotal volume and creates a compact, stable platform for the graft.[1][3]

Surgical Technique​

  1. Debridement — serial returns to OR until margins are clean and viable.[3][4]
  2. Timing — graft typically 1–2 weeks after the final debridement, once the patient is stable and healthy granulation has formed.[1][3]
  3. Orchidopexy — testes brought together and secured at the penoscrotal junction; redundant cord coiled under the abdominal wall.[3]
  4. Harvest — STSG at 0.046 cm (18/1000 inch) via dermatome from thigh / buttock / other donor.[1][3]
  5. Mesh — 2:1 to allow drainage and conformity.[1]
  6. Application — apply meshed graft directly to tunica vaginalis or overlying granulation; ensure complete contact, no air pockets or fluid collections.[1]
  7. Fixation — one of:
    • Bolster — Xeroform + mineral-oil-soaked cotton sutured over the graft for 5–7 days.[1][3]
    • NPWT at −80 mmHg (see below).[15][17]
    • Fibrin sealant — dilute fibrin glue can secure the graft-bed interface, reducing the need for fixation sutures or staples.[18]
  8. Postoperative — bed rest or limited ambulation × 5–7 days; scrotal support after bolster / NPWT removal. Median LOS after STSG ~9 days in Hayon's NSTI series.[3]

Two-Stage Wrap-Around Technique (Konofaos)​

For near-total or total scrotal loss, a two-stage strategy improves cosmesis over single-stage STSG:[19]

  • Stage 1 — each testis is individually wrapped with STSG ("wrap-around"), creating two grafted units.
  • Stage 2 (after maturation) — the two grafted units are reapproximated in the midline and the neoscrotum is shaped, optimizing volume without testicular compression.

In 6 patients (mean follow-up 18 months), all achieved satisfactory cosmetic and functional outcomes; the main drawback is the two-stage requirement.

NPWT — Bed Preparation and Graft Fixation​

NPWT has two distinct scrotal-graft roles:

Pre-grafting (wound-bed preparation)​

NPWT accelerates granulation, lowers bacterial bioburden, and optimizes the bed for subsequent grafting.[15][20] In a Fournier's case, 10 days of pre-graft NPWT yielded 98% take after subsequent STSG.[15]

Post-grafting (fixation)​

NPWT over an STSG replaces the traditional bolster. The scrotum — irregular, mobile — is an ideal candidate:

  • Cao RCT (Level I, irregular high-mobility areas): take 97.6% vs 81.7% with conventional dressing (p < 0.05).[17]
  • Lee meta-analysis (16 RCTs, 812 patients): NPWT yields 8.3% higher overall take, higher success (OR 1.86), lower loss (OR 0.44), and lower reoperation (OR 0.31) vs conventional dressing.[21]
  • Optimal pressure — −80 mmHg (not −125 mmHg) improves take in subgroup analysis.[21][22]

Outcomes​

OutcomeResultSeries
Graft take >90%52/54 (96%)Alwaal UCSF, n = 54, mixed etiology[8]
Scrotal STSG take100%, no revisionsHayon, n = 10 Fournier's[3]
STSG take for AABPmean 91.7% (range 80–100%)n = 12 AABP[23]
FTSG take for AABP100%Monn, n = 13 AABP[12]
Chronic pain / discomfortNone at median 8 moHayon, n = 10[3]
Revision required0/10Hayon, n = 10[3]
Erectile function preserved/improved52/54Alwaal UCSF[8]
Voiding function normal52/54Alwaal UCSF[8]
Patient satisfaction (AABP)81.3%Gül, n = 22 STSG vs FTSG[7]
Lymphedema recurrence0/9Morey, n = 9[6]

Complications​

  • Graft failure / poor take — uncommon (1/54, UCSF). Risk: diabetes, cardiovascular disease, active infection, inappropriate bed (dartos fascia or tunica albuginea).[8][11]
  • Partial graft loss — 6–13% of FTSG cases in AABP; all losses in the Jeng FTSG series occurred in diabetic patients.[11]
  • Wound infection — most common complication in AABP repair (41% in one FTSG series; mean BMI 44, 69% diabetic).[11]
  • Wound dehiscence — 88% in AABP-plus-scrotal-lymphedema reconstruction; most healed conservatively.[24]
  • Contracture — theoretical concern with STSG, not observed at long-term follow-up in penoscrotal avulsion series; FTSG is preferred on the penis specifically to minimize this.[9][13]
  • Impaired thermoregulation / spermatogenesis — grafted skin permanently lacks dartos and sudomotor responses; in Demir's animal model, STSG produced significantly diminished spermatogenesis (lower testicular weight, shorter germinal epithelium, lower Johnsen scores) vs both controls and flap reconstruction.[10]
  • Altered sensation / hypersensitivity / hypertrophic scarring — can affect sitting, voiding, sexual function, and quality of life.[7]
  • Meshed-pattern visibility — the diamond pattern often persists indefinitely.[19]

Cross-references​

References​

1. Hamad J, McCormick BJ, Sayed CJ, et al. "Multidisciplinary update on genital hidradenitis suppurativa: a review." JAMA Surg. 2020;155(10):970–977. doi:10.1001/jamasurg.2020.2611

2. Schifano N, Castiglione F, Cakir OO, Montorsi F, Garaffa G. "Reconstructive surgery of the scrotum: a systematic review." Int J Impot Res. 2022;34(4):359–368. doi:10.1038/s41443-021-00468-x

3. 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

4. Susini P, Marcaccini G, Efica J, et al. "Fournier's gangrene surgical reconstruction: a systematic review." J Clin Med. 2024;13(14):4085. doi:10.3390/jcm13144085

5. Malloy TR, Wein AJ, Gross P. "Scrotal and penile lymphedema: surgical considerations and management." J Urol. 1983;130(2):263–265. doi:10.1016/s0022-5347(17)51097-6

6. 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

7. 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

8. 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

9. McAninch JW. "Management of genital skin loss." Urol Clin North Am. 1989;16(2):387–397.

10. 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

11. 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

12. 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

13. Biju NE, Sadiq M, Raj S, et al. "Fournier's gangrene reconstruction: a 10-year retrospective analysis of practice at Guys and St Thomas's NHS Foundation Trust." J Plast Reconstr Aesthet Surg. 2023;80:13–15. doi:10.1016/j.bjps.2023.02.030

14. 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

15. 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

16. Hallock GG. "The cosmetic split-thickness skin graft donor site." Plast Reconstr Surg. 1999;104(7):2286–2288. doi:10.1097/00006534-199912000-00057

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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