Penile Primary Closure ± Z-Plasty
Primary closure is an option when healthy, mobile skin can cover the defect without restricting penile expansion. A local scar release or Z-plasty can redistribute available skin; it cannot replace a large missing skin envelope. Assess the underlying problem—skin loss, a superficial contracture, concealment, or deeper penile curvature—before selecting the operation.[1][2]
For the wider reconstructive plan, see Penile Reconstruction, Penile Skin Grafting, and Buried Penis Repair.
Selecting closure
| Finding | Implication |
|---|---|
| Small defect with viable, sufficiently mobile surrounding skin | Direct approximation may be suitable; assess tension with the shaft extended. |
| Superficial linear scar or penoscrotal web with adjacent tissue available | Consider local rearrangement, including Z-plasty. Determine whether the deformity is confined to skin. |
| Healthy dorsal skin with a ventral shortage | Selected rotational or advancement flaps may redistribute skin. |
| Extensive or circumferential nonviable skin | Graft or flap coverage may be needed; forcing direct closure risks tethering and breakdown. |
| Active infection, uncertain viability, or substantial inflammatory edema | Treat the underlying process and individualize the timing of definitive coverage. |
These are tissue-based decisions, not a mandatory sequence of operations. Buried-penis series describe different combinations of release, fixation, local flaps and grafting; their results do not establish one closure for all defects.[1][3]
Preserve available skin during planning. In an already circumcised patient with a trapped or buried penis, another circumcision can worsen shaft-skin deficiency. A phimotic appearance alone does not establish that further circumferential skin removal is appropriate.[1]
Operative considerations
- Expose only as required. A focal skin defect does not automatically require complete penile degloving. When release or degloving is indicated, preserve viable coverage and protect the urethra and neurovascular structures.
- Assess skin requirements with the shaft extended. Check mobility, perfusion, asymmetry and tension before final closure. Stretch helps reveal a shortage that is obscured when the penis is retracted; it does not prove that every closure performed in a flaccid state will fail.
- Keep fixation separate from skin closure. Selected concealed-penis repairs address deficient skin attachments, but anchoring is not obligatory for every primary closure. The described fixation planes vary: Frenkl's technique fixes subcutaneous skin to Buck's fascia at 3 and 9 o'clock; other approaches use lateral tunical fixation. These are different operations, not interchangeable anatomical instructions.[1][4]
- Change the coverage plan when necessary. A wound that can be sutured closed but blanches, distorts the shaft, or cannot accommodate extension needs reassessment. The reconstruction should address the actual shortage rather than rely on tighter sutures.[1][2]
Routine pharmacologic erection or postoperative tadalafil is not established for simple primary closure. Iblher's report combined intraoperative prostaglandin, postoperative tadalafil and negative-pressure dressings in only four skin-graft patients. It cannot isolate a drug effect or establish a routine drug regimen for this procedure.[5]
Byars-type skin redistribution
Dorsal skin can be divided and rotated ventrally in selected reconstructions. Availability, vascularity, previous operations and the underlying diagnosis determine suitability. A published midline-incision rotation-flap series involved 18 young boys and combined several operative steps; it does not establish the best technique for adult acquired defects.[6]
Z-plasty
A basic Z-plasty transposes two triangular skin flaps to lengthen and redirect a scar. A symmetric 60-degree design has a theoretical 75% gain along the original central limb and approximately 90-degree reorientation; actual tissue gain is smaller and depends on local laxity and tension. This is geometric scar lengthening, not a predicted increase in penile length.[2]
Z-plasty may help a selected superficial contracture or web. It does not correct intrinsic corporal curvature or supply enough tissue for every ventral deficit. Preserve flap perfusion and avoid closure under tension; necrosis, hematoma, wound separation and recurrent tethering remain possible.[2][7]
A 2025 retrospective pediatric series reported 98% primary healing among 100 Z-plasty procedures performed for mixed indications, including primary and revision hypospadias. Follow-up was available for 97%, over one to two years. This supports feasibility in that setting; it is not a controlled comparison or an adult durability estimate.[7]
Follow-up
Individualize dressing, catheter need and activity restrictions to the actual repair and associated urethral work. Check perfusion, wound healing, voiding and emerging tethering. Sexual activity should resume after adequate healing and the operating team's assessment, rather than according to an unvalidated universal schedule.
Painful curvature or recurrent concealment requires assessment of its cause. Neither finding automatically calls for immediate reoperation: distinguish superficial tethering, recurrent inflammation, deeper deformity and wound complications. Continue disease-specific care when lichen sclerosus or another inflammatory condition is present.[1]
See also
References
1. Ho TS, Gelman J. Evaluation and management of adult acquired buried penis. Transl Androl Urol. 2018;7(4):618–627. doi:10.21037/tau.2018.05.06
2. Salam GA, Amin JP. The basic Z-plasty. Am Fam Physician. 2003;67(11):2329–2332. Full article
3. 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
4. Frenkl TL, Agarwal S, Caldamone AA. Results of a simplified technique for buried penis repair. J Urol. 2004;171(2 Pt 1):826–828. doi:10.1097/01.ju.0000107824.72182.95
5. 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):1377–1383. doi:10.1016/j.bjps.2012.04.020
6. 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
7. 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