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Pedicled Penile / Preputial Skin Flap

Penile and preputial skin flaps transfer skin with a preserved vascular pedicle. They can provide a urethral patch, replace a selected segment, or cover a penile defect. A free penile/preputial graft is detached from its donor blood supply and has different requirements and evidence.[1][2]

For adult urethroplasty, EAU 2026 recommends a graft when graft and flap are equally suitable; a vascularized flap remains useful when the recipient bed is poorly vascularized. Selection depends on the urethral plate, donor skin, prior operations, stricture cause and available oral mucosa. Neither a flap nor a graft makes a compromised reconstruction risk-free.[2]

Vascular Anatomy​

The skin-dartos complex carries the superficial penile cutaneous circulation. Grossman's 12-cadaver injection study identified paired axial vessels in the dartos supplying shaft skin, with deeper perforators contributing to the glans/subcoronal region. Later work describes external pudendal contributions and additional preputial supply; the small imaging study by Kureel specifically concerned six patients with exstrophy/epispadias, rather than normal anatomy in a large population.[3][4][5]

McAninch terminology needs care. The original 1993 description calls Buck's fascia the vascular conduit. Carney and McAninch subsequently distinguish Buck's supporting fascia from the dartos vascular pedicle carried toward the skin island. The practical principle is preservation of the superficial vascular fascial attachments, with correct separation of the skin and deeper fascial planes. This is not a flap based on deliberate division of the deep dorsal penile arterial supply.[6][7][8]

Protect both the flap and the remaining penile skin: avoid stripping the vascular attachments, pedicle torsion, constriction and tension. Confirm that the selected skin is hair-free; ventral shaft skin near the raphe can bear hair. Previous circumcision limits preputial options but does not automatically exclude a distal shaft-skin flap.[2][7]

Configurations​

ConfigurationTissue and useImportant distinction
Transverse preputial/distal penile island — Duckett/Quartey familySkin island on a vascular fascial pedicle; onlay or selected tubularized repairPediatric hypospadias and adult stricture series are different populations; reach depends on the actual pedicle and defect[9][10]
Longitudinal/oblique preputial islandInner and outer preputial surfaces incorporated into the reconstructionChen's report describes a specific hypospadias modification[11]
Double-face preputial islandInner surface for urethra, outer surface for ventral skin coverageCan preserve coverage for subsequent repair, but substantial reoperation remains possible[12]
OrandiLongitudinal ventral penile skin islandThe dorsal-onlay modification is distinct from the original ventral configuration[13][8]
McAninch circular fasciocutaneousDistal circumferential skin island opened into a longitudinal stripOften provides about 13–15 cm; selected circumcised patients remain candidates; longer defects may require another tissue transfer[6][7]
Circumpenile shaft flapNon-hair-bearing shaft skin when prepuce is unavailableFeasibility depends on residual skin and perfusion, not circumcision status alone[14]
Dartos flap without skinVascularized fascial coverage over a urethral repairAn interposition/coverage layer, not a skin-lined substitute urethra[15][16]

A reported maximum length or a short operating time from one series is not a universal design limit or performance target. These descriptions do not replace the detailed technique pages and operative assessment.

Adult Urethral Reconstruction​

Indications and tissue selection​

A penile flap may be appropriate for a long or complex anterior stricture, a poorly vascularized recipient bed, or a reconstruction needing more than one tissue type. Adequate healthy donor skin and a viable pedicle are essential. A previously operated recipient bed may be a reason to consider a vascularized flap; previous surgery is not itself an absolute prohibition. Prior surgery or irradiation of the donor tissue/pedicle requires a separate viability assessment.[2][7]

Avoid genital skin for LS-associated urethral strictures. Use non-hair-bearing tissue for intraluminal reconstruction. When oral mucosa is suitable and a graft can work, current guidelines generally favor oral grafting. These rules concern urethral reconstruction; external skin coverage is a different application.[17][2]

Onlay versus tube​

An onlay preserves usable native urethral plate. In the 1998 McAninch/Morey 66-patient cohort, recurrence occurred in 7/54 onlay repairs (13%) and 7/12 tubularized repairs (58%), with mean follow-up of 41 months. The overall initial success was 52/66; the higher 95% eventual success included subsequent procedures. These are observational results affected by case selection.[18]

Those figures are not from the original 1993 ten-patient report, which had no recurrence at mean 14.4 months and used supplemental grafts in two of the longest defects. The two cohorts should not be merged into one durability estimate.[6]

If a complete tube is required in one stage, a vascularized flap and a tubularized free graft are not interchangeable. EAU advises against a free graft fashioned as a complete tube in a single-stage repair.[2]

Dorsal versus ventral placement​

Bhandari's nonrandomized 40-patient comparison reported sacculation/pseudodiverticulum with dribbling in 6/21 ventral versus 0/19 dorsal repairs. The published abstract's ventral recurrence count and percentage are inconsistent, so they should not be used as a precise comparative estimate. The study supports attention to flap support; it does not establish that every dorsal flap is superior.[19]

Barbagli's dorsal Orandi modification succeeded in 10/12 cases, without fistula or diverticulum in that small series. This is feasibility evidence, not a guarantee of zero complications or a standard 60-minute operation.[13]

Flap versus buccal graft: keep the comparisons separate​

Dubey 2007 randomized 55 patients to a dorsal penile-skin flap or dorsal buccal mucosa graft. Reported success was 85.6% versus 89.9%, without a significant difference; flap surgery took longer and had more penile donor morbidity and troublesome dribbling. The study does not prove equivalence or supply complication rates for a free penile-skin graft.[20]

PeeBuSt and Alrefaey 2025 compare free penile-skin grafts with buccal grafts. They are discussed on the graft page. Their results cannot be used to claim that newer penile-flap techniques have become equivalent to BMG.[21][22]

The GURS survey reflects practice preference: 134 of 350 invited members responded; 99% of those respondents preferred buccal mucosa as their primary graft site. For penile urethroplasty, BMG was preferred to a flap by 95% for circumcised and 84% for uncircumcised patients. These are respondent preferences, not outcome comparisons or a census of all reconstructive urologists.[23]

Combined graft and flap​

A dorsal BMG with a ventral penile flap may be used for selected narrow or deficient plates. Karapanos's 12-patient series reported 11/12 success at median 38 months, with three transient fistulas and dribbling in five patients. This is a specialist option supported by limited observational evidence, not an established replacement for staged reconstruction.[24][2]

Contemporary circular-flap reports​

Zhao's 2026 retrospective series of 54 patients reported no recurrence at average 15 months, but dribbling in 13/54 and mild torsion in 8/54. Short follow-up and absence of a comparison group prevent claims of superiority or a zero long-term failure rate. This preliminary modification does not change the guideline preference for a suitable graft when both options are reasonable.[25][2]

Hypospadias​

The decision to preserve or transect the urethral plate, the residual curvature after straightening, tissue availability and the patient's previous repairs determine whether an onlay, tubularized flap or staged approach is appropriate. Current EAU guidance emphasizes adequate coverage and long-term follow-up. Dartos is one coverage option; tunica vaginalis is another. No coverage layer guarantees prevention of a fistula.[16]

StudyPopulation and designFinding and limitation
Wiener 1997132 repairs, retrospective single-surgeon comparisonDiverticula occurred in 9/74 tubularized versus 0/58 onlay repairs; overall complication rates were 36% versus 31%. Selection and anatomy differ between groups[26]
Blanc 202175 severe cases, double-face flap series36/75 required redo surgery; final success after additional procedures was 96%. Final success must not be presented as single-operation success[12]
Wang 2019320 Duckett repairs, retrospective seriesReported complications in 125/320 (39.1%); mean follow-up 40.2 months, with only 39 patients followed beyond five years. Late presentation occurred, but the series does not provide complete long-term surveillance of all patients[27]
Wang 2023152 proximal cases, nonrandomized comparisonStaged TPIF had fewer reported complications, but shorter follow-up, surgeon selection and exclusion of first-stage complications from the overall rate favor that comparison. The internally derived 4.55-cm cutoff is not a validated treatment threshold[28]

Historical six-patient dartos-coverage and other small technique reports illustrate feasibility; they do not justify a universal “waterproofing” rule. Preserve penile-skin perfusion while obtaining a suitable coverage layer.[15][29][16]

Resurfacing and Other Genital Reconstruction​

Preserved inner preputial skin can cover selected shaft defects. Fuller's three-patient burn report describes this option when the inner prepuce is spared; it is not comparative evidence against skin grafting. See buried penis repair and Fournier's gangrene for condition-specific reconstruction.[30]

Penile skin is also used in penile-inversion vaginoplasty, with additional grafts or other lining options when necessary. Skin lining and a sensate glans-based clitoral flap are distinct structures with different vascular requirements; the adult urethroplasty outcome data above do not describe vaginoplasty. See feminizing procedures.[31][32]

Small historical pediatric genitoplasty reports do not establish long-term sexual or reproductive outcomes, or resolve decisions about timing and consent. Savanelli's 14-child report explicitly acknowledged that follow-up had not reached those outcomes.[33]

Complications and Counseling​

Discuss recurrent stenosis, fistula, sacculation/diverticulum, postvoid dribbling, skin or flap ischemia, altered sensation, torsion/curvature and possible further procedures. Rates depend on the indication, flap configuration, failure definition and length of follow-up. Do not compare adult circular-flap and pediatric hypospadias percentages as if they were randomized treatment arms.[2][8][18]

Assess perfusion, donor closure, support of the reconstructed lumen and pedicle orientation. Plan follow-up for voiding function, recurrence and the patient's functional and cosmetic concerns. A patent lumen alone is not the whole outcome.[2][16]

See Also​

References​

1. Joshi PM, Bandini M, Kulkarni SB. "Common Flaps in Genitourinary Reconstruction." Urol Clin North Am. 2022;49(3):361–369. doi:10.1016/j.ucl.2022.04.001

2. EAU. Urethral Strictures: Tissue Transfer. 2026, sections 9.1–9.3.

3. Grossman JA, Caldamone A, Khouri R, Kenna DM. "Cutaneous Blood Supply of the Penis." Plast Reconstr Surg. 1989;83(2):213–216. doi:10.1097/00006534-198902000-00001

4. Kureel SN, Gupta A, Singh CS, Kumar M. "Surgical Anatomy of Penis in Exstrophy-Epispadias: A Study of Arrangement of Fascial Planes and Superficial Vessels of Surgical Significance." Urology. 2013;82(4):910–916. doi:10.1016/j.urology.2013.04.041

5. Lohasammakul S, Turbpaiboon C, Ratanalekha R, Ungprasert P, Yodrabum N. "Inferior External Pudendal Artery Anastomosis: Additional Approach to Prevent Skin Necrosis in Replanted Penis." Plast Reconstr Surg. 2018;142(4):535e–540e. doi:10.1097/PRS.0000000000004818

6. McAninch JW. "Reconstruction of Extensive Urethral Strictures: Circular Fasciocutaneous Penile Flap." J Urol. 1993;149(3):488–491. doi:10.1016/s0022-5347(17)36125-6

7. Carney KJ, McAninch JW. Penile circular fasciocutaneous flaps to reconstruct complex anterior urethral strictures. Urol Clin North Am. 2002;29:397–409. doi:10.1016/S0094-0143(02)00046-0.

8. Kim KR, Suh JG, Paick JS, Kim SW. Surgical outcome of urethroplasty using penile circular fasciocutaneous flap for anterior urethral stricture. World J Mens Health. 2014;32:87–92. doi:10.5534/wjmh.2014.32.2.87.

9. Quartey JK. "One-Stage Penile / Preputial Cutaneous Island Flap Urethroplasty for Urethral Stricture: A Preliminary Report." J Urol. 1983;129(2):284–287. doi:10.1016/s0022-5347(17)52051-0

10. Ghali AM. "Hypospadias Repair by Skin Flaps: A Comparison of Onlay Preputial Island Flaps With Either Mathieu's Meatal-Based or Duckett's Tubularized Preputial Flaps." BJU Int. 1999;83(9):1032–1038. doi:10.1046/j.1464-410x.1999.00083.x

11. Chen S, Wang G, Wang M. "Modified Longitudinal Preputial Island Flap Urethroplasty for Repair of Hypospadias: Results in 60 Patients." J Urol. 1993;149(4):814–816. doi:10.1016/s0022-5347(17)36216-x

12. Blanc T, Peycelon M, Siddiqui M, et al. "Double-Face Preputial Island Flap Revisited: Is It a Reliable One-Stage Repair for Severe Hypospadias?" World J Urol. 2021;39(5):1613–1624. doi:10.1007/s00345-020-03324-7

13. Barbagli G, Joshi PM, Kulkarni SB, et al. "Penile Urethroplasty Using Orandi's Dorsal Skin Flap: A New Technique." BJU Int. 2019;124(5):892–896. doi:10.1111/bju.14881

14. Srivastava A, Vashishtha S, Singh UP, et al. "Preputial / Penile Skin Flap, as a Dorsal Onlay or Tubularized Flap: A Versatile Substitute for Complex Anterior Urethral Stricture." BJU Int. 2012;110(11 Pt C):E1101–E1108. doi:10.1111/j.1464-410X.2012.11296.x

15. Churchill BM, van Savage JG, Khoury AE, McLorie GA. "The Dartos Flap as an Adjunct in Preventing Urethrocutaneous Fistulas in Repeat Hypospadias Surgery." J Urol. 1996;156(6):2047–2049. doi:10.1016/S0022-5347(01)65432-6.

16. EAU. Paediatric Urology: Hypospadias. Current surgical coverage and long-term follow-up recommendations.

17. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. "Urethral Stricture Disease Guideline Amendment (2023)." J Urol. 2023;210(1):64–71. doi:10.1097/JU.0000000000003482

18. McAninch JW, Morey AF. Penile circular fasciocutaneous skin flap in 1-stage reconstruction of complex anterior urethral strictures. J Urol. 1998;159:1209–1213. doi:10.1016/S0022-5347(01)63558-4.

19. Bhandari M, Dubey D, Verma BS. "Dorsal or Ventral Placement of the Preputial / Penile Skin Onlay Flap for Anterior Urethral Strictures: Does It Make a Difference?" BJU Int. 2001;88(1):39–43. doi:10.1046/j.1464-410x.2001.02257.x

20. Dubey D, Vijjan V, Kapoor R, et al. "Dorsal Onlay Buccal Mucosa Versus Penile Skin Flap Urethroplasty for Anterior Urethral Strictures: Results From a Randomized Prospective Trial." J Urol. 2007;178(6):2466–2469. doi:10.1016/j.juro.2007.08.010

21. Tyagi S, Parmar KM, Singh SK, et al. "'Pee'BuSt Trial: A Single-Centre Prospective Randomized Study Comparing Functional and Anatomic Outcomes After Augmentation Urethroplasty With Penile Skin Graft Versus Buccal Mucosa Graft for Anterior Urethral Stricture Disease." World J Urol. 2022;40(2):475–481. doi:10.1007/s00345-021-03843-x

22. Alrefaey A, Anwar MA, Abdelmagid ME, et al. "Comparative Outcomes of Penile Skin Grafts Versus Buccal Mucosal Grafts in Urethroplasty for the Treatment of Extensive Anterior Urethral Strictures." Sci Rep. 2025;15(1):29508. doi:10.1038/s41598-025-14191-w

23. Berg C, Singh A, Hu P, et al. "Current Trends in the Use of Buccal Grafts During Urethroplasty Among Society of Genitourinary Reconstructive Surgeons." Urology. 2024;191:139–143. doi:10.1016/j.urology.2024.06.019

24. Karapanos L, Halbe L, Storz E, et al. "Preservation of the Native Urethral Plate and Corpus Spongiosum Combined With Buccal Mucosa Graft Plus Orandi's Penile Skin Flap as an Alternative to Staged Urethroplasty for Narrow Penile Strictures." Int J Urol. 2024;31(10):1095–1101. doi:10.1111/iju.15521

25. Zhao T, Ji F, Liu Y, Wang L, Lyu X. "Preliminary Experience and Outcomes of Modified Distal Penile Circular Fasciocutaneous Flap for the Treatment of Anterior Urethral Strictures." World J Urol. 2026;44(1):191. doi:10.1007/s00345-026-06289-1

26. Wiener JS, Sutherland RW, Roth DR, Gonzales ET. "Comparison of Onlay and Tubularized Island Flaps of Inner Preputial Skin for the Repair of Proximal Hypospadias." J Urol. 1997;158(3 Pt 2):1172–1174. doi:10.1097/00005392-199709000-00123

27. Wang CX, Zhang WP, Song HC. "Complications of Proximal Hypospadias Repair With Transverse Preputial Island Flap Urethroplasty: A 15-Year Experience With Long-Term Follow-Up." Asian J Androl. 2019;21(3):300–303. doi:10.4103/aja.aja_115_18

28. Wang YS, Song HC, Liu P, Fang YW, Zhang WP. "Comparison of Outcomes in Three Surgical Techniques for Proximal Hypospadias: Staged Transverse Preputial Island Flap Urethroplasty Versus Single-Stage Repairs." Asian J Androl. 2023;25(5):616–620. doi:10.4103/aja2022106

29. Liang W, Ji C, Chen Y, et al. "Surgical Repair of Mid-Shaft Hypospadias Using a Transverse Preputial Island Flap and Pedicled Dartos Flap Around Urethral Orifice." Aesthetic Plast Surg. 2016;40(4):535–539. doi:10.1007/s00266-016-0659-0

30. Fuller SM, Roughton MC, Gottlieb LJ. "The Inner Prepuce Flap for Penile Scald Burns." J Burn Care Res. 2014;35(4):e250–e257. doi:10.1097/BCR.0000000000000055

31. Saylor L, Bernard S, Vinaja X, Loukas M, Schober J. "Anatomy of Genital Reaffirmation Surgery (Male-to-Female): Vaginoplasty Using Penile Skin Graft With Scrotal Flaps." Clin Anat. 2018;31(2):140–144. doi:10.1002/ca.23015

32. Perovic SV, Stanojevic DS, Djordjevic ML. "Vaginoplasty in Male Transsexuals Using Penile Skin and a Urethral Flap." BJU Int. 2000;86(7):843–850. doi:10.1046/j.1464-410x.2000.00934.x

33. Savanelli A, Alicchio F, Esposito C, De Marco M, Settimi A. "A Modified Approach for Feminizing Genitoplasty." World J Urol. 2008;26(5):517–520. doi:10.1007/s00345-008-0298-4