V-I Penoscrotal Reconfiguration (Bagnara)
The V-I penoscrotal reconfiguration is a flap-free technique for congenital webbed penis (CWP) that converts the V-shaped ventral web into a linear (I-shaped) midline closure after dartos-band release — eliminating the web and recreating a normal penoscrotal angle without flap transposition or tissue excision.[1] It was described by Bagnara et al. (2024) as a deliberately simplified alternative to Z-plasty.[1][2] For the broader webbing-correction toolkit see Penoscrotal-Web Correction; for the male cosmetic decision framework see the Male Cosmetic Genital Surgery atlas page.
Background
Congenital webbed penis sits within the "inconspicuous penis" spectrum alongside buried and trapped penis, and the broader group of penoscrotal positional anomalies.[3][4] In the Bagnara 21-patient series, CWP was isolated in 24%, associated with phimosis in 52%, hypospadias in 14%, and both in 10%.[1]
El-Koutby severity grading (Bagnara series distribution):[1]
| Grade | Description | n (%) |
|---|---|---|
| 1 | Mild — scrotal skin to proximal shaft | 5 (24%) |
| 2 | Moderate — scrotal skin to mid-shaft | 5 (24%) |
| 3 | Severe — scrotal skin to distal shaft / coronal sulcus | 11 (52%) |
Indications
| Setting | Best for / indications |
|---|---|
| Congenital webbed penis | Any El-Koutby grade (1–3); correction advocated in childhood to prevent psychological distress and future intercourse problems.[1] |
| CWP + phimosis | Single-stage concurrent circumcision (52% of original series).[1] |
| CWP + hypospadias | Performed alongside hypospadias repair (14% of original series).[1] |
| Adult aesthetic webbing | Not studied — Thomas & Navia algorithm still recommends Z-plasty for the adult cosmetic population.[6] |
Principle
The V-shaped ventral web at the penoscrotal junction is incised through skin and superficial dartos, tethering dartos bands are divided, the scrotal skin drops inferiorly to its anatomically correct level, and the resulting defect is closed as a single linear vertical (I-shaped) midline scar. No flap is designed, no tissue is excised, and no geometric transposition is required — the technique relies on dartos-band release and the native elasticity of penoscrotal skin.[1]
Stepwise Operative Protocol[1]
- Positioning / anesthesia. Supine; general anesthesia (pediatric series).
- Identify the web. Place the penis on gentle stretch; mark the apex of the V at the highest point of abnormal scrotal-skin insertion on the ventral shaft, with the two limbs extending laterally along the penoscrotal junction.
- V-incision. Incise along the marked V through skin and superficial dartos.
- Dartos-band release. Divide fibrous dartos bands tethering scrotal skin to the ventral penile shaft; allow the scrotal skin to fall inferiorly to its anatomic position.
- Reconfigure to I-closure. Advance the released scrotal skin inferiorly and approximate the wound edges along a single vertical midline — converting the V-defect into a straight ventral midline scar.
- Closure. Dartos with absorbable braided suture; skin with fine absorbable suture.
- Concurrent procedures. Add circumcision when phimosis coexists; perform hypospadias repair when indicated.
Key technical points — no flap transposition, no tissue excision, no complex geometry; success depends on adequate dartos-band release and native skin elasticity.
Outcomes (Bagnara 2024, n = 21)[1]
| Outcome | Result |
|---|---|
| Postoperative complications | 0% |
| Redo surgery | 0% |
| Parent satisfaction 4/5 (Likert) | 81% (17/21) |
| Parent satisfaction 3/5 (Likert) | 19% (4/21) |
| Cosmetic outcome | Excellent in all cases |
| Follow-up schedule | 2 wk, 1 mo, 6 mo, 12 mo — physical + psychological assessment at each visit |
Formal psychological assessment at every follow-up visit distinguishes this series from most pediatric webbing repair literature.
Comparison With Alternatives
| Feature | V-I (Bagnara) | Z-plasty | Scrotal raphe (Borsellino) |
|---|---|---|---|
| Complexity | Simple — no flap design | Moderate — precise flap geometry | Simple — raphe incision |
| Flap transposition | None | Required | None |
| Risk of flap-tip necrosis | None | Present | None |
| Tissue excision | None | Minimal | None |
| Complication rate | 0% (n = 21) | 2% (n = 100) | 0% (n = 11 webbed-penis subset) |
| Recurrence | 0% at 12 mo | Stable in 97% at 1–2 yr | 0% at > 1 yr |
| Scar orientation | Linear vertical midline | Oblique / reoriented | Along scrotal raphe |
| Lengthening mechanism | Tethering release + elastic redistribution | Geometric flap transposition (up to ~75%) | Tethering release via raphe |
| Severe (Grade 3) webbing | Demonstrated (52% of series) | Effective across all grades | Demonstrated in webbed-penis subset |
| Evidence level | Level IV (single series) | Level IV (largest n = 100) | Level IV (n = 11 webbed-penis) |
Advantages and Limitations
Advantages. Simplicity, no flap-related complications (tip necrosis, trapdoor effect, mismatch), tissue preservation, reproducibility for surgeons without dedicated plastic-surgery training, applicability across all El-Koutby grades including severe (Grade 3) webbing, and 0% complication / redo rate in the index series.[1]
Limitations.
- Single-center, single-series evidence (n = 21); no independent replication or head-to-head comparison with Z-plasty.[1]
- Pediatric only — not validated for adult aesthetic webbing, where Z-plasty remains the algorithmic standard.[1][6]
- No follow-up beyond 12 months — durability through puberty / adulthood unknown.
- Lengthening capacity is bounded by tissue release and elasticity rather than the defined geometric gain of Z-plasty (up to ~75% of central-limb length) — potentially less effective in scarred or inelastic tissue.[2]
- Parent-reported outcomes only; no validated patient-reported instruments.
Postoperative Care
- Follow-up at 2 weeks, 1 month, 6 months, and 12 months, with both physical examination and psychological assessment at each visit.[1]
- Absorbable sutures — no removal required.
- Activity restrictions appropriate to the pediatric population.
Positioning in the Surgical Armamentarium
V-I reconfiguration is a simplified, flap-free alternative for congenital webbed penis. Other non-Z-plasty options include the Borsellino scrotal-raphe approach (0% recurrence in 11 webbed-penis cases) and various degloving-based penoplasty techniques.[5][7] Z-plasty remains the most extensively studied and versatile technique (Álvarez Vega 2025: n = 100, 98% primary healing) and continues to be the algorithmic choice for adult aesthetic penoscrotal webbing, where V-I has not been evaluated.[2][6]
See Also
- Penoscrotal-Web Correction (umbrella)
- Reduction Scrotoplasty
- Male Cosmetic Genital Surgery
- Foundations — Z-Plasty
References
1. Bagnara V, Donà A, Berrettini A, et al. The "V-I penoscrotal reconfiguration": a simple technique for the surgical treatment of congenital webbed penis. Int J Urol. 2024;31(8):886–890. doi:10.1111/iju.15476
2. Álvarez Vega DR, Mendelson JL, Gitlin JS, Joshi P, Hanna MK. Optimizing pediatric genital reconstruction: the role of Z-plasty in enhancing aesthetic and functional outcomes. Urology. 2025. doi:10.1016/j.urology.2025.06.011
3. Fahmy MA, El Shennawy AA, Edress AM. Spectrum of penoscrotal positional anomalies in children. Int J Surg. 2014;12(9):983–988. doi:10.1016/j.ijsu.2014.08.001
4. Bergeson PS, Hopkin RJ, Bailey RB, McGill LC, Piatt JP. The inconspicuous penis. Pediatrics. 1993;92(6):794–799.
5. Borsellino A, Spagnoli A, Vallasciani S, Martini L, Ferro F. Surgical approach to concealed penis: technical refinements and outcome. Urology. 2007;69(6):1195–1198. doi:10.1016/j.urology.2007.01.065
6. Thomas C, Navia A. Aesthetic scrotoplasty: systematic review and a proposed treatment algorithm for the management of bothersome scrotum in adults. Aesthet Plast Surg. 2021;45(2):769–776. doi:10.1007/s00266-020-01998-3
7. Xu JG, Lv C, Wang YC, Zhu J, Xue CY. Management of concealed penis with modified penoplasty. Urology. 2015;85(3):698–702. doi:10.1016/j.urology.2014.06.044