Ventral Slit Scrotal Flap (VSSF — Westerman / Tausch)
The ventral slit scrotal flap (VSSF) is a single-stage, outpatient technique for adult buried penis caused by lichen sclerosus (LS) or phimosis with viable dorsal penile skin and a ventral-only skin deficiency. After ventral release of the phimotic ring, two local scrotal rotation flaps are advanced superiorly to resurface the ventral hemicircumference — avoiding any skin graft. In the original Westerman / Tausch series of 15 patients, all were treated as same-day surgery with mean OR 83 min, 0% perioperative complications, and 73.3% durable satisfaction without further intervention.[1]
For the integrated AABP workflow, see Buried Penis Repair. For higher-complexity escutcheonectomy + grafting pathways, see Escutcheonectomy and Penile Skin Grafting. For circumferential-defect scrotal flaps, see Fakin, Murányi, Yao, and Pribaz / McLaughlin staged.
Rationale and Position in the Algorithm
AABP is heterogeneous — obesity (~ 45%), LS (~ 23%), genital lymphedema (~ 20%), or combinations.[2] Traditional complex repairs (escutcheonectomy + STSG ± panniculectomy) are inpatient procedures with 27–50% complication rates.[3][2]
The VSSF carves out the specific subset of LS / phimotic trapped penis with viable dorsal skin — the lowest-complexity tier (Pariser Category I / Tausch first-line ventral release). The dorsal native penile skin is preserved; only the ventral deficit after phimotic-ring release is reconstructed.[1][4][5]
Indications and Contraindications
Indications
- Adult buried penis from LS with phimotic-ring trapping (87% of the original series)
- Adult buried penis from phimosis (non-LS) with ventral skin deficiency after release
- Viable dorsal penile shaft skin — the key prerequisite
- Ventral-only deficiency after the slit
- Intact uninvolved scrotal skin (PAS S0) with adequate laxity
- Outpatient candidate
Contraindications
- Circumferential nonviable penile skin → convert to complete excision + STSG / FTSG[5][6]
- Severe abdominal lipodystrophy requiring escutcheonectomy / panniculectomy (Pariser IV–V)
- Genital lymphedema involving the scrotum — scrotal donor unsuitable
- Scrotal-skin LS involvement — flap donor must be disease-free
Operative Technique
1. Ventral slit of the phimotic ring
- Identify the constricting phimotic / scarred ring
- Ventral midline slit through the ring extending proximally toward the penoscrotal junction; release the trapped penis
- Excise all encountered diseased / LS-involved tissue
- Assess dorsal skin viability — if circumferentially nonviable, convert to complete excision + STSG
2. Assess the ventral defect
- Measure length and width of the exposed ventral shaft (dorsal skin remains intact and covers the dorsal hemicircumference)
3. Ventral midline scrotal incision
- Extend a midline scrotal incision along the raphe from the penoscrotal junction inferiorly; length matches the ventral defect
4. Horizontal relaxing (back-cut) incisions
- T-shape or inverted-T relaxing incisions at the proximal and / or distal ends of the midline scrotal incision through skin and dartos, preserving external spermatic fascia / tunica vaginalis
- These permit advancement of the scrotal skin as bilateral local rotation flaps
5. Scrotal flap rotation
- Each flap rotated superiorly and laterally to cover the corresponding half of the ventral defect
- Right flap → right hemi-ventral defect; left flap → left hemi-ventral defect
- Inset tension-free
6. Flap inset and suturing
- Distal edges to subcoronal skin / glans margin
- Proximal edges to the penoscrotal-junction skin
- Lateral edges to the viable dorsal penile-skin edges at 3 and 9 o'clock
- The two flaps meet at the ventral midline → longitudinal closure
- Interrupted absorbable sutures
7. Penoscrotal angle reconstruction
- Anchor the penoscrotal skin to the proximal shaft (Buck's fascia) to recreate the penoscrotal angle and prevent recurrent concealment — the critical durability step shared with the Alter / Ehrlich principle
8. Donor closure
- Primary closure of the scrotum; relaxing incisions closed or allowed to heal by secondary intention depending on tension
9. Dressing and discharge
- Light compressive dressing
- All 15 patients in the original series discharged same-day
Position in the Tausch / Pariser Algorithm
| Pariser tier | Anatomy | Procedure | VSSF role |
|---|---|---|---|
| I | Viable penile skin, local-flap-sufficient | Unburying + local flap | Primary technique |
| II | Nonviable penile skin, no abdominal / scrotal component | Skin excision + STSG | n/a |
| III | Scrotal surgery needed | Scrotoplasty ± STSG | n/a |
| IV | Escutcheonectomy needed | Escutcheonectomy + STSG | n/a |
| V | Panniculectomy needed | Panniculectomy + escutcheonectomy + STSG | n/a |
The Tausch algorithm opens every AABP case with a ventral release. Viable shaft skin → ventral scrotal-flap closure (= VSSF); nonviable → STSG.[5]
PAS-Driven Selection
The ideal VSSF candidate is P1-A0-S0 or P2a-A1-S0 — sufficient penile skin, no contributory pannus, normal scrotal skin (which is the most common scrotal subtype, 71% in the PAS validation cohort).[11]
| PAS axis | Favors VSSF | Requires escalation |
|---|---|---|
| P | P1, P2a | P2b, P2c |
| A | A0, A1 | A2 (panniculectomy) |
| S | S0 | S1, S2 (scrotoplasty / scrotectomy) |
Outcomes — Westerman / Tausch (n = 15)[1]
| Parameter | Result |
|---|---|
| Mean age | 51 y (26–75) |
| Mean BMI | 42.6 kg/m² (29.8–53.9) |
| LS etiology | 13 / 15 (87%) |
| Phimosis (non-LS) | 2 / 15 (13%) |
| Setting | Outpatient — 100% same-day discharge |
| Mean OR time | 83 min (35–145) |
| Mean EBL | 57 cc (25–200) |
| Perioperative complications | 0 / 15 |
| Satisfied without further intervention | 11 / 15 (73.3%) |
| Recurrence | 3 / 15 (20%) |
| Subsequent STSG for recurrence | 2 / 3 → successful |
Recurrence analysis
| Cause | Why VSSF was insufficient |
|---|---|
| LS progression | Chronic disease — inherent to any LS-related repair, not VSSF-specific[7] |
| Panniculus migration | Suprapubic adiposity not addressed — these patients need escutcheonectomy / Pariser IV[5][4] |
| Edematous groin tissue | Lymphedema not addressed |
The 20% recurrence sits within the broader AABP literature — Plamadeala n = 204 multicenter cohort: 12.7% overall recurrence; 91.5% RFS at 12 mo, 83.7% at 24 mo; higher complexity (Pariser ≥ III) was associated with reduced recurrence (p = 0.018) — supporting escalation for higher-PAS patients.[2]
Comparison With Other AABP Pathways
| Feature | VSSF (Westerman) | Escutcheonectomy + STSG (Staniorski) | Escutcheonectomy + FTSG (Jeng) | Plamadeala low-complexity |
|---|---|---|---|---|
| Complexity tier | Pariser I (low) | IV–V (high) | IV–V (high) | I–II (low) |
| Setting | Outpatient | Inpatient | Inpatient | Variable |
| Skin graft | None | STSG | FTSG (escutcheon) | Variable |
| Mean OR time | 83 min | n/r | n/r | n/r |
| Perioperative complications | 0% | 50% | 56% | 13.3% |
| Wound dehiscence | n/r | 31% | n/r | n/r |
| Wound infection | n/r | 30% | 41% | n/r |
| Recurrence | 20% | 3.9% revision | 13% surgical failure | 12.7% overall |
| Satisfaction | 73.3% | n/r | n/r | 86.8% |
| Separate donor site | None | Thigh or escutcheon | Escutcheon | Variable |
Advantages
- Outpatient — 100% same-day discharge — no other AABP technique consistently achieves this
- No skin grafting — eliminates thigh donor or escutcheon-graft harvest
- Zero perioperative complications — the only AABP series with 0%
- Short OR time (83 min) and minimal blood loss (57 cc)
- Preserves viable dorsal native skin — maintains native sensation
- Scrotal skin closely matches penile shaft skin in thickness, elasticity, and hair pattern
- Technically straightforward — basic local-flap principles, no microsurgical expertise
- Feasible in obese patients — mean BMI 42.6 kg/m² in the series
- Low resource use — fits an ambulatory reconstructive practice
Limitations and Disadvantages
- Limited to ventral-only deficits — does not cover circumferential defects
- 20% recurrence — higher than the 3.9% revision rate in high-complexity escutcheonectomy + STSG (less aggressive ≠ more durable)
- Not suitable for high-PAS patients — A2 / S1–S2 / P2b–c need escalation
- LS progression risk — chronic disease drives ongoing re-scarring regardless of technique[7]
- Small series (n = 15) — limited evidence vs Plamadeala n = 204 or Tausch n = 56
- No validated PROMs in the original series — modern AABP literature uses IIEF-15, IPSS, POSAS[10]
- No long-term follow-up data beyond recurrence notation
- Potential penoscrotal webbing if the anchoring step is omitted
- Hair-bearing variability — anterior scrotal skin usually non-hair-bearing but individual variability
Place in the Broader Tausch Series (n = 56)
The VSSF is the entry point of the Tausch algorithm:[5]
- All cases start with ventral release
- Viable skin → VSSF
- Nonviable → complete excision + STSG
- Severe abdominal lipodystrophy → adjacent-tissue transfer
- Genital lymphedema → excision of lymphedematous tissue + primary closure ± STSG
- Overall success 88% (49 / 56)
Pariser n = 64: low-complexity (I–II) had 0% Clavien ≥ 3 complications vs 23% in high-complexity (p = 0.02); all failures occurred in the high-complexity group — supporting the VSSF as highly reliable when appropriately indicated.[4]
Patient Selection — When VSSF Wins
| Choose VSSF | Consider escalation |
|---|---|
| Trapped penis from LS or phimosis with viable dorsal skin | Circumferential nonviable penile skin → STSG / FTSG[6][8] |
| Ventral-only deficiency after ring release | Significant suprapubic fat pad (PAS A2) → escutcheonectomy + STSG (Pariser IV) |
| Normal scrotal skin (PAS S0), adequate laxity | Abdominal pannus contributing → panniculectomy + escutcheonectomy + STSG (Pariser V) |
| PAS A0 / A1, no significant suprapubic adiposity | Genital lymphedema → scrotoplasty / scrotectomy + STSG |
| Outpatient preference, low-morbidity priority | Circumferential paraffinoma defect → Fakin / Murányi / Yao / Pribaz staged[12] |
| Poor STSG candidates (anticoagulation, donor concerns) |
Key Takeaways
- The only AABP technique consistently performed outpatient with 0% perioperative complications and no skin graft
- Strictly Pariser Category I / Tausch first-line ventral release — preserves viable dorsal native skin and resurfaces only the ventral deficit with bilateral local rotation flaps
- 20% recurrence reflects appropriate patient selection — when PAS A2 / S1–S2 / P2b–c is missed, escalation is required and the Plamadeala data support that higher complexity reduces recurrence
- Penoscrotal-angle anchoring to Buck's fascia is the critical durability step shared with the Alter / Ehrlich anti-recurrence principle
- LS chronic progression is a disease-specific recurrence risk distinct from the technique itself
Cross-references
- Buried Penis Repair — integrated AABP workflow
- Escutcheonectomy — Pariser IV escalation
- Panniculectomy — Pariser V escalation
- Penile Skin Grafting — STSG / FTSG when shaft skin is non-viable
- Penile Primary Closure ± Z-plasty — alternative for very small ventral deficits
- Bipedicled Anterior Scrotal Flap (Fakin), Murányi tunnel, Yao butterfly, Pribaz / McLaughlin staged — circumferential-defect alternatives
- Penile Reconstruction — full decision framework
References
1. Westerman ME, Tausch TJ, Zhao LC, et al. "Ventral Slit Scrotal Flap: A New Outpatient Surgical Option for Reconstruction of Adult Buried Penis Syndrome." Urology. 2015;85(6):1501–4. doi:10.1016/j.urology.2015.02.030
2. 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
3. Staniorski CJ, Myrga JM, Vasan RV, Klein RD, Rusilko PJ. "Surgical Outcomes and Prediction of Complications Following High-Complexity Buried Penis Reconstruction." J Urol. 2023;210(5):782–790. doi:10.1097/JU.0000000000003669
4. Pariser JJ, Soto-Aviles OE, Miller B, Husainat M, Santucci RA. "A Simplified Adult Acquired Buried Penis Repair Classification System With an Analysis of Perioperative Complications and Urethral Stricture Disease." Urology. 2018;120:248–252. doi:10.1016/j.urology.2018.05.029
5. 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
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. Kulkarni S, Barbagli G, Kirpekar D, Mirri F, Lazzeri M. "Lichen Sclerosus of the Male Genitalia and Urethra: Surgical Options and Results in a Multicenter International Experience With 215 Patients." Eur Urol. 2009;55(4):945–54. doi:10.1016/j.eururo.2008.07.046
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. 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
10. Falcone M, Preto M, Timpano M, et al. "The Outcomes of Surgical Management Options for Adult Acquired Buried Penis." Int J Impot Res. 2023;35(8):712–719. doi:10.1038/s41443-022-00642-9
11. 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
12. Fakin R, Zimmermann S, Jindarak S, et al. "Reconstruction of Penile Shaft Defects Following Silicone Injection by Bipedicled Anterior Scrotal Flap." J Urol. 2017;197(4):1166–1170. doi:10.1016/j.juro.2016.11.093