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V-Y Advancement Plasty — Genital Applications

The V-Y advancement plasty is a versatile tissue-rearrangement technique applied across the genital reconstructive and aesthetic spectrum. A V-shaped incision is made, the triangular flap is slid forward into the defect, and the donor site closes as a Y. The net effect is unidirectional advancement. In Andrades's geometric analysis, flap height follows from the largest defect diameter and the alpha angle of the V, and the depth of the pivot plane follows from the shortest diameter and the depth of the defect.[20] In genital surgery it serves three principal contexts:

  1. Dorsal or penopubic application. Suprapubic skin is advanced distally during suspensory-ligament division (SLD) for cosmetic penile lengthening, the most studied use.[1][2][3][4]
  2. Ventral or penoscrotal application. Chang described upward advancement of a triangular flap at the penoscrotal junction to lengthen ventral penile skin, with the paraspongiosal arteries preserved beneath it.[31] Thomas and Navia's adult algorithm instead proposes Z-plasty.[14]
  3. Scrotal reconstruction. Tissue-expanded V-Y scrotoplasty covers the testes after extensive scrotal skin loss (Rapp 2005).[21]

Cocci reported V-Y skin plasty in 2 of 47 adult buried-penis repairs.[32] Tausch reported 49/56 patients with symptom resolution without further procedures after ventral release with skin viability-based flaps, grafts, or adjacent tissue transfer.[8] Knoll described modified suprapubic V-Y plasty with tissue debulking during prosthesis implantation for penile fibrosis.[11] Kim described a bipedicled scrotal flap combined with an inverted V-Y suprapubic incision for shaft resurfacing after paraffin-induced lipogranuloma excision (5 cases).[22]

For the broader male cosmetic-genital-surgery decision framework see the Male Cosmetic Genital Surgery atlas page. For the foundational geometric flap principle see V-Y Advancement (Foundations). For SLD see Suspensory Ligament Division.

I. Definition and Principle​

The V-Y advancement plasty (also called inverted V-Y plasty or V-Y advancement flap) is a plastic-surgery technique in which a V-shaped incision is made in the suprapubic skin, the triangular flap is advanced distally toward the penile base, and the wound is closed in a Y configuration. This recruits suprapubic skin to cover the penile base after suspensory-ligament release changes presymphyseal curvature and increases visible shaft exposure; the corpora themselves are not lengthened.[2][3][5][27]

Biomechanical principle. After SLD the corpora cavernosa can slide forward, but the overlying skin remains fixed to the pubis. The intended gain is visible flaccid shaft exposure rather than longer corporal tissue.[26] Without skin advancement, the skin acts as a tether that pulls the penis back (retraction).[2][4] V-Y plasty advances skin distally to reduce tethering; retraction occurred in 4 of 35 men in the cited V-Y group.[2][4]

II. Indications​

A. Cosmetic penile lengthening (primary indication)​

V-Y plasty is performed as an adjunct to SLD for cosmetic penile lengthening in:[1][3][4][6]

  • Small-penis anxiety (SPA). Men with normal dimensions who report size concerns require assessment of expectations and screening for penile dysmorphic disorder before invasive treatment. The SMSNA position states that dysmorphic disorder must be ruled out and that SLD counseling should address erectile dysfunction, sensory change and penile instability.[23] For adults without structural or functional penile abnormalities, the 2026 BAUS consensus recommends against surgical penile augmentation because supporting evidence is low quality.[24]
  • True micropenis. Congenital stretched penile length more than 2.5 standard deviations below the mean for age and population group warrants evaluation for an endocrine or genetic cause. The EAU discusses suspensory-ligament release (SLR) with possible V-Y skin plasty for congenital intrinsic shortness; it gives SLR a weak recommendation and extensive complication counseling a strong recommendation. For congenital micropenis with severe penile insufficiency, the EAU separately gives total phallic reconstruction a weak recommendation to restore genital anatomy.[25]

B. Buried / concealed penis correction[7][8][9][10]​

V-Y coverage is selective after release and assessment of available skin: Borsellino's pediatric cohort used no flaps, whereas Yener described dorsal flaps or ventral V-Y when skin was deficient.[9][34]

  • Adult-acquired buried penis. From obesity, prior circumcision scarring, or lymphedema.
  • Congenital buried penis. In pediatric patients.
  • Trapped penis. From cicatricial scarring after circumcision.

C. Penile fibrosis with prosthesis implantation​

Knoll 1996 described a modified suprapubic V-Y advancement flap with tissue debulking in patients with extensive cavernous fibrosis undergoing penile-prosthesis implantation, achieving 3.5–6.5 cm of additional functional length in 11 patients.[11]

D. Penoscrotal-web correction​

V-Y advancement and Bagnara's V-I reconfiguration are distinct operations for penoscrotal webbing; V-I closes in an I rather than a Y. The adult algorithm cited here proposes Z-plasty.[12][14] Avoid excessive ventral closure tension, which can constrict the shaft circumferentially and cause wound breakdown.[28] In a retrospective 103-patient implant-associated scrotoplasty cohort, 15/103 had dehiscence; diabetes (OR 6.1; CI 1.5–25.0) and V-Y technique (OR 4.9; reported CI 1.2–8.6) were associated with it.[29] One patient required operating-room washout and implant exchange.[29] See Penoscrotal-Web Correction.[12][13][14]

E. Scrotal reconstruction — tissue-expanded V-Y scrotoplasty (Rapp 2005)​

For reconstruction of the scrotal sac after extensive scrotal skin loss (Fournier's gangrene, trauma, tumor excision):[21]

  • Stage 1: tissue expansion. Subcutaneous tissue expanders placed in residual scrotal or perineal skin and serially inflated over weeks to generate additional native-quality skin.
  • Stage 2: V-Y advancement. Expanded skin incised in a V pattern and advanced as a V-Y flap to reconstruct the scrotal envelope and cover the testes.

Rapp describes the technique as giving good functional and cosmetic results after extensive scrotal skin loss.[21] Expanded local scrotal or perineal skin is native-quality tissue. See also Scrotal Reconstruction Techniques.

F. Combined scrotal flap and Y-V incision (Kim 2014)​

Kim et al. reported 5 patients with paraffin-induced penile lipogranuloma and skin necrosis. After complete excision, the shaft was resurfaced with a bipedicled scrotal flap. To prevent shortening, an inverted V incision on the suprapubic skin with partial suspensory-ligament resection was closed in an inverted Y, extending dorsal skin toward the penis. No shortening or girth reduction was reported, and all patients were satisfied with the appearance.[22]

III. Surgical Technique — Standard V-Y Advancement Plasty​

Step-by-step (classic technique).[1][2][5]

  1. Patient positioning. Supine, under general or regional anesthesia.
  2. Marking. An inverted V is drawn on the suprapubic skin with the apex pointing cephalad (toward the umbilicus) and the base at the penopubic junction. The V is typically 5–8 cm in height with the base spanning the width of the penile base.
  3. Incision. V-shaped incision through skin and subcutaneous tissue down to the rectus or Scarpa's fascia.
  4. Suspensory-ligament division. Through the same incision, identify and divide the superficial fundiform ligament before the deeper suspensory ligament, which extends from the pubic symphysis to the deep penile fascia. The fundiform origin varies among the linea alba, Scarpa's fascia, or both. Protect the external pudendal vessels near the fundiform insertion and the dorsal penile neurovascular bundle beneath the median suspensory blade; the seven-cadaver dissection identified median-blade division as the highest-risk step. In a separate 34-cadaver study, the deep dorsal vein was found at the deep suspensory margin in 18/34 specimens.[27][33]
  5. Penile advancement. The penis is pulled distally, exteriorizing the previously intracorporeal portion of the shaft.
  6. Flap advancement. The V-shaped skin flap is advanced distally to cover the newly exposed proximal penile shaft.
  7. Closure. The V incision is closed as a Y; the limbs of the V are approximated, and the vertical limb of the Y extends distally along the dorsal penile shaft.
  8. Anti-retraction measures. Various strategies prevent the penis from retracting back (see Section VI).

IV. Technical Modifications​

Several modifications have been developed to address the well-known complications of the standard V-Y plasty.

A. V-Y half-skin half-fat advancement flap with T-closure (Shaeer 2006)[2]​

  • The caudal half of the V flap is deskinned, leaving a cranial skin-covered V flap and a caudal rectangular fat flap.
  • The fat flap is advanced into the dead space between the penile base and pubis, preventing reattachment of the penis to the pubis.
  • The V incision is closed as a Y; the separate penopubic incision is closed as a T to avoid pulling the penis back during skin closure.[2]
  • A stay suture from the glans to the thigh maintains the penis in the stretched position.
  • In this case report, the six-month assessment found no loss of gained length, no hump and a faint scar; the patient reported an erection angle similar to baseline.[2]

B. Inverted V-Y plasty with distally based fat flaps (Deskoulidi & Caminer 2023)[1]​

  • After inverted V-Y plasty and SLD, two distally based fat flaps are advanced into the dead space created by ligament division.
  • Combined with fat injections for girth enhancement.[23] For cosmetic augmentation, the SMSNA separately recommends against graft-and-flap procedures outside a research protocol.[23]
  • n = 75 patients; the authors report 15 years of experience.[1]
  • Length gain 2–4 cm (flaccid).
  • Girth gain about 1 cm (from fat injections).
  • Three patients (4%) returned for revision of fat injections at 6–12 months.
  • The authors, describing 15 years of experience, report "very pleasing results with minimal complications."

C. Modified V-Y with scrotal-flap coverage (Shirong 2000)[15]​

  • After SLD, the exposed corpus cavernosum is covered with either a scrotal flap or skin graft.
  • V-Y suture technique used to prevent traction.
  • n = 52 patients (39 congenital short penis, 13 traumatic).
  • Satisfactory results in appearance and length.

D. Diamond-shaped penoplasty for adult-acquired buried penis (Wang 2025)[16]​

  • A diamond-shaped incision at the penopubic junction, related geometrically to V-Y advancement.
  • Combined with circumcision (32 patients) and suprapubic liposuction (28 patients).
  • n = 42 adult males with buried penis (mean BMI 35.56); retrospective.
  • Mean flaccid unstretched length 1.94 to 5.55 cm (mean gain 3.61 cm; P < 0.01).
  • Satisfaction at 3 months: mean 4.02/5.[16]
  • Transient penile lymphedema occurred in 42/42, was treated with two weeks of compression and resolved within three weeks; wound disruption occurred in 3/42 (7.1%) and infection in 2/42 (4.8%). Mean follow-up was 6.7 months.[16]

V. Outcomes​

StudynTechniqueLength gainComplicationsSatisfactionFollow-up
Deskoulidi & Caminer 2023[1]75Inverted V-Y + SLD + fat flaps + fat injection2–4 cm flaccid3 fat-injection revisions (4%) at 6–12 moImproved sexual self-esteem and function reported—
Mertziotis 2013 (V-Y group)[4]35V-Y plasty + SLDSimilar to circumcision groupHypertrophic scars 51%; retraction 11%Satisfaction-score improvement lower than circumcision group (p = 0.007)Length and questionnaires measured at 12 mo (7-year study period)
Shaeer 2006[2]1 caseV-Y half-skin half-fat + T-closure + SLDNo loss of gained length at 6 moNo hump, faint scar; erection angle similar to preoperative (patient-reported)Not reported6 mo
Shirong 2000[15]52SLD + scrotal flap + V-Y sutureSatisfactoryNot detailedSatisfactory—
Knoll 1996[11]11Modified V-Y + prosthesis + tissue debulking3.5–6.5 cm functionalNo prosthesis infections (0/11)Not reported; all devices functionalMean 12 mo
Wang 2025[16]42Diamond-shaped penoplasty for adult-acquired buried penis (32 with circumcision; 28 with liposuction)3.61 cm flaccid unstretchedWound disruption 7.1%, infection 4.8%4.02/5 at 3 moMean 6.7 mo

Systematic-review context. Vyas 2020 (16 studies, 1,192 patients across all augmentation techniques): length gain 8–83% (flaccid), 12–53% (erect); pooled complication rate 14.6%; combined length-and-girth augmentation had the highest complication rate; satisfaction 50–100%. Authors concluded that "enhancement procedures are controversial and investigational" with "inconsistent methodology" and "poor" study quality.[6]

VI. Complications​

The V-Y plasty has documented complications that have driven the development of alternative approaches.[2][4][17]

A. Hypertrophic / wide scarring​

  • In the Mertziotis V-Y group, 18 of 35 men (51%) developed hypertrophic scars and five obese men (14%) had wound dehiscence; one underwent reoperation for debris removal.[4]
  • The suprapubic V-Y scar is in a high-tension area prone to hypertrophic healing.
  • Cosmetically unacceptable in many patients seeking aesthetic improvement.
  • Alter 1997 described patients presenting for reconstruction specifically due to "hypertrophic and / or wide scars" from prior V-Y plasty.[17]

B. Proximal penile "hump"​

  • A thick, hair-bearing mound at the base of the penis created by the advanced V-Y flap, which carries suprapubic subcutaneous fat and hair-bearing skin onto the proximal penile shaft.[17]
  • Alter listed the hump among the complaints of men presenting for reconstruction after augmentation phalloplasty performed elsewhere.
  • The Shaeer modification (deskinning the caudal half of the V) was specifically designed to eliminate this problem.[2]

C. Penile retraction​

  • Retraction occurred in 4 of 35 men (11%) in the V-Y group and 3 of 47 (6%) in the circumcision group in the Mertziotis series (p = 0.453).[4]
  • Retraction occurs when the penis retracts back into the pubic fat pad due to scar contracture, reattachment of the ligament, or inadequate skin advancement.

Prevention strategies.

  • Dead-space obliteration. Fat flaps (Deskoulidi, Shaeer) to prevent penile reattachment to the pubis.[1][2]
  • Stay sutures. Temporary traction suture from glans to thigh.[2]
  • Postoperative penile traction therapy (PTT). Penile-stretching devices worn for weeks to months after surgery.[3]
  • Anti-retraction sutures. Tacking the caudal ligament remnant to Buck's fascia.[2]
  • T-closure of the penopubic incision. In Shaeer's modification, the V incision remains closed as a Y; the separate penopubic incision closes as a T to avoid pulling the penis back during skin closure.[2]

D. Altered erection angle​

  • Division of the suspensory ligament causes the erect penis to hang lower rather than pointing upward.
  • The Shaeer modification reported preserved erection angle at 6 months.[2]

E. Hair-bearing skin on the penile shaft​

  • The V-Y flap advances pubic skin (which is hair-bearing) onto the proximal penile shaft.
  • Can result in hair growth on the penile shaft; cosmetically undesirable and may cause discomfort during intercourse.[17]

F. Low-hanging penis​

  • Alter described a "low-hanging penis" as a complaint after V-Y plasty and SLD, resulting from loss of the normal penopubic angle.[17]

VII. V-Y Plasty vs Alternative Approaches​

A. Circumcision ligamentolysis (Mertziotis 2013) — a sequential, nonrandomized comparison[4]​

ParameterV-Y plasty (n = 35)Circumcision approach (n = 47)p value
Operative time150.7 min125.2 min0.005
Length gainSimilarSimilarNS
Girth gain with concomitant augmentation in 79/82 men2.21 cm mean2.00 cm mean0.220
Hypertrophic scars51%No major wound complications recorded—
Penile retraction11%6%0.453
Satisfaction scoreLowerHigher0.007
SEAR improvementLowerHigher< 0.001

The authors concluded that, with strict selection criteria, the circumcision-ligamentolysis procedure "demonstrated improved results in terms of safety, operation time, retraction rate and cosmetic appearance without any compromise in the gained penile size."[4]

B. Trans-scrotal approach (Karimian 2026)[18]​

  • Novel approach performing SLD through a scrotal incision, avoiding any suprapubic scar.
  • The 21-patient cohort included 14 men labeled as having body dysmorphic disorder, two with hypospadias and five with micropenis.[18] For invasive cosmetic augmentation in men without objective penile deformity, the SMSNA position calls for penile dysmorphic disorder to be ruled out.[23]
  • Flaccid length gain 2.6 ± 1.66 cm; stretched-length gain 2.4 ± 0.57 cm.
  • No major complications were reported among 21 patients, and all were discharged within 24 hours.[18]
  • Significant improvement in Male Genital Self-Image Scale (MGSIS).
  • IIEF-5 did not change significantly in this 21-patient uncontrolled series.[18]

VIII. V-Y Plasty for Buried / Concealed Penis​

In adult-acquired buried penis, ventral release, flap or graft coverage, and anchoring are selected according to penile-skin viability and surrounding tissue involvement to restore functional exposure.[7][8][10]

Classification and approach (Tausch 2016, n = 56).[8]

  • All procedures begin with ventral penile release.
  • If penile skin is viable, phalloplasty with scrotal flaps and penoscrotal-skin anchoring.
  • If penile skin is nonviable, complete skin excision and split-thickness skin graft (STSG).
  • Severe abdominal lipodystrophy: adjacent tissue transfer.
  • Overall success rate 88% (49/56), defined as resolution of symptoms without additional procedures.

Principles (Alter & Ehrlich 1999).[10]

  • In Alter and Ehrlich's 13-patient hidden-penis series, ventral tacking sutures from penoscrotal subdermis to tunica albuginea were used to stabilize mobile skin and dartos and limit retraction.[10]
  • Without these tacking sutures, the corporeal bodies "telescope proximally inside the scrotum and pubis," leading to surgical failure.

For the operative deep-dive on buried-penis repair see Buried Penis Repair (04e).

IX. Reconstruction of V-Y Plasty Complications​

Alter 1997 published the seminal series on reconstruction of deformities resulting from penile-enlargement surgery, including V-Y plasty complications.[17]

  • 19 men underwent 24 reconstructive operations from 1994–1996.
  • Procedures included:
    • Scar revisions for hypertrophic / wide V-Y scars.
    • V-Y advancement-flap reversal. Converting the Y back to a V to remove the hair-bearing hump.
    • Fat-nodule removal for complications of concurrent fat injection.
  • Alter reported improved penile appearance and function after reconstruction.[17]
  • Complications of reconstruction: 1 hematoma, minor wound complications, 1 inadequately reversed V-Y flap.

X. Evidence Quality and Limitations​

The evidence base for V-Y plasty in penile cosmetics is limited and of low quality.[3][6][19]

  • One single-center, open-label study of men with normal-sized penises reported computer-generated allocation to V-Y plus SLD (35 men) or cross-plasty plus SLD (30 men). At three months, mean flaccid length gain was 1.6 versus 2.8 cm.[30] Both groups received a silicone spacer and were advised postoperative traction; the cross-plasty method also included corporal mobilization and penoscrotal fixation.[30]
  • A comparative study (Mertziotis) was non-randomized and sequential (V-Y performed first, then circumcision approach), introducing selection and learning-curve bias.[4]
  • Most series are single-surgeon, single-center with short follow-up.
  • Inconsistent outcome measurement. No standardized method for measuring penile-length gain across studies.[6][19]
  • The García Gómez 2022 narrative review concluded that "the low scientific quality of the analyzed papers makes it difficult to establish recommendations to choose one technique over any other" and suggested that, when possible, "non-invasive techniques should be proposed as a first-line treatment."[3]
  • The Vyas 2020 SR found "poor" study quality regarding methodology for patient selection and outcomes reporting.[6]

XI. Clinical Summary​

V-Y advancement is the skin-management technique traditionally combined with suspensory-ligament division for penile lengthening. Shaeer describes it as the most commonly used technique. Deskoulidi and Caminer report 2–4 cm of flaccid length gain; their series included 75 patients.[1][2] Reported complications include hypertrophic scarring (51% in the Mertziotis V-Y group), a proximal hair-bearing hump and penile retraction (11%).[4][17]

These complications motivated modifications, including the half-skin half-fat flap with T-closure (Shaeer) and distally based fat flaps (Deskoulidi), and approaches that avoid the suprapubic V-Y incision entirely, including the circumcision ligamentolysis (Mertziotis) and trans-scrotal approach (Karimian).[1][2][4][18]

In Mertziotis's sequential, nonrandomized comparison (n = 82), the circumcision group had similar length and girth gains with better satisfaction (p = 0.007) and SEAR improvement (p < 0.001). The authors labeled 79 men as having penile dysmorphophobia, and 79/82 also received girth augmentation; selection and concomitant grafting limit attribution of outcomes to incision choice.[4] The authors questioned whether V-Y plasty is necessary for penile lengthening.[4]

For adult buried penis, Tausch reported an 88% success rate (49/56) for a classification-based, multimodal approach that always began with ventral penile release.[8] Ventral tacking sutures are described as necessary to prevent recurrence.[8][10]

See Also​

References​

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2. Shaeer O, Shaeer K, el-Sebaie A. Minimizing the losses in penile lengthening: "V-Y half-skin half-fat advancement flap" and "T-closure" combined with severing the suspensory ligament. J Sex Med. 2006;3(1):155–160. doi:10.1111/j.1743-6109.2005.00105.x

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