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Penile Skin Grafting

Penile skin grafting is the cross-cutting reconstructive technique used to resurface the penile shaft when skin loss is too extensive for primary closure. It is the workhorse of adult-acquired buried penis (AABP) repair, Fournier's-gangrene reconstruction, penile lymphedema debulking, glans resurfacing after partial penectomy / glansectomy, hidradenitis-suppurativa resection, foreign-body / filler-granuloma excision, and circumcision / traumatic skin loss. Both STSG and FTSG are used, and graft take exceeds 90% in most modern series.[1][2]

For indication-specific workflows see Buried Penis Repair, Penile Reconstruction, Scrotal Reconstruction, and Glans Reconstruction. This page focuses on the graft technique itself — donor-site selection, harvest, application, bolster fixation, and outcomes.

Indications​

IndicationNotes
Adult-acquired buried penis (AABP)Most frequent urologic indication; LS-driven in ~55% of grafted cases[2]
Fournier's gangreneAfter radical debridement; FTSG specifically recommended on the penis to avoid contracture[3]
Penile / scrotal lymphedemaAfter radical excision of lymphedematous tissue[4]
Penile cancer (organ-sparing)Glans resurfacing or distal-shaft WLE; local recurrence 0–10%[5]
Hidradenitis suppurativaAfter wide local excision[6]
Foreign-body / filler granulomaAfter complete granuloma excision; dermal substitute + NPWT + STSG[7]
Circumcision injury / traumaIncluding post-circumcision buried penis[8]

STSG vs FTSG​

FeatureSTSGFTSG
Thickness12–18 / 1000 inch (0.30–0.46 mm)Full dermis
Take rate80–100% (mean ~92%)~100% in selected series
Contracture riskHigher (~13–19%)Lower
Hair bearingNoDonor-dependent
Donor morbidityLower (re-epithelialization)Higher (primary closure required)
Preferred whenLarge defect, contaminated / compromised bed, AABP defaultSmaller defect, well-vascularized bed, potency priority, Fournier's

A comparative analysis (Gül 2026, n = 22) found no significant difference between STSG and FTSG in complications (p = 0.397), recurrence (p = 0.375), or functional outcomes (IIEF and IPSS both improved, p < 0.001).[9]

Donor Sites​

  • Anterolateral / medial thigh — traditional dermatome STSG donor[1][10]
  • Excised escutcheon — "same-field" donor that eliminates a separate wound; specimen is laid skin-up on a back table and dermatomed (STSG) or sharp-dissected + defatted (FTSG). The Jeng 2026 series of 32 patients using escutcheon-derived FTSG for AABP + LS achieved 87% complete graft success[11][12][13]
  • Pannus (Figler trapezoid technique) — pannus mobilized with superior attachments intact; STSG harvested at 18 / 1000 inch in 2-inch sections before the pannus is excised[14]
  • Posterior auricular / suprapubic / abdominal — for FTSG in glans resurfacing
  • Buccal mucosa — not for shaft coverage; reserved for combined urethral or meatal reconstruction

Surgical Technique​

1. Penile degloving and skin excision​

  • Circumferential incision at the corona; deglove to Buck's fascia
  • Aggressive circumferential excision of all diseased shaft skin (LS, lymphedematous, scarred, granulomatous) to bleeding healthy edges
  • Limited debridement → high reburying and disease progression; Santucci staging captures this (Stage 2 = penile-skin excision + STSG; Stage 3 adds scrotal excision; Stage 4 adds escutcheonectomy; Stage 5 adds panniculectomy)[15]
  • Send all excised tissue to pathology (penile cancer found in ~5% of AABP specimens)

2. Wound bed preparation​

  • Recipient bed must be well-vascularized Buck's fascia or dartos
  • Contaminated wounds (Fournier's, HS): 1–2 weeks of wound care or NPWT for granulation before grafting[6]
  • Two-stage dermal-substitute protocol: Integra® or Matriderm® + NPWT × 3 weeks → STSG; complete take and 6-month elasticity in penile lymphedema and complex defects[16][7]

3. Graft harvest​

  • STSG depth 12–18 / 1000 inch (0.30–0.46 mm) with electric / air-powered dermatome in 2-inch sections
  • For escutcheon / pannus donor, specimen on flat back table, skin-side up, stretched taut; keep moist with saline gauze until applied
  • FTSG: sharp-dissect skin off subcutaneous fat; meticulous defatting of the deep dermal surface — residual fat is the dominant cause of FTSG failure

4. Mesh vs sheet​

  • Unmeshed sheet preferred for penile cosmesis[6][17]
  • Meshed unexpanded (1:1) acceptable; slits oriented transversely; seam placed ventrally in a zigzag fashion to prevent circumferential contracture (Black series — 100% take, satisfactory cosmesis)[17]
  • Expanded mesh (≥ 1:1.5) avoided on penis — poor cosmesis

5. Graft application — on stretch​

  • Penis must be on stretch (simulating erection) during graft fixation; otherwise tethering and acquired curvature on tumescence[6]
  • Iblher pharmacologic-stretch technique: intraoperative prostaglandin E1 to induce erection during graft tailoring → non-erect / erect ratio 50–72%; preserved IIEF-5[18]
  • Graft wrapped circumferentially with ventral zigzag seam
  • Secure with absorbable suture or staple

6. Bolster fixation​

TechniqueDetailEvidence
Traditional bolsterPetrolatum gauze → mineral-oil cotton gauze → dry gauze; sutured / stapled to penis; left undisturbed 5–7 daysFigler, Strother, Tang series[14][12]
Rook eggcrate-foam bolsterSpikes toward wound over silver dressing; staple-secured cylindrically; removed median 4 days21 pts — median 100% take through POD 14, 95% at days 15–30[19]
NPWT bolster−80 to −125 mmHg circumferentiallyLee 2025 SR (16 RCTs): + 8.3% take, OR 0.44 for loss, OR 0.31 for reoperation; Cao 2022 RCT: 97.6% vs 81.7% take in irregular high-mobility areas[20][21]
TODGA (glans resurfacing)Proflavine-soaked gauze + tie-over sutures × 10 days1 / 29 needed re-graft[22]
Fibrin sealantThin layer between graft and bed; reduces hematomaAdjunct to any bolster

Postoperative Management​

  • Foley catheter for the duration of the bolster to keep urine off the graft
  • Bolster removal at 5–7 days (traditional) or 4–5 days (Rook / NPWT)[14][19]
  • Ambulate early; avoid sexual activity 6–8 weeks to allow maturation
  • Postoperative tadalafil 5 mg daily to pharmacologically expand the graft and prevent contracture (Iblher protocol; Post / Pre ratios 81–87%)[18]
  • Pelvic-floor rehabilitation can improve deviation, sensation, and sexual-function satisfaction in patients with graft-related contracture (Tremblay 2026 protocol)[23]

Outcomes​

  • Graft take — STSG 80–100% (mean ~92%); FTSG ~100% in selected series; ≥ 95% in outpatient pannus-donor STSG[10][11][14]
  • Length / function — Plamadeala 2026 multicenter (n = 204): mean stretched length + 3.0 cm; significant urinary + sexual function improvement; recurrence-free survival 91.5% at 12 mo, 83.7% at 24 mo[24]
  • Voiding — 63.6% of voiding-dysfunction patients improve[9]
  • Sexual function — IIEF 22.8 vs 14.1 preoperatively (p = 0.03)[8]
  • Higher complexity → lower recurrence (p = 0.018) — supports aggressive initial repair[24]

Complications​

ComplicationRateNotes
Wound infection26–41%Antibiotics, local care[14][13]
Wound dehiscence16–31%Suprapubic closure; expected in high-BMI
Graft contractureLong-term concern (esp. STSG)Curvature / tethering on erection; tadalafil + PFPT
Partial graft loss6–13%Diabetes / CVD predict; usually conservative care
Complete graft loss~3% (FTSG series)All in diabetic patients (Jeng 2026)[13]
Decreased sensation~15% in long-term post-circumcision-AABP follow-up[8]
Reburying12.7% overall; hematoma is the strongest predictor[24]

Special Considerations​

Lichen sclerosus​

AUA Urethral Stricture Disease Guideline (2023): genital skin grafts / flaps should be avoided for urethral lining in LS due to high failure — use oral mucosa (buccal / lingual) for urethroplasty.[25] Genital skin grafts remain appropriate for shaft skin coverage in LS (graft replaces external skin, not urethral lining).[9][13]

Staged dermal-substitute protocol​

For complex defects (Fournier's, extensive lymphedema, foreign-body granuloma), Integra® / Matriderm® + NPWT × 3 wk → STSG provides excellent take and elasticity without free tissue transfer.[16][7]

When to choose a flap over a graft​

  • Exposed corpora cavernosa / testes / urethra → pedicled scrotal flap (bipedicled, butterfly, EPAP hemi-scrotal) or thigh-based flap
  • Massive defect or radiation field → pedicled ALT / VRAM or free tissue transfer
  • Bothersome STSG contracture → revision with bipedicled scrotal flap or dermal-substitute regrafting[26][5]

Glans-specific grafting​

Glans resurfacing after PeIN or partial glansectomy uses STSG or FTSG over cavernosal bed; TODGA tie-over bolster is well-suited to the spherical glans surface.[22][5]

Key Technical Pearls​

  • All diseased skin must be excised before grafting — limited debridement → reburying / disease progression
  • Penis on stretch during graft application — prevents acquired curvature on tumescence
  • Ventral zigzag seam — avoids circumferential contracture rings
  • Same-field donor (escutcheon / pannus) — eliminates thigh donor-site morbidity in AABP
  • NPWT bolster outperforms tie-over on the high-mobility irregular penile surface
  • Diabetes is the dominant FTSG-loss predictor — optimize glycemic control before grafting
  • Postoperative tadalafil + PFPT are adjuncts for contracture prevention / management

Cross-references​

References​

1. Alwaal A, McAninch JW, Harris CR, Breyer BN. "Utilities of Split-Thickness Skin Grafting for Male Genital Reconstruction." Urology. 2015;86(4):835–9. doi:10.1016/j.urology.2015.07.005

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

3. Biju NE, Sadiq M, Raj S, et al. "Fournier's Gangrene Reconstruction: A 10-Year Retrospective Analysis." J Plast Reconstr Aesthet Surg. 2023;80:13–15. doi:10.1016/j.bjps.2023.02.030

4. Morey AF, Meng MV, McAninch JW. "Skin Graft Reconstruction of Chronic Genital Lymphedema." Urology. 1997;50(3):423–6. doi:10.1016/S0090-4295(97)00259-8

5. Kristinsson S, Johnson M, Ralph D. "Review of Penile Reconstructive Techniques." Int J Impot Res. 2021;33(3):243–250. doi:10.1038/s41443-020-0246-4

6. 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

7. Kang D, Hong SE, Kim YH. "Single-Stage Penile Resurfacing for Foreign Body Granuloma: A Simplified Negative Pressure Wound Therapy-Assisted Protocol With Dermal Substitute." Urology. 2026. doi:10.1016/j.urology.2026.04.013

8. Kara Ö, Teke K, Çiftçi S, et al. "Buried Penis in Adults as a Complication of Circumcision: Surgical Management and Long-Term Outcomes." Andrologia. 2021;53(2):e13921. doi:10.1111/and.13921

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Liguori G, Papa G, Boltri M, et al. "Reconstruction of Penile Skin Loss Using a Combined Therapy of NPWT, Dermal Regeneration Template, and STSG." Int J Impot Res. 2020;33(8):854–859. doi:10.1038/s41443-020-00343-1

17. 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

18. 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

19. 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

20. Lee SC, Bayan L, Sato A, et al. "Benefits of Negative Pressure Wound Therapy in Skin Grafts: A Systematic Review and Meta-Analysis of Randomised Controlled Trials." J Plast Reconstr Aesthet Surg. 2025;102:204–217. doi:10.1016/j.bjps.2025.01.036

21. Cao X, Hu Z, Zhang Y, et al. "Negative-Pressure Wound Therapy Improves Take Rate of Skin Graft in Irregular, High-Mobility Areas: A Randomized Controlled Trial." Plast Reconstr Surg. 2022;150(6):1341–1349. doi:10.1097/PRS.0000000000009704

22. Malone PR, Thomas JS, Blick C. "A Tie-Over Dressing for Graft Application in Distal Penectomy and Glans Resurfacing: The TODGA Technique." BJU Int. 2011;107(5):836–840. doi:10.1111/j.1464-410X.2010.09576.x

23. Tremblay C, Edger-Lacoursière Z, Schneider G, et al. "Rehabilitation Evaluation and Treatment for Skin Graft Complications of the Genitalia." J Burn Care Res. 2026;47(3):868–878. doi:10.1093/jbcr/irag016

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. 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

26. Yao H, Zheng D, Xie M, et al. "A Modified Bilateral Scrotal Flap for Penile Skin Defect Repair." J Vis Exp. 2022;(189). doi:10.3791/64017