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Buried Penis Repair

This is the surgical-technique atlas for adult-acquired buried penis (AABP). For etiology (morbid obesity, lichen sclerosus, prior circumcision scarring, genital lymphedema, hidradenitis), classification systems in detail (Pariser, PAS, Mirastschijski, Ngaage), full preoperative evaluation, and the lichen-sclerosus / obesity / urethral-stricture cycle, see the clinical-conditions page: Adult-Acquired Buried Penis. This page focuses on the operative anatomy, repair components, technique detail, and outcomes.

Decision Framework​

Modern AABP repair is multi-component, not a single operation. Operative planning starts from one of the validated classification systems and assigns each of three anatomic axes: penis / escutcheon, abdominal pannus, scrotum (the PAS axes). The dominant lesson of the last decade is that isolated escutcheonectomy or isolated panniculectomy fails — durable unburying requires combined penile-skin management, escutcheonectomy when contributory, scrotoplasty when contributory, and anchoring fixation.[1][2][3]

AxisDecision driversProcedure to add
P — Penis / escutcheonP2a (contributory escutcheon, sufficient penile skin) → escutcheonectomy alone; P2c (contributory escutcheon + insufficient skin) → escutcheonectomy + STSG or FTSGEscutcheonectomy ± skin graft
A — Abdominal pannusA2 (pannus contributory)Panniculectomy
S — ScrotumS1 / S2 (lymphedematous or diseased)Scrotoplasty / scrotectomy
Lichen sclerosusPresent in ~23% of cases; predicts stricture (OR 2.3) and graft failure (esp. with diabetes)Excise diseased shaft skin; send for path; FTSG over STSG for elasticity
Urethral stricture31–47% prevalence; near-universally anterior; ≥ 6 cm in 61%Stage Kulkarni urethroplasty first, then AABP repair
BMI≥ 40 kg/m² = 12.7× recurrence; ≥ 38 = 6.7× complication oddsPreoperative weight optimization; do not delay symptomatic cases indefinitely

Core Procedure Components​

1. Penile liberation and degloving​

  • Circumferential incision at the corona, with degloving down to Buck's fascia
  • Aggressive excision of all diseased shaft skin — lichen sclerosus, scarring, chronic dermatitis — to bleeding healthy edges
  • Lysis of fibrotic tethers between the penile base and prepubic fat
  • All excised tissue sent to pathology — penile cancer identified in ~5% of AABP-repair specimens[4]

2. Escutcheonectomy​

Excision of the suprapubic fat pad (skin + subcutaneous fat + tethering fibrous tissue down to anterior rectus fascia) — performed in ~55% of AABP repairs.[3][5][6] The escutcheon is anatomically distinct from the overhanging abdominal pannus.

Incision design:

  • Transverse curvilinear incision: superior border at the level of the ASIS bilaterally, inferior border curving down to ~1 cm above the penile base[5][7]
  • Modified trapezoid design for cases requiring concurrent panniculectomy[8]

Excision plane:

  • Dissection down to anterior rectus / lower-abdominal fascia
  • En bloc removal of skin, subcutaneous fat, and the fibrous tissue tethering the penile base
  • Preserve spermatic cords and neurovascular structures
  • The penile shaft is fully liberated during this dissection

Closure and fixation:

  • Multilayer closure — deep fascial sutures, subcutaneous sutures, skin closure
  • Anchoring sutures — penopubic dermis to rectus fascia or pubic periosteum with permanent or long-lasting absorbable suture to prevent re-retraction[7][9]
  • Closed-suction drain in the escutcheonectomy bed

Why isolated escutcheonectomy fails: early approaches that excised the fat pad alone, without addressing diseased penile skin and scrotal contribution, produced high reburying rates. Modern consensus is that escutcheonectomy should never be performed in isolation in adults with significant penile-skin or scrotal disease.[2][1]

3. Penile skin resurfacing​

After degloving + escutcheonectomy, the shaft is typically circumferentially denuded. Options:

OptionBest forNotes
STSG from excised escutcheonDefault for most cases; outpatient-feasibleTake rate 80–100% (mean ~92%); no thigh donor site
FTSG from excised escutcheonConcurrent LS, younger / lower-BMI patients prioritizing durabilityTake 87–100%; less contracture; technically harder (defatting); diabetes is the main loss risk
Thigh-donor STSGWhen escutcheon insufficient or non-viableAdds a thigh wound; comparable take
Ventral slit scrotal flap (VSSF)LS / phimosis without massive obesity; outpatientMean OR 83 min, EBL 57 cc, satisfaction 73%, recurrence ~20%[10]
Diamond-shaped penoplasty ± suprapubic liposuctionModerate AABP without major escutcheon diseaseMean flaccid length 1.94 → 5.55 cm[11]
Local advancement / Z-plasty on stretch< 30% circumferential defectCloses only under stretch to avoid acquired curvature

4. Scrotoplasty / scrotectomy​

Performed in ~48% of AABP repairs[3]: reduction of redundant or lymphedematous scrotal skin, often as part of the same closure. See Scrotal Reconstruction.

5. Panniculectomy (when A2)​

Removal of overhanging abdominal pannus — performed in ~7–28% of AABP repairs depending on cohort severity.[12][3] NSQIP and SR data show no significant increase in 30-day complications when panniculectomy is added on multivariate analysis, though BMI remains the dominant predictor.[12]

6. Concurrent urethral stricture (when present)​

  • Stricture present in 31–47% of AABP candidates; near-universally anterior; ≥ 6 cm in 61%[13][14]
  • LS predicts stricture (OR 2.3) and worse graft outcomes[4]
  • Stage Kulkarni dorsal-onlay BMG urethroplasty first, then AABP repair — preserves the ability to deglove safely at the subsequent repair[14]

Skin-Graft Harvest from the Escutcheon Specimen​

A key innovation in AABP repair is using the excised escutcheon as the graft donor, eliminating a separate thigh wound.[1][2]

STSG from escutcheon — Strother / Kovell technique[1]​

  1. Escutcheonectomy completed; specimen placed skin-side up on a flat back table, stretched taut
  2. Electric or air-powered dermatome harvests STSG in 2-inch sections at 0.012–0.018 inch (0.30–0.46 mm) depth
  3. Unmeshed sheet preferred for cosmesis; 1:1 meshed unexpanded acceptable, with mesh slits transverse and seam placed ventrally in a zigzag[15]
  4. Specimen kept moist with saline-soaked gauze on the back table while penile degloving and defect measurement are completed

FTSG from escutcheon — Monn / Mellon technique[16]​

  1. Escutcheon specimen brought to the back table
  2. Skin sharp-dissected off the underlying fat with scalpel / scissors, preserving full epidermis + dermis
  3. Meticulous defatting of the deep surface — the most technically demanding step; residual fat is the dominant cause of FTSG failure
  4. Defatted FTSG wrapped circumferentially over the degloved shaft and bolstered

Graft fixation​

  • Bolster dressing — petrolatum gauze → mineral-oil cotton gauze → dry cotton gauze, sutured / stapled to the penis; removed at 5–7 days[17]
  • Rook (eggcrate-foam) bolster — spikes toward wound, layered over silver dressing, removed at median 4 days; reported 100% take through POD 14[18]
  • Fibrin sealant as thin layer between graft and bed; reduces hematoma; may be combined with bolster
  • Penis placed on stretch during fixation to prevent erection-time tethering / chordee

Postoperative graft care​

  • Indwelling Foley catheter for the duration of the bolster to keep urine off the graft
  • Pharmacologic erection suppression in selected patients
  • Activity restriction through the early healing window
  • Counsel patients on expected wound dehiscence at the suprapubic closure (up to 88% in high-BMI cohorts) — managed conservatively with local wound care[19]

STSG vs FTSG from escutcheon​

The Gül 2026 comparative analysis found no significant difference between STSG and FTSG in operative time, overall or severe (Clavien ≥ 3) complications, recurrence, or patient satisfaction. IIEF and IPSS improved significantly with both.[20] Choice is therefore driven by surgeon comfort, LS-related cosmesis preference, and diabetes status (diabetes was the dominant predictor of FTSG loss in the Jeng series).[21]

Outpatient vs Inpatient​

PatternSettingEvidence
Penile liberation + escutcheonectomy + STSGOutpatient or same-day discharge feasibleErpelding (62.5% same-day, all Clavien II, 100% STSG take); Figler outpatient series (30-day complications 19–25%, all Clavien II)[22][17]
Adds extensive scrotoplasty + panniculectomy3–5 day stay typicalFuller / Rusilko Pittsburgh cohort[5]

Outcomes​

OutcomeData
Successful unburying91–100% (Pariser, modern multi-component series)[23][3]
STSG take rate80–100% (mean ~92%)[1][15]
FTSG take rate87–100%[16][21]
Overall complications27–50%, mostly Clavien I–II (dehiscence, cellulitis)
High-grade (Clavien ≥ 3)0–23%, almost exclusively in high-complexity Pariser ≥ III repairs[19]
Recurrence12.7–22%; recurrence-free survival 91.5% at 12 mo, 83.7% at 24 mo[24]
Revision rate3.9%
Stretched penile length gain+ 3.0 cm
Patient satisfaction85–97% would undergo again[24]
Improvement in hygiene100%
Improvement in urination91%
Improvement in sexual function41–50%

The largest multicenter European cohort (Plamadeala 2026, n = 204) confirmed that high-complexity repair has higher immediate complications (32.6% vs 13.3%) but lower recurrence than limited repairs.[24] Hematoma was the complication most strongly associated with recurrence.

Complications​

ComplicationFrequencyNotes
Wound dehiscence~31%Suprapubic closure line; high-BMI cohorts; conservative care[19]
Wound infection26–41%Warm moist suprapubic fold; staged-dressing care[21][19]
Graft loss< 10% partial; < 5% completeAll FTSG losses in Jeng series had diabetes
Hematoma / seromaVariableDrain placement and meticulous hemostasis
Recurrence / reburying12.7–22%BMI is dominant predictor
DVTRareNone in published outpatient series

Preoperative Optimization​

  • BMI is the most important modifiable risk — BMI ≥ 40 → 12.7× recurrence; each + 1 BMI → + 12% recurrence / + 11% complications[25]
  • Bariatric referral for BMI ≥ 40, with the understanding that surgery should not be indefinitely delayed in symptomatic patients
  • Modified Frailty Index ≥ 2 → 6.4× complications[19]
  • Diabetes control — the dominant FTSG-loss predictor; glycemic optimization before grafting
  • Tobacco cessation — at least 4–6 weeks
  • Preoperative cystoscopy / RUG to screen for stricture, especially in LS
  • PAS classification photographs preoperatively for planning and inter-institution communication[3]

Pediatric Buried Penis (Brief)​

Congenital BP is anatomically and surgically distinct. See pediatric AABP. Mainstays:

  • Degloving + fixation of penile skin to Buck's fascia at 3 and 9 o'clock[9]
  • Circumcision or prepuce reconstruction
  • Division of fundiform / suspensory ligaments when indicated
  • Anatomical resection of the deep layer of dartos fascia (Zhang 2020 — no recurrence in 78 patients)[26]
  • External phallopexy ("3-stitch") for simpler cases[27]
  • Recurrence 9–14%

Multidisciplinary Approach​

Complex AABP repair benefits from a combined urology + plastic-surgery team, especially for cases requiring panniculectomy, scrotoplasty, and skin grafting together.[1][2][16] Standardized PAS photography facilitates planning and communication.[3]

Key Takeaways​

  • AABP repair is multi-component — penile skin management, escutcheonectomy, scrotoplasty, panniculectomy, and anchoring fixation as dictated by the PAS axes
  • Isolated escutcheonectomy or isolated panniculectomy fails — durable unburying requires concurrent penile-skin reconstruction
  • The excised escutcheon is the graft donor of choice (STSG or FTSG) — eliminates thigh donor-site morbidity
  • STSG and FTSG from escutcheon produce equivalent functional outcomes; FTSG is preferred when LS / cosmesis dominate and diabetes is controlled
  • Stage Kulkarni dorsal-onlay BMG urethroplasty before AABP repair when concurrent stricture is present
  • BMI ≥ 40, diabetes, and frailty are the dominant modifiable / predictive determinants of complication and recurrence

See Also​

Videos​

Trapped Penis Repair in Lichen Sclerosus
Marcel Rad MD (2023)
Hidden / Buried Penis Surgery
Souvik Adhikari MCh (2021)

References​

1. 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

2. Tang SH, Kamat D, Santucci RA. "Modern Management of Adult-Acquired Buried Penis." Urology. 2008;72(1):124–7. doi:10.1016/j.urology.2008.01.059

3. 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

4. Daly WC, Klein RD, Myrga JM, Quiroga-Garza G, Rusilko PJ. "Lichen Sclerosus in Patients Undergoing Adult-Acquired Buried Penis Repair: A Large Cohort Review." Urology. 2025. doi:10.1016/j.urology.2025.07.061

5. 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

6. Jun MS, Gallegos MA, Santucci RA. "Contemporary Management of Adult-Acquired Buried Penis." BJU Int. 2018;122(4):713–715. doi:10.1111/bju.14230

7. Alter GJ, Ehrlich RM. "A New Technique for Correction of the Hidden Penis in Children and Adults." J Urol. 1999;161(2):455–9.

8. Baumgarten AS, Beilan JA, Shah BB, et al. "Suprapubic Fat Pad Excision With Simultaneous Placement of Inflatable Penile Prosthesis." J Sex Med. 2019;16(2):333–337. doi:10.1016/j.jsxm.2018.12.005

9. Frenkl TL, Agarwal S, Caldamone AA. "Results of a Simplified Technique for Buried Penis Repair." J Urol. 2004;171(2 Pt 1):826–8. doi:10.1097/01.ju.0000107824.72182.95

10. 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

11. Wang J, Ni J, Xu Y, et al. "A Diamond-Shaped Penoplasty Technique With or Without Concurrent Suprapubic Liposuction for Adult-Acquired Buried Penis." Asian J Androl. 2025;27(1):72–75. doi:10.4103/aja202476

12. Barrow B, Laspro M, Brydges HT, et al. "Technical Considerations and Outcomes for Panniculectomy in the Setting of Buried Penis Patients: A Systematic Review and Database Analysis." Ann Plast Surg. 2024;93(3):355–360. doi:10.1097/SAP.0000000000004025

13. 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

14. Fuller TW, Pekala K, Theisen KM, et al. "Prevalence and Surgical Management of Concurrent Adult Acquired Buried Penis and Urethral Stricture Disease." World J Urol. 2019;37(7):1409–1413. doi:10.1007/s00345-018-2514-1

15. Black PC, Friedrich JB, Engrav LH, Wessells H. "Meshed Unexpanded Split-Thickness Skin Grafting for Reconstruction of Penile Skin Loss." J Urol. 2004;172(3):976–9. doi:10.1097/01.ju.0000133972.65501.44

16. 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

17. Figler BD, Gan ZS, Mohan CS, Zhang Y, Filippou P. "Outpatient Panniculectomy and Skin Graft for Adult Buried Penis." Urology. 2020;143:255–256. doi:10.1016/j.urology.2020.04.129

18. Richards P, Yadav K, Coakes C, et al. "Rook to the Rescue: A Case Series on the Novel Use of Eggcrate Foam Bolsters for Skin Grafts in Penile and Genital Reconstruction." Ann Plast Surg. 2026. doi:10.1097/SAP.0000000000004649

19. 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

20. 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." Int J Impot Res. 2026;38(3):259–265. doi:10.1038/s41443-024-00832-7

21. 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

22. Erpelding SG, Hopkins M, Dugan A, Liau JY, Gupta S. "Outpatient Surgical Management for Acquired Buried Penis." Urology. 2019;123:247–251. doi:10.1016/j.urology.2018.10.002

23. Mirastschijski U. "Classification and Treatment of the Adult Buried Penis." Ann Plast Surg. 2018;80(6):653–659. doi:10.1097/SAP.0000000000001410

24. 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

25. Chestnut C, Koch G, Stewart A, et al. "Increased Body Mass Index Is Associated With Recurrence and Complications Following Repair for Adult Acquired Buried Penis." J Sex Med. 2025. doi:10.1093/jsxmed/qdaf149

26. Zhang H, Zhao G, Feng G, et al. "A New Surgical Technique for the Treatment of Congenital Concealed Penis Based on Anatomical Finding." J Urol. 2020;204(6):1341–1348. doi:10.1097/JU.0000000000001300

27. Radwan AB, GadAllah MA, Soliman MH, AbouZeid AA. "External Phallopexy: A Revisited Technique and Algorithm for Simple Management of Buried Penis." J Pediatr Surg. 2023;58(3):580–586. doi:10.1016/j.jpedsurg.2022.07.028