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Staged Bipedicled Scrotal Flap (Pribaz / McLaughlin Technique)

The staged bipedicled scrotal flap is a two-stage penile resurfacing technique in which the denuded shaft is first buried into the anterior scrotum to allow neovascularization, then unburied 3–6 weeks later with the adherent scrotal skin divided and inset as a new penile envelope. In the original Pribaz / McLaughlin series of 8 patients, all achieved satisfactory outcomes with only 2 minor complications and no flap loss.[1] It is the preferred scrotal-flap approach when wound conditions preclude safe single-stage reconstruction.

For single-stage variants, see Bipedicled Anterior Scrotal Flap (Fakin), Modified Bipedicle Scrotal Tunnel Flap (Murányi), and Modified Bilateral Butterfly Scrotal Flap (Yao). For graft alternatives, see Penile Skin Grafting. For the full decision framework, see Penile Reconstruction.

Rationale​

The staged approach exploits the well-established reconstructive principle that buried flaps develop reliable neovascularization from the recipient bed — sufficient new blood supply forms within 4–11 days in animal models, though clinical practice allows 3–6 weeks for robust vascularization.[2]

Reasons to choose staged over single-stage scrotal flap reconstruction:[1][3][4]

  • Contaminated or actively infected wounds — burial protects the wound and allows it to heal before definitive reconstruction
  • Uncertain wound-bed viability — residual foreign material, prior radiation, prior failed reconstruction
  • Significantly lower complication rate — Lumbiganon head-to-head: 83.3% complication-free (two-stage) vs 43.5% (single-stage), p significant[3]
  • Surgeon preference for safety — built-in delay guarantees neovascularization before the original pedicle is divided

Indications​

  • Circumferential shaft defects where single-stage is too risky
  • Penile foreign-body granuloma (paraffinoma / siliconoma) with contaminated bed or residual material on corpora
  • Fournier's gangrene — after radical debridement before the wound is clean enough for single-stage coverage
  • Penile cancer — after WLE with uncertain margins
  • Circumcision complications — complete skin loss with active infection or necrosis
  • Iatrogenic trapped penis — Zucchi variant[5]
  • Trauma — bite / avulsion injuries with contaminated wounds

Stage 1 — Penile Burial ("Scrotalization")​

1. Circumferential incisions and excision​

  • Subcoronal circumferential incision + second at the penoscrotal junction (or proximal margin of diseased tissue)
  • Excise all involved skin / scar / granuloma to Buck's fascia; fully denude the shaft
  • If contaminated: thorough irrigation and debridement

2. Scrotal pocket / tunnel​

  • Horizontal or longitudinal anterior-scrotal incision
  • Develop a subcutaneous pocket between scrotal skin / dartos and external spermatic fascia / tunica vaginalis
  • Pocket sized to accommodate the entire shaft without compression
  • Zucchi variant — intrascrotal tunnel through the full thickness of the scrotum with glans emerging from the opposite side[5]

3. Penile transposition​

  • Transpose the denuded shaft into the pocket / tunnel
  • Bring the glans externally — critical for urethral access and meatal patency

4. Fixation sutures​

  • 3–4 nonresorbable 0 / 2-0 quilting sutures crossing through the entire scrotum, ventral to the penis (Zucchi)[5]
  • Eliminate dead space; maximize scrotal-skin / shaft contact for neovascularization

5. Closure and dressing​

  • Scrotal skin closed over the buried shaft with interrupted absorbable suture
  • Foley catheter; light compressive dressing
  • Counsel patient: penis buried 3–6 weeks (Pribaz / McLaughlin) or 6–12 weeks (Zucchi)

Stage 1 mean OR time ~ 75 ± 15 min (Zucchi)[5]

Interval Period (3–12 weeks)​

  • Neovascularization from corpora cavernosa / Buck's fascia into the overlying scrotal skin
  • Scrotal skin becomes adherent to the shaft via fibrovascular ingrowth
  • Voiding through the exposed glans
  • No intercourse possible during this period
  • Monitor for infection, hematoma, skin necrosis
  • Optimal Stage-2 timing by clinical assessment of skin adherence and wound healing
  • Perfusion fluorometry — at least 25% normal skin fluorescence during pedicle occlusion predicts safe pedicle division and has supported flap division as early as 11 days in animal data[2]

Stage 2 — Penile Unburial ("Descrotalization")​

1. Incision planning​

  • Palpate the buried shaft contour
  • Mark circumferential incisions around the shaft at the penoscrotal junction (proximal) and the coronal sulcus (distal)
  • Preserve enough cuff of adherent scrotal skin on the shaft, and enough remaining scrotal skin for donor closure

2. Bilateral circumferential scrotal-skin incision​

  • Divide the scrotal skin around the penis into:
    • Penile portion — adherent skin that becomes the new penile envelope
    • Scrotal portion — remaining skin for scrotal reconstitution

3. Penile shaft liberation​

  • Elevate the shaft (now covered by adherent scrotal skin) out of the pocket
  • The neovascularized skin remains attached to the shaft via its new blood supply from corpora / Buck's
  • The original scrotal pedicle is divided — the flap survives entirely on neovascularization

4. Flap inset​

  • Distal circumferential inset to the subcoronal margin / glans
  • Proximal inset to the penile base / pubic skin
  • Trim excess scrotal skin to a smooth, non-redundant envelope
  • Dorsal and ventral closure with interrupted absorbable suture

5. Scrotal donor-site closure​

  • Advance remaining scrotal skin medially; close primarily over the testes

6. Dressing and postoperative care​

  • Light compressive dressing
  • Short-term Foley if needed
  • Intercourse typically resumed 4–8 weeks after Stage 2[5]

Stage 2 mean OR time ~ 45 ± 10 min (Zucchi)[5]

Outcomes​

Pribaz / McLaughlin (n = 8)[1]​

  • Etiologies: infection, scar, urologic procedure complications
  • Flap survival 100%; satisfactory outcomes 100%
  • Minor complications 2 / 8 (25%); major complications 0
  • Level of evidence — therapeutic V

Zucchi (n = 10, iatrogenic trapped penis)[5]​

  • Stage 1 OR 75 ± 15 min; Stage 2 OR 45 ± 10 min
  • Major complications 0; minor 1 / 10 (superficial scrotal hematoma)
  • Median follow-up 20 mo (range 6–72)
  • Median VAS 97 / 100 (range 85–100) — highest patient satisfaction among scrotal-flap techniques
  • 100% recovery of normal spontaneous erection
  • 100% regular intercourse at 4–8 weeks after Stage 2

Napolitano SR (152 paraffinoma cases, 1956–2022)[4]​

Two-stage scrotal-flap reconstruction yields "excellent cosmetic and functional outcomes, with a low rate of complications."

Head-to-Head: Two-Stage vs Single-Stage (Lumbiganon 2023, n = 35)​

OutcomeSingle-stage (n = 23)Two-stage (n = 12)Significance
Wound infection8.7%0%NS
Wound dehiscence21.7%8.3%NS
Reoperation rate26.1%8.3%NS
Postoperative fever56.5%8.3%RR 6.78 (1.01–43.83)
Complication-free rate43.5%83.3%RR 0.53 (0.31–0.89)
Total hospital stay7.4 ± 3.2 d10.9 ± 1.6 dMD −3.42 d

Two-stage has significantly fewer overall complications and less postoperative fever, at the cost of a longer total hospital stay.[3]

Comparison With Other Scrotal-Flap Techniques​

FeaturePribaz / McLaughlinFakinMurányi tunnelYao butterflyZucchi
StagingTwoSingleSingleSingleTwo
Interval3–6 wkn/an/an/a6–12 wk
Flap blood supply at divisionNeovascularization onlyBilateral anterior scrotalBilateral external pudendalBilateral anterior scrotalNeovascularization only
Flap survival100% (n = 8)100% (n = 43)90% (n = 49)100% (n = 7)100% (n = 10)
Complication rate25% (minor only)~ 40% combined26.5%28.6% partial necrosis10% (minor only)
Operative complexityLower per stageModerateLowerModerateLower per stage
Contaminated-wound suitabilityExcellentPoorPoorPoorExcellent

Pribaz / McLaughlin vs Zucchi (related two-stage techniques)​

FeaturePribaz / McLaughlinZucchi
Primary indicationAcquired defects (infection, scar, urologic)Iatrogenic trapped penis (post-circumcision, post-cancer)
Interval3–6 wk6–12 wk
Fixation suturesNot specifically described3–4 nonresorbable quilting sutures through entire scrotum
Pocket vs tunnelPocket (anterior scrotum)Tunnel through full scrotal thickness
Glans exposureProtrudesProtrudes opposite side
Series size810
Follow-upNot specifiedMedian 20 mo
Satisfaction100% satisfactoryMedian VAS 97 / 100

The Zucchi variant uses a longer interval and explicit nonresorbable quilting sutures to promote more robust neovascularization.[5]

Advantages​

  1. Significantly lower complication rate vs single-stage scrotal flaps
  2. Suitable for contaminated wounds — the defining advantage; no other scrotal-flap technique tolerates active infection or unstable beds
  3. Neovascularization independence — by Stage 2 the flap has its own blood supply, eliminating pedicle-kinking, compression, and tethering complications
  4. Technically simpler per stage — Stage 1 ~ 75 min, Stage 2 ~ 45 min
  5. No pedicle-tethering pain on erection (unlike Murányi 10%)[7]
  6. Highest reported satisfaction in any scrotal-flap series (median VAS 97 / 100, Zucchi)[5]
  7. 100% erectile-function preservation in both Pribaz and Zucchi series
  8. No partial flap necrosis in either staged series (vs 9–28.6% in single-stage series)

Limitations and Disadvantages​

  1. Two operations — cumulative anesthesia / surgical risk
  2. Longer total hospital stay (10.9 ± 1.6 d vs 7.4 ± 3.2 d single-stage)[3]
  3. Temporary buried penis 3–12 weeks — psychological burden, voiding issues, no intercourse
  4. Delayed return to sexual function — 7–20 weeks from initial surgery to intercourse
  5. Small series evidence (n = 8 + n = 10) vs single-stage Fakin (n = 43) and Murányi (n = 49)
  6. Class-effect scrotal-flap morbidity — testicular ascension (~ 22.7%), late skin retraction (~ 27.3%) reported in larger bilateral-scrotal-flap series[9]
  7. Hair-bearing variability — anterior scrotal skin generally non-hair-bearing but varies
  8. Nocturnal erections during burial may theoretically disrupt neovascularization — not reported as a clinical problem

Marín-Martínez Paraffinoma Algorithm​

Two-center experience (Spain / Israel, n = 8):[11]

  • Limited skin involvement + viable shaft skin → single-stage excision + primary closure / local flap
  • Extensive skin involvement (liquid paraffin) → two-stage surgery or skin graft
  • All liquid-paraffin patients had extensive involvement requiring two-stage or grafting
  • 100% erectile-function preservation
  • Authors emphasize a combined urology / plastic-surgery team for optimal outcomes

Emerging Adjuncts​

ICG-directed scrotal flap design (Klein 2026)​

Multicenter study (n = 15 AABP) — ICG lymphography mapped preserved posterior-scrotum-to-perineum lymphatic drainage and guided flap boundaries to exclude tissue with lymphatic congestion. Could be applied to staged designs to reduce postoperative lymphedema.[13]

Perfusion fluorometry for Stage-2 timing​

In animal models, ≥ 25% normal skin fluorescence during pedicle occlusion predicts safe pedicle division — supports earlier-than-expected division (as early as 11 d for cross-leg flaps). Direct application to staged scrotal flaps could shorten the interval while maintaining safety.[2]

Patient Selection — When Staged Wins​

Choose Pribaz / McLaughlin stagedConsider single-stage instead
Contaminated / actively infected woundClean well-vascularized bed → Fakin / Murányi / Yao
Uncertain wound-bed viability (RT, residual material, prior failed reconstruction)Patient strongly prefers a single operation
High-comorbidity patient (diabetes, smoking, immunosuppression) — flap survival concernInsufficient scrotal skin → STSG / FTSG or regional flap
Iatrogenic trapped penis (Zucchi variant)
Patient prioritizes lowest complication rate over convenience

Key Takeaways​

  • The two-stage burial-then-unburial sequence delivers the lowest complication rate of any scrotal-flap technique (83.3% complication-free vs 43.5% single-stage)
  • Neovascularization (3–6 wk Pribaz / 6–12 wk Zucchi) makes Stage-2 division independent of the original pedicle
  • The only scrotal-flap pathway suitable for contaminated / actively infected wounds
  • Zucchi variant adds explicit nonresorbable quilting sutures and a longer interval to maximize neovascularization
  • Tradeoff: two operations, 7–20-week delay before intercourse

Cross-references​

References​

1. McLaughlin MM, Abbassi B, Pribaz JJ. "Bipedicled Scrotal Flap for Penile Resurfacing." Plast Reconstr Surg. 2024;153(4):935–942. doi:10.1097/PRS.0000000000010811

2. Gatti JE, LaRossa D, Brousseau DA, Silverman DG. "Assessment of Neovascularization and Timing of Flap Division." Plast Reconstr Surg. 1984;73(3):396–402. doi:10.1097/00006534-198403000-00010

3. Lumbiganon S, Pachirat K, Sirithanaphol W, et al. "Surgical Treatment of Penile Foreign Body Granuloma: Penile Shaft Reconstruction With Single- Versus Two-Stage Scrotal Flap Techniques." Int J Urol. 2023;30(8):681–687. doi:10.1111/iju.15209

4. Napolitano L, Marino C, Di Giovanni A, et al. "Two-Stage Penile Reconstruction After Paraffin Injection: A Case Report and a Systematic Review of the Literature." J Clin Med. 2023;12(7):2604. doi:10.3390/jcm12072604

5. Zucchi A, Perovic S, Lazzeri M, et al. "Iatrogenic Trapped Penis in Adults: New, Simple 2-Stage Repair." J Urol. 2010;183(3):1060–3. doi:10.1016/j.juro.2009.11.030

6. Fakin R, Zimmermann S, Jindarak S, et al. "Reconstruction of Penile Shaft Defects Following Silicone Injection by Bipedicled Anterior Scrotal Flap." J Urol. 2017;197(4):1166–1170. doi:10.1016/j.juro.2016.11.093

7. Murányi M, Varga D, Kiss Z, Flaskó T. "A New Modified Bipedicle Scrotal Skin Flap Technique for the Reconstruction of Penile Skin in Patients With Paraffin-Induced Sclerosing Lipogranuloma of the Penis." J Urol. 2022;208(1):171–178. doi:10.1097/JU.0000000000002480

8. 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

9. Mendel L, Neuville P, Allepot K, et al. "Bilateral Pedicled Scrotal Flaps as an Alternative to Skin Graft in Penile Shaft Defects Repair." Urology. 2023;176:206–212. doi:10.1016/j.urology.2023.03.025

10. Jeong JH, Shin HJ, Woo SH, Seul JH. "A New Repair Technique for Penile Paraffinoma: Bilateral Scrotal Flaps." Ann Plast Surg. 1996;37(4):386–93. doi:10.1097/00000637-199610000-00007

11. Marín-Martínez FM, Guzmán Martínez-Valls PL, Dekalo S, Weiss J, Haran O. "Aesthetic and Functional Results After Single- and Two-Stage Resection and Reconstruction of Penile Paraffinomas." Urology. 2023;171:227–235. doi:10.1016/j.urology.2022.09.022

12. 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

13. Klein RD, Sarrami SM, Mazarei M, et al. "ICG-Directed Scrotal Flap Design for Adult-Acquired Buried Penis Repair." J Plast Reconstr Aesthet Surg. 2026;115:74–80. doi:10.1016/j.bjps.2026.02.011