Penile Primary Closure ± Z-Plasty (on Stretch)
Primary closure with the penis on stretch is the preferred reconstructive approach for small penile skin defects where sufficient native shaft skin remains to achieve tension-free approximation in the erect state. When a linear scar or contracture band is present, Z-plasty is added to lengthen the scar, redistribute tension, and prevent tethering during erection.[1][2][3]
For broader options when primary closure is not feasible, see Penile Reconstruction and Penile Skin Grafting. For the integrated buried-penis workflow, see Buried Penis Repair.
Why "On Stretch"?
Penile shaft skin is thin, non-hair-bearing, and must freely translate over deeper tissue while accommodating the substantial length change of erection. Closing in the flaccid, retracted state produces a closure that is under unacceptable tension during erection, with predictable consequences:[1][4]
- Tethering — restricted penile mobility
- Acquired curvature — asymmetric tension → ventral or lateral deviation on tumescence
- Pain with erection — scar contracture across the closure line
- Wound dehiscence — repeated mechanical stress from nocturnal erections
Manual maximal stretch (assistant holds the glans distally to simulate erect length) is the minimum requirement. Intraoperative prostaglandin E1 (10–20 µg intracavernosal) induces a pharmacologic erection and provides the most physiologic assessment of skin requirements (Iblher protocol).[4] The principle applies to all penile closures — primary, flap, and graft.
Indications
| Scenario | Notes |
|---|---|
| Stage 1 buried penis (Santucci) | Phimotic-band-only — circumcision / dorsal slit + primary closure[5] |
| Concealed / hidden penis (pediatric or adult) | After degloving + release of dartos fibrous bands with adequate residual shaft skin[3][6] |
| Penoscrotal webbing | Z-plasty at the penoscrotal junction to reconstruct the penoscrotal angle[2][3][7] |
| Chordee | Ventral skin-contracture release with Z-plasty[2] |
| Small traumatic / surgical defects | Partial skin loss from circumcision complications or minor debridement[1] |
| Hypospadias revision | Z-plasty addresses ventral skin shortage or scar contracture[2] |
When defects exceed what tension-free on-stretch closure can cover, proceed to Penile Skin Grafting or flap reconstruction.[1][8]
Decision Algorithm
After degloving + excision of diseased tissue, the intraoperative decision branches:[8]
- Viable residual shaft skin + tension-free closure on stretch → Primary closure ± Z-plasty
- Viable shaft skin but ventral deficit → Byar's flaps or scrotal advancement flaps[9][10]
- Circumferential non-viable skin or large defect → STSG / FTSG (see Penile Skin Grafting)
- Contaminated bed → staged NPWT → delayed graft
The Tausch classification explicitly recommends that if uncovered shaft skin is non-viable after degloving, it should be completely excised and replaced with STSG rather than attempting primary closure.[8]
Technique — Primary Closure on Stretch
- Degloving — circumferential subcoronal incision; deglove to Buck's fascia; sharp release of all tethering dartos fibrous bands[3][11][6]
- Excise diseased tissue — phimotic ring, LS-affected skin, scar; assess viability of remaining skin[5][8]
- Penile fixation (anchoring sutures) — tack the subdermis of the penoscrotal junction to the tunica albuginea ventrally (typically 3 + 9 o'clock or 2 + 10 o'clock). This prevents the shaft from re-retracting into the scrotum and is the dominant determinant of durable repair in the Alter/Ehrlich series[3][11][12]
- Place penis on maximal stretch — assistant or PGE1-induced erection[4]
- Approximate with interrupted absorbable suture (4-0 / 5-0 chromic or Vicryl); closure line typically ventral or along the median raphe; no tension at full stretch is the success criterion[1]
- Skin redistribution if needed — if dorsal skin is in excess and ventral deficient (common post-degloving), use Byar's flaps to advance dorsal preputial / shaft skin ventrally[9]
Byar's flaps
Split the dorsal preputial / shaft skin in the midline and rotate the two halves ventrally to cover a midline ventral deficit. Avoids tubularized closure under tension. A workhorse adjunct to primary closure when degloving leaves a dorsal-rich / ventral-deficient skin envelope.[9]
Z-Plasty on the Penis
Z-plasty is added when a linear scar or contracture band would otherwise restrict erect length or cause curvature. Particularly valuable at the penoscrotal junction and along the ventral shaft.[2][3][12][7]
Z-plasty principles
- Two triangular flaps of equal dimension on either side of the scar
- Classic 60° angle on each side → lengthens the scar by 50–70% and reorients the central limb by 90°[12]
- Flaps transposed and sutured into new positions; precise flap-length / angle equality is essential
Penile-specific applications
| Variant | Indication | Outcome |
|---|---|---|
| Penoscrotal Z-plasty | Most common — reconstructs penoscrotal angle, eliminates webbing | Xu series (n = 41): 100% correction; median flaccid-length gain 2.1 cm; no erectile discomfort[6] |
| Lateral shaft Z-plasty | Lateral contracture-band release for curvature | Combined with suprapubic dermatolipectomy + ventral tacking sutures (Alter/Ehrlich)[3] |
| Serial / multiple Z-plasties | Longer contracture bands | Distributes lengthening; avoids large single flaps[2] |
| Double-opposing Z-plasty | Bifid scrotum, complex penoscrotal anomalies | Maximal rearrangement with minimal donor-site morbidity[2] |
| Penile-lengthening combination | Post-circumcision traumatic short penis | Z-plasty of penoscrotal web + suspensory-ligament release + suprapubic liposuction → mean erect-length gain 23 ± 4 mm, no complications[7] |
Outcomes (Álvarez Vega 2025)
Retrospective analysis of 100 consecutive Z-plasty procedures in pediatric genital reconstruction — 41 hypospadias revisions, 28 primary hypospadias repairs, 10 chordee corrections, 21 other reconstructive procedures:[2]
- 98% primary flap healing
- 1% suture-line separation
- 1% hypertrophic scarring
- Stable corrections with minimal visible scarring at ≥ 1 year in all patients with complete follow-up
Complications and Pitfalls
| Complication | Cause / Mitigation |
|---|---|
| Flap necrosis | High wound tension, thin flaps, compromised blood supply[12] |
| Hematoma under flap | Compromises viability — meticulous hemostasis[12] |
| Recurrence of concealment | Omitted ventral tacking sutures — the dominant cause of failure in Alter/Ehrlich data[3] |
| Trapdoor effect | Lymphatic disruption with thick flaps — more common with bulky subcutaneous tissue[12] |
| Insufficient lengthening | Defect too large for Z-plasty — convert to STSG / FTSG per Tausch[8] |
| Acquired curvature on erection | Closure not performed on stretch — re-explore early; reopen and re-close on stretch ± Z-plasty |
| Wound dehiscence | Tension at full stretch; manage with local wound care; secondary intention if small[1] |
Intermediate Option — Ventral Slit Scrotal Flap (VSSF)
For trapped penis from LS / phimosis with adequate scrotal skin: a ventral slit in the phimotic ring + rotated scrotal flap resurfaces the ventral shaft without skin grafting. Westerman series (n = 15): 73% satisfied without further intervention; ~ 20% recurrence (2 / 3 required subsequent STSG).[10]
Postoperative Care
- Compressive dressing for 48 h
- Foley catheter for 24–48 h if closure crosses near the meatus
- Avoid sexual activity / masturbation 4–6 weeks to allow scar maturation
- Postoperative tadalafil 5 mg daily can pharmacologically expand the closure and reduce contracture (Iblher adjunct)[4]
- Counsel patients on expected mild contracture in the first 6–8 weeks and to report early curvature / tethering
Key Takeaways
- On-stretch closure (manual or PGE1-induced erection) is non-negotiable — flaccid-state closure produces acquired curvature, tethering, and dehiscence
- Ventral subdermis-to-tunica-albuginea tacking sutures are the dominant predictor of durable repair in concealed-penis cases
- Add Z-plasty for any linear scar or contracture band that would otherwise limit erect length
- Byar's flaps redistribute dorsal-rich / ventral-deficient skin without graft
- If skin viability or quantity is inadequate, convert to STSG / FTSG — do not push primary closure under tension
- VSSF is a viable intermediate option for selected LS / phimosis trapped-penis cases
Cross-references
- Penile Reconstruction — full decision framework
- Penile Skin Grafting — STSG / FTSG when primary closure not feasible
- Buried Penis Repair — integrated AABP workflow
- Escutcheonectomy — suprapubic fat-pad excision
- Z-plasty (foundations)
- Penoscrotal-Web Z-Plasty (male cosmetic)
References
1. Hamad J, McCormick BJ, Sayed CJ, et al. "Multidisciplinary Update on Genital Hidradenitis Suppurativa: A Review." JAMA Surg. 2020;155(10):970–977. doi:10.1001/jamasurg.2020.2611
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. Alter GJ, Ehrlich RM. "A New Technique for Correction of the Hidden Penis in Children and Adults." J Urol. 1999;161(2):455–9.
4. Iblher N, Fritsche HM, Katzenwadel A, et al. "Refinements in Reconstruction of Penile Skin Loss Using Intra-Operative Prostaglandin Injections, Postoperative Tadalafil Application and Negative Pressure Dressings." J Plast Reconstr Aesthet Surg. 2012;65(10):1377–83. doi:10.1016/j.bjps.2012.04.020
5. 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
6. 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
7. Mokhless IA, Abdeldaeim HM, Rahman A, Zahran M, Safwat A. "Penile Advancement and Lengthening for the Management of Post-Circumcision Traumatic Short Penis in Adolescents." Urology. 2010;76(6):1483–7. doi:10.1016/j.urology.2010.06.018
8. 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
9. Manasherova D, Kozyrev G, Gazimiev M. "Buried Penis Surgical Correction: Midline Incision Rotation Flaps." Urology. 2020;138:174–178. doi:10.1016/j.urology.2020.01.021
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. 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
12. Salam GA, Amin JP. "The Basic Z-Plasty." Am Fam Physician. 2003;67(11):2329–32.