Rectus Abdominis Myofascial Flap Neoglans (Shaeer Technique)
The Shaeer / El-Sebaie rectus abdominis myofascial flap neoglans (2005) is a single-stage neoglans reconstruction that uses a pedicled infraumbilical rectus abdominis myofascial flap — based on the deep inferior epigastric vessels — tunneled subcutaneously to the penile tip and sculpted into a neoglans with a corona and terminal urethral meatus. It is the only described technique that uses muscle and fascia (rather than skin, mucosa, or graft) as the primary neoglans tissue, producing a neoglans with similar consistency, color, and shape to the native glans at 6-month follow-up.[1]
For the urethral-flap and scrotal-flap alternatives, see Inverted Urethral Flap (Belinky / Chavarriaga), Gulino Everted Urethral Flap, and Scrotal Flap (Mazza / Cheliz). For the comparative umbrella, see Glanuloplasty With Flaps. For the STSG standard, see Glansectomy With STSG. Decision framework: Penile Reconstruction.
Historical Context and Innovation
Before 2005, all described neoglans techniques used epithelial tissue — keratinized skin (STSG / FTSG, scrotal flap) or mucosa (urethral, oral). Shaeer recognized that the native glans is fundamentally a vascular, spongy, muscular structure — the expanded distal end of the corpus spongiosum — not a skin-covered surface. A myofascial flap could more closely replicate its consistency and turgor.[1]
The technique was developed in the context of circumcision injury (one of the most devastating iatrogenic male-circumcision complications; complication rate 0.1–35%). Shaeer subsequently developed two additional penile-reconstruction techniques addressing different defect levels:[1][2][3]
| Technique | Year | n | Indication |
|---|---|---|---|
| Rectus myofascial neoglans | 2005 | 1 | Glans loss (circumcision) |
| Shaeer's A-Y plasty | 2008 | 32 | Shaft amputation (circumcision) |
| Shaeer glans augmentation (dermal fat graft) | 2012 | 10 | Glans hypoplasia |
The technique was also designed for application to phalloplasty — where neoglans creation at the tip of a neophallus has historically relied on skin manipulation. The Hage 1993 review concluded that the Norfolk technique (coronal ridge and sulcus from skin flaps) had the best skin-based results, but no prior technique used muscle.[4]
Anatomical Basis — Deep Inferior Epigastric Pedicle
| Feature | Value |
|---|---|
| DIEA origin | External iliac artery, just above the inguinal ligament[5][6] |
| Course | Within rectus sheath, posterior to rectus abdominis |
| Venae comitantes | Two associated veins in 90%[6] |
| Large perforators (> 0.5 mm) | Mean 5.4 per hemiabdomen, concentrated paraumbilically |
| Dominant division | Lateral (80% of cases — 80 vs 28 medial perforators) |
| Collateral | "Choke" anastomoses with superior epigastric well above the umbilicus; deep circumflex iliac; lower intercostal[5][7] |
| Tendinous intersections | Transverse arcades with higher perforator density per cm² than the rest of the muscle[8] |
| Vascular territory | Entire rectus abdominis (symphysis → costal arch) + medial 10–15 cm of transversus abdominis |
Myofascial vs myocutaneous distinction
Excluding the skin island avoids bulkiness and the hair-bearing nature of abdominal skin. The exposed muscle surface undergoes secondary epithelialization and develops a pinkish-red mucosal-like appearance that resembles native glans color, unlike keratinized skin grafts.[1]
Indications
- Glans amputation at circumcision — index case
- Glans loss from strangulation by a hair coil (hair tourniquet syndrome)
- Self-mutilation with glans loss
- Phalloplasty neoglans — to create a glans-like tip on a neophallus and provide structural support for a penile prosthesis
- Any traumatic / iatrogenic glans loss with preserved penile shaft and corpora
Surgical Technique — Single-Stage
1. Flap design
- 12 × 4 cm segment of the infraumbilical rectus abdominis
- Based on the deep inferior epigastric vessels entering the muscle posteriorly near the arcuate line
- Myofascial — muscle + posterior rectus sheath; no skin island
2. Abdominal incision and flap harvest
- Paramedian incision over the rectus
- Incise anterior rectus sheath; dissect the infraumbilical muscle segment off the anterior sheath
- Preserve the posterior sheath and inferior epigastric pedicle
- Elevate superior → inferior, maintaining the pedicle
- Residual rectus function preserved; abdominal wall not significantly weakened[1][9]
3. Penile preparation
- Partial degloving through a circumferential incision 1 cm below the penile summit
4. Urethral elongation
- Use the distal penile skin (mobilized by degloving) to elongate the urethra, so the meatus will sit at the very tip of the neoglans
5. Subcutaneous tunneling
- Reflect and tunnel the harvested flap subcutaneously beneath the mons veneris and alongside the penis
- Blunt dissection to avoid pedicle injury
- Flap emerges distal to the penile summit
- Long, reliable DIEA pedicle eliminates the need for a staged pedicle phase (vs Mazza scrotal flap)
6. Neoglans sculpturing
- Circumferential wrapping of the rectangular myofascial flap around the distal tip + neourethra → cylindrical / conical structure
- Corona creation by tucking the proximal edge of the flap to its undersurface → raised ridge simulating the coronal sulcus, built from muscle bulk rather than skin folds
- Meatal positioning at the very tip via the elongated neourethra
7. Fixation and closure
- Secure neoglans with absorbable suture
- Re-drape penile skin and suture to the proximal edge of the neoglans at the created corona level
- Repair anterior rectus sheath to prevent hernia
- Close abdominal donor site in layers
Outcomes — Shaeer / El-Sebaie 2005 (n = 1)[1]
| Parameter | Result |
|---|---|
| Etiology | Glans amputation at circumcision |
| Flap dimensions | 12 × 4 cm |
| Pedicle | Inferior epigastric vessels |
| Flap type | Myofascial (muscle + fascia, no skin) |
| Stages | 1 |
| Follow-up | 6 months |
| Neoglans consistency | Similar to native glans |
| Neoglans color | Similar to native glans |
| Neoglans shape | Similar to native glans |
| Corona | Present — created by tucking |
| Urethral meatus | At the very tip of the neoglans |
| Flap necrosis | 0% |
| Complications | None reported |
| Cosmetic result | Satisfactory |
Authors' conclusion: "Construction of a neoglans penis is possible using the described sculpturing techniques, with satisfactory cosmetic results."
Key Innovations
1. Myofascial tissue as neoglans material — paradigm shift
The only neoglans technique using muscle + fascia rather than skin or mucosa.
| Technique | Primary tissue | Surface | Consistency |
|---|---|---|---|
| Shaeer (myofascial) | Rectus muscle + fascia | Epithelializes secondarily | Spongy, similar to native glans |
| STSG neoglans | Split-thickness skin | Keratinized epithelium | Thin, dry |
| Gulino / Belinky urethral flap | Urethral mucosa | Non-keratinized mucosa | Mucosal, moist |
| Mazza scrotal flap | Scrotal skin | Keratinized epithelium (hair-bearing) | Thin, elastic |
| Oral mucosa graft | Buccal / lingual mucosa | Non-keratinized mucosa | Mucosal, moist |
The native glans is not primarily a skin-covered structure — it is the spongy expansion of the corpus spongiosum. A myofascial flap more closely replicates this turgor than any epithelial tissue.[1]
2. Subcutaneous tunneling — avoids pedicle phase
Unlike the Mazza scrotal flap (4–6 wk pedicle tethering), the long reliable DIEA pedicle allows single-stage reconstruction without staged division.
3. Corona sculpturing by tucking
Creates the corona from muscle bulk rather than skin folds. Unlike the Hage-reviewed Norfolk / Munawar techniques (which create the coronal ridge from skin manipulation), this builds the corona structurally from within the flap.[4]
4. Urethral elongation with distal penile skin
Positions the meatus at the tip without requiring separate urethral reconstruction — distinct from IUF (urethra itself becomes neoglans) and from phalloplasty tube-within-a-tube urethroplasty.[18]
Other Rectus Abdominis Applications in Penile / Perineal Reconstruction
Context for the Shaeer technique:
| Study | Year | Application | Flap type | n | Key finding |
|---|---|---|---|---|---|
| Shaeer / El-Sebaie[1] | 2005 | Neoglans construction | Myofascial (no skin) | 1 | Similar consistency / color / shape to native glans |
| Santi[9] | 1988 | Total penile reconstruction | Myocutaneous (with skin) | — | One-stage; abdominal wall not significantly weakened |
| Bare[22] | 1994 | Groin reconstruction post-ILND | Muscle only (DIEA-based) | 3 | All wounds healed; useful for suppurative inguinal metastases |
| Kayes[23] | 2007 | Palliative resection of advanced penile SCC | VRAM | 4 | All grafts viable; excellent satisfaction and symptom relief |
| Ye / Wang[24] | 2012 | Total phallic reconstruction | Pedicled DIEP (perforator) | 2 | Aesthetically acceptable functional neopenis at 4 y |
| Yilmaz[25] | 2000 | Secondary epispadias repair | Myocutaneous | 1 | One-stage urethra + chordee + contour |
Shaeer is unique in using rectus abdominis specifically for neoglans creation rather than shaft reconstruction, wound coverage, or total phalloplasty — and in using a myofascial (rather than myocutaneous) variant.
Comparison With All Other Neoglans Techniques
| Parameter | Shaeer (myofascial) | STSG SR | IUF (Chavarriaga) | Gulino (eversion) | Mazza (scrotal) |
|---|---|---|---|---|---|
| n | 1 | 327 | 74 | 14 | 34 |
| Follow-up | 6 mo | 40.7 mo | 72 mo | 13 mo | 73.2 mo |
| Stages | 1 | 1 | 1 | 1 | 2 |
| Tissue | Muscle + fascia | Keratinized skin | Urethral mucosa | Urethral mucosa | Keratinized skin (hair-bearing) |
| Donor site | Abdomen (rectus) | Thigh | None | None | Scrotum |
| Consistency | Similar to native glans | Thin, dry | Mucosal, moist | Mucosal, moist | Thin, elastic |
| Color | Similar to native glans | Pale | Pink (mucosal) | Pink (mucosal) | Scrotal-skin color |
| Corona | Yes (tucking) | Variable | Yes | Yes | Yes |
| Terminal meatus | Yes | Yes | Yes | Yes | Yes |
| Hair growth | No | No | No | No | 17.6% |
| Flap necrosis | 0% | 6.1% | 0% | 0% | 5.8% |
| Meatal stenosis | n/r | 8.1% | 0% | 0% | 2.9% |
| Sensation | n/r | 83.7% | n/r | 100% | n/r |
| Erectile function | n/r | 91.1% preserved | IIEF-5 17.3 | 71% rigid | 20.5% potency |
| Abdominal-wall morbidity | Potential hernia risk | None | None | None | None |
Phalloplasty Neoglans — Where the Shaeer Technique Fits
Hage 1993 reviewed glans sculpturing in phalloplasty:[4]
| Technique | Description | Strengths | Weaknesses |
|---|---|---|---|
| Shaeer myofascial flap[1] | Rectus muscle sculpted into glans shape | Natural consistency, color; supports prosthesis | Separate abdominal donor; single case |
| Norfolk | Coronal ridge + sulcus from skin flaps | Best skin-based cosmetic results | Skin-based; no bulk |
| Munawar | Skin manipulation for coronal ridge | Simple | Obsolete — coronal-ridge flattening |
| Tattoo | Coronal sulcus simulated by tattoo | Non-surgical | No structural change; fades |
| STSG | Skin graft over neophallus tip | Widely available | Thin, dry, no bulk |
Gobbo 2025 reviewed phalloplasty after penectomy for penile cancer — radial-artery free flap and ALT are preferred for total phallic reconstruction (complication rates up to 64.3%, especially urethral strictures / fistulas). The Shaeer myofascial neoglans could in principle improve the cosmetic tip and provide bulk for prosthesis support.[29]
Advantages
- Unique tissue match — myofascial tissue replicates native-glans turgor better than any epithelial alternative
- Natural color after healing
- Single-stage
- No hair growth — unlike scrotal flaps
- Robust DIEA pedicle — 100% flap survival rates in large rectus-flap series (Xing-Quan n = 42)[20]
- Corona built from muscle bulk via tucking — convincing structural coronal ridge
- Terminal urethral meatus via distal-skin urethral elongation
- Applicable to phalloplasty — can support a penile prosthesis tip
- Abdominal-wall preservation — residual rectus function preserved (Santi 1988 principle)
Limitations
- Single case report (n = 1) — Level V evidence; the lowest of all neoglans techniques
- Short follow-up (6 mo) — long-term atrophy, fibrosis, and contracture unknown
- No functional outcome data — no sensation / erection / voiding / sexual-function assessment
- No validated QoL instruments
- Abdominal donor morbidity — hernia, seroma, abdominal-wall weakness, paramedian scar[26]
- Technically complex — abdominal dissection + subcutaneous tunneling + flap sculpting
- No oncologic application data — described for traumatic loss, not penile SCC; oncologic safety unknown
- Unknown long-term tissue behavior — denervated skeletal muscle typically undergoes progressive atrophy and fibrotic replacement
- No sensation data — intercostal-nerve innervation (T7–T12) divided at harvest; flap unlikely to develop erogenous sensation
- Not mentioned in any guideline
- No external validation — no other group has reported this technique[27][28]
Guideline Context
| Guideline | Statement |
|---|---|
| NCCN[27] | "Treatment is followed in certain instances with an STSG or FTSG to create a neoglans" — myofascial reconstruction not mentioned |
| EAU-ASCO 2023[28] | Recommends organ-sparing surgery with reconstructive techniques; in locally advanced resectable cases "flaps may be needed to cover the surgical defect" — does not specifically reference Shaeer technique |
Future Directions
- Larger case series with standardized outcome reporting
- Long-term follow-up for tissue atrophy, fibrosis, contracture, durability
- Functional outcome assessment — biothesiometry / somatosensory evoked potentials, IIEF-5, ICIQ-MLUTS, EQ-5D
- Oncologic application — evaluation after glansectomy / partial penectomy for SCC
- Histologic characterization of the healed myofascial neoglans (keratinization, atrophy, fibrosis)
- Nerve coaptation — intercostal-nerve stumps to dorsal nerve of the penis for sensory recovery
- Direct comparison with STSG, IUF, OMG in matched cohorts
- Phalloplasty integration with RAFFF or ALT total phallic reconstruction
- Minimally invasive harvest — Friedlander 1996 endoscopic harvesting demonstrated in cadaver / porcine models[26]
Key Takeaways
- The only neoglans technique that uses muscle and fascia (not epithelial tissue) — replicates native-glans consistency more closely than any alternative
- Single-stage via subcutaneous tunneling on the DIEA pedicle
- Corona built by tucking the proximal flap edge to its undersurface — structural ridge from muscle bulk
- Terminal urethral meatus via distal-skin urethral elongation
- Capable of supporting a penile prosthesis tip in phalloplasty contexts
- Level V evidence (n = 1, 6-mo follow-up) — the lowest among neoglans options; broader validation, long-term tissue behavior, oncologic application, and sensory outcomes all unknown
- Abdominal donor morbidity (hernia risk) is the principal drawback vs urethral or scrotal alternatives
Cross-references
- Glanuloplasty With Flaps — comparative umbrella
- Inverted Urethral Flap (IUF) Glanuloplasty
- Gulino Everted Urethral Flap
- Scrotal Flap Glanuloplasty (Mazza / Cheliz)
- Glansectomy With STSG
- Glans Resurfacing — includes OMG section
- Penile Reconstruction — decision framework
- Penile Replantation — traumatic-amputation context
- GAS Masculinizing Surgery — phalloplasty context (RAFFF / ALT neoglans)
- Foundations — Plastic Surgery Principles
References
1. Shaeer O, El-Sebaie A. "Construction of Neoglans Penis: A New Sculpturing Technique From Rectus Abdominis Myofascial Flap." J Sex Med. 2005;2(2):259–65. doi:10.1111/j.1743-6109.2005.20237.x
2. Shaeer O. "Restoration of the Penis Following Amputation at Circumcision: Shaeer's a-Y Plasty." J Sex Med. 2008;5(4):1013–1021. doi:10.1111/j.1743-6109.2007.00675.x
3. Shaeer O. "Shaeer's Glans Augmentation Technique: A Pilot Study." J Sex Med. 2012;9(12):3264–9. doi:10.1111/j.1743-6109.2012.02966.x
4. Hage JJ, de Graaf FH, Bouman FG, Bloem JJ. "Sculpturing the Glans in Phalloplasty." Plast Reconstr Surg. 1993;92(1):157–61.
5. Boyd JB, Taylor GI, Corlett R. "The Vascular Territories of the Superior Epigastric and the Deep Inferior Epigastric Systems." Plast Reconstr Surg. 1984;73(1):1–16. doi:10.1097/00006534-198401000-00001
6. El-Mrakby HH, Milner RH. "The Vascular Anatomy of the Lower Anterior Abdominal Wall: A Microdissection Study on the Deep Inferior Epigastric Vessels and the Perforator Branches." Plast Reconstr Surg. 2002;109(2):539–43. doi:10.1097/00006534-200202000-00020
7. Konerding MA, Gaumann A, Shumsky A, Schlenger K, Hockel M. "The Vascular Anatomy of the Inner Anterior Abdominal Wall." Plast Reconstr Surg. 1997;99(3):705–10. doi:10.1097/00006534-199703000-00016
8. Whetzel TP, Huang V. "The Vascular Anatomy of the Tendinous Intersections of the Rectus Abdominis Muscle." Plast Reconstr Surg. 1996;98(1):83–9. doi:10.1097/00006534-199607000-00013
9. Santi P, Berrino P, Canavese G, et al. "Immediate Reconstruction of the Penis Using an Inferiorly Based Rectus Abdominis Myocutaneous Flap." Plast Reconstr Surg. 1988;81(6):961–4. doi:10.1097/00006534-198806000-00026
10. Zeng A, Xu J, Yan X, You L, Yang H. "Pedicled Deep Inferior Epigastric Perforator Flap: An Alternative Method to Repair Groin and Scrotal Defects." Ann Plast Surg. 2006;57(3):285–8. doi:10.1097/01.sap.0000221466.97653.15
11. Gulino G, Sasso F, Falabella R, Bassi PF. "Distal Urethral Reconstruction of the Glans for Penile Carcinoma." J Urol. 2007;178(3 Pt 1):941–4. doi:10.1016/j.juro.2007.05.059
13. Belinky JJ, Cheliz GM, Graziano CA, Rey HM. "Glanuloplasty With Urethral Flap After Partial Penectomy." J Urol. 2011;185(1):204–6. doi:10.1016/j.juro.2010.09.010
14. Chavarriaga J, Becerra L, Camacho D, et al. "Inverted Urethral Flap Reconstruction After Partial Penectomy: Long-Term Oncological and Functional Outcomes." Urol Oncol. 2022;40(4):169.e13–169.e20. doi:10.1016/j.urolonc.2022.02.006
16. Mazza ON, Cheliz GM. "Glanuloplasty With Scrotal Flap for Partial Penectomy." J Urol. 2001;166(3):887–9.
17. Pang KH, Alnajjar HM, Muneer A. "Functional Outcomes of Glansectomy to Treat Localised Penile Cancer: A Systematic Review." Int J Impot Res. 2026;38(3):206–213. doi:10.1038/s41443-025-01062-1
18. Yao A, Ingargiola MJ, Lopez CD, et al. "Total Penile Reconstruction: A Systematic Review." J Plast Reconstr Aesthet Surg. 2018;71(6):788–806. doi:10.1016/j.bjps.2018.02.002
20. Xing-Quan Z, Shao-Dong W, Qing-Yu F, Bao-An M. "Versatility of Rectus Abdominis Free Flap for Reconstruction of Soft-Tissue Defects in Extremities." Microsurgery. 2004;24(2):128–33. doi:10.1002/micr.20007
22. Bare RL, Assimos DG, McCullough DL, et al. "Inguinal Lymphadenectomy and Primary Groin Reconstruction Using Rectus Abdominis Muscle Flaps in Patients With Penile Cancer." Urology. 1994;44(4):557–61. doi:10.1016/s0090-4295(94)80059-6
23. Kayes OJ, Durrant CA, Ralph D, et al. "Vertical Rectus Abdominis Flap Reconstruction in Patients With Advanced Penile Squamous Cell Carcinoma." BJU Int. 2007;99(1):37–40. doi:10.1111/j.1464-410X.2007.06582.x
24. Ye X, Wang C, Yu Y, Zheng S. "Pedicled Deep Inferior Epigastric Perforator Flap for Total Phallic Reconstruction." Ann Plast Surg. 2012;69(1):64–6. doi:10.1097/SAP.0b013e3182223d29
25. Yilmaz M, Vayvada H, Menderes A, Barutcu A. "Secondary Epispadias Repair With Rectus Abdominis Musculocutaneous Flap." Ann Plast Surg. 2000;45(5):550–3. doi:10.1097/00000637-200045050-00016
26. Friedlander LD, Sundin J. "Minimally Invasive Harvesting of Rectus Abdominis Myofascial Flap in the Cadaver and Porcine Models." Plast Reconstr Surg. 1996;97(1):207–11. doi:10.1097/00006534-199601000-00034
27. National Comprehensive Cancer Network. Penile Cancer. Updated 2025-11-12.
28. Brouwer OR, Albersen M, Parnham A, et al. "European Association of Urology-American Society of Clinical Oncology Collaborative Guideline on Penile Cancer: 2023 Update." Eur Urol. 2023;83(6):548–560. doi:10.1016/j.eururo.2023.02.027
29. Gobbo A, Christopher AN, di Giovanni A, et al. "Sexual and Urological Reconstruction Following Penectomy for Penile Cancer: Phalloplasty." Int J Impot Res. 2025. doi:10.1038/s41443-025-01161-z