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Combined Reduction Scrotoplasty + Penoscrotal Z-Plasty

The third and most comprehensive pathway in the Thomas & Navia algorithm for the bothersome scrotum, designed for patients presenting with both excessive scrotal laxity and penoscrotal webbing simultaneously.[1] The two component techniques — vertical midline scrotal-skin resection and penoscrotal-junction Z-plasty — are performed as a single-stage operation; Schifano confirms they are "easy, safe, and effective solutions to improve genital cosmesis, being carried out in isolation or in combination."[2]

For the two component deep-dives see Reduction Scrotoplasty and Penoscrotal-Web Correction (Z-plasty). For the broader male cosmetic framework see the Male Cosmetic Genital Surgery atlas page.

Indications​

Patient meets both criteria on examination:[1][2]

  • Scrotal laxity — scrotal bag hanging > 1–2 cm below the penile tip (discomfort with ambulation, sports, intercourse, or loose clothing).
  • Penoscrotal webbing — scrotal skin extending abnormally onto the ventral penile shaft, obscuring the penoscrotal angle and causing perceived penile shortening.

High-yield contexts:

  • Adjunct to penile-prosthesis implantation — Miranda-Sousa 2007: ventral phalloplasty added to IPP gave 84% perceived penile lengthening and 98% overall satisfaction with only ~12 min of added OR time; concurrent midline reduction further optimizes the penile-to-scrotal ratio.[3]
  • Post-circumcision webbing layered on age-related laxity.[1][4]
  • Concealed / hidden penis with scrotal redundancy — combine with Alter ventral tacking and other adjuncts.[4]

Thomas & Navia Algorithm — where the combined approach fits[1]​

  1. Patient presents with bothersome scrotum.
  2. Assess: scrotal laxity? penoscrotal webbing?
  3. Three pathways:
    • Laxity only → vertical midline scrotal-skin resection.
    • Webbing only → penoscrotal-junction Z-plasty.
    • Both → combined reduction scrotoplasty + Z-plasty (this page).

Operative Protocol​

Preoperative planning​

  1. Anesthesia — supine; local cord block (1% lidocaine / epinephrine + 0.25% bupivacaine) ± sedation, or general.[4]
  2. Standing / dependent assessment — quantify how far the scrotum hangs below the penile tip and how high the web extends with the penis on stretch.
  3. Mark the Z-plasty. Central limb along the line of maximal web at the ventral midline; two peripheral limbs of equal length at 60° from each end of the central limb (one onto ventral penile shaft, one onto scrotal skin).[5][6]
  4. Mark the midline ellipse along the median raphe inferior to the Z-plasty design, centered on maximal redundancy.

Integrated design. The inferior limb of the Z-plasty must transition into the superior extent of the midline ellipse so the two incision lines are continuous and tissue rearrangement at the penoscrotal junction is not disrupted by the midline excision below it.

Component 1 — Penoscrotal Z-plasty​

  1. Full-thickness incisions along all three Z limbs through skin and superficial dartos, preserving urethra / corpus spongiosum.
  2. Elevate the two triangular flaps in the subdartos plane with adequate thickness to preserve perfusion.[7]
  3. Divide fibrous dartos bands tethering the ventral shaft.
  4. Transpose the flaps — converts the vertical web into a transverse / oblique axis and lengthens ventral skin by up to ~75% of the central-limb length at 60°.[5][6]
  5. Inset and layered closure with absorbable suture.

Component 2 — Vertical midline scrotal-skin resection​

  1. Full-thickness elliptical excision along the median raphe, superficial to the scrotal septum and tunica vaginalis.
  2. Adjuncts as needed for larger resections:[8]
    • Septum division — communicates the hemiscrotums.
    • Dartos mobilization off the tunica vaginalis.
    • Gubernacular division — allows superior testicular repositioning.
    • Spermatic-cord mobilization + scrotopexy at the penoscrotal junction.
  3. Layered closure — dartos with 3-0 / 4-0 absorbable braided; skin with absorbable along the raphe.

Final steps​

  1. Meticulous hemostasis throughout (dartos is highly vascular).
  2. Compressive supportive garment; remove at 5–7 days. Same-day discharge.

Geometric and Vascular Considerations​

Three scrotal cutaneous territories (two inferior external pudendal + one perineal / central) are richly inter-anastomosed, giving the combined operation a vascular safety margin.[9] Specific risks to manage:

  • Limit inferior undermining of the Z-plasty flaps — the midline excision has already narrowed the central vascular territory beneath them.
  • Maintain Z-plasty flap thickness to preserve the random-pattern blood supply.[10]
  • Avoid tension at the Z-plasty / midline closure junction — a competing-vector T-junction.
  • Calibrate excision volume — midline over-resection puts the Z-plasty flaps under excessive tension; the Z-plasty itself further tightens the envelope. Native elasticity tolerates resection of up to ~50% of the scrotum with primary closure, even in the combined setting.[8]

Isolated vs Combined Approach​

FeatureMidline resection aloneZ-plasty aloneCombined
Primary pathologyScrotal laxityPenoscrotal webbingBoth simultaneously
Skin excisionFusiform along rapheNone (rearrangement only)Fusiform + flap transposition
Geometric lengtheningNoUp to ~75% at 60°Yes — at penoscrotal junction
Scar locationMidline raphePenoscrotal junction (oblique)Both, joined at a T
Operative complexityLowModerateModerate–high
CPT code55175 (simple)55180 (complicated)55180 (complicated)
Adjunctive scrotopexyOptionalAtypicalOften beneficial
Algorithm indicationLaxity onlyWebbing onlyLaxity + webbing
[1][2][6][8]

Outcomes​

No published series reports outcomes specifically for the combined procedure as a defined entity; data are extrapolated from each component.[1]

OutcomeMidline resectionZ-plastyCombined (extrapolated)
Primary healing~95%+98% (Álvarez Vega n = 100)~95%+
Hypertrophic scarringNot reported1%Low
Wound dehiscenceNot reported1% (suture separation)Slightly higher (two suture lines + T-junction)
Recurrence of webbingN/A0% (Borsellino webbed-penis subset)Low
Recurrence of laxityUnknownN/AUnknown
Perceived penile lengtheningNot the primary goal84% (with IPP)Similar
Overall satisfaction"Satisfactory"98% (with IPP)Expected high
[1][2][3][6][12]

Additive Complications Specific to the Combined Approach​

  • Increased operative time vs either component alone.
  • Hematoma / seroma — two dissection planes create more potential dead space.
  • Vascular compromise at the Z-plasty / midline junction — the area of greatest vulnerability; avoid aggressive undermining and excessive tension here.
  • T-junction dehiscence — competing tension vectors at the junction of the Z-plasty closure and the midline closure.
  • Over-correction — combined skin excision and tissue rearrangement can create an uncomfortably tight scrotum if not carefully calibrated.

General benign-scrotal-surgery risk factors (Rezaee 2022 NSQIP, n = 12,917; 30-day event rate 4.1%) — malnourishment OR 4.1, decreased functional status OR 3.8, bleeding disorders OR 3.4, COPD OR 1.8, age ≥ 40 OR 1.6, smoking OR 1.4, diabetes OR 1.3.[13]

Application Variants​

  • Scrotal massive localized lymphedema (MLL) in obesity — Machol 2014 used laterally based scrotal flaps ± mid-raphe Z-plasty for anatomic reconstruction after MLL excision (n = 4, average BMI 53.9, average resected 3,492 g): 50% recurrence; mean 2 operations during follow-up; improved urinary function and overall symptoms.[14] This is a pathologic rather than aesthetic use of the combined design.
  • Concurrent with penile prosthesis — single anesthetic event delivers web release (recovers perceived length), midline reduction (optimizes penile-to-scrotal ratio), and prosthesis placement; directly addresses the 84% Miranda-Sousa shortening complaint after IPP without web release.[3]

CPT Coding​

  • CPT 55180 — scrotoplasty, complicated — covers the flap-transposition + reconstruction components of the combined operation.
  • Coded separately from IPP placement codes (54400–54405) when performed concurrently.[1][2]

Postoperative Care​

  • Same-day discharge.
  • Scrotal support / jockstrap × 2–4 weeks.
  • Bolster dressing removed at 5–7 days.
  • Activity restriction (no strenuous activity, lifting, or intercourse) × 2–4 weeks.
  • Wound check at 1–2 weeks; final assessment at 4–6 weeks.

Evidence Limitations​

  • Algorithm-recommended but no dedicated case series for the combined procedure.
  • All outcome data are extrapolated from component techniques.
  • Overall evidence base for aesthetic scrotoplasty is Level IV.
  • No validated patient-reported outcomes for the combined procedure.
  • No comparative studies vs either component alone.

See Also​

References​

1. Thomas C, Navia A. Aesthetic scrotoplasty: systematic review and a proposed treatment algorithm for the management of bothersome scrotum in adults. Aesthet Plast Surg. 2021;45(2):769–776. doi:10.1007/s00266-020-01998-3

2. Schifano N, Castiglione F, Cakir OO, Montorsi F, Garaffa G. Reconstructive surgery of the scrotum: a systematic review. Int J Impot Res. 2022;34(4):359–368. doi:10.1038/s41443-021-00468-x

3. Miranda-Sousa A, Keating M, Moreira S, Baker M, Carrion R. Concomitant ventral phalloplasty during penile-implant surgery: a novel procedure that optimizes patient satisfaction and their perception of phallic length after penile-implant surgery. J Sex Med. 2007;4(5):1494–1499. doi:10.1111/j.1743-6109.2007.00551.x

4. Alter GJ, Ehrlich RM. A new technique for correction of the hidden penis in children and adults. J Urol. 1999;161(2):455–459.

5. Salam GA, Amin JP. The basic Z-plasty. Am Fam Physician. 2003;67(11):2329–2332.

6. 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

7. 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

8. 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

9. Carrera A, Gil-Vernet A, Forcada P, et al. Arteries of the scrotum: a microvascular study and its application to urethral reconstruction with scrotal flaps. BJU Int. 2009;103(6):820–824. doi:10.1111/j.1464-410X.2008.08167.x

10. Shaeer O, Shaeer K, el-Sebaie A. Minimizing the losses in penile lengthening: "V-Y half-skin half-fat advancement flap" and "T-closure" combined with severing the suspensory ligament. J Sex Med. 2006;3(1):155–160. doi:10.1111/j.1743-6109.2005.00105.x

11. Borsellino A, Spagnoli A, Vallasciani S, Martini L, Ferro F. Surgical approach to concealed penis: technical refinements and outcome. Urology. 2007;69(6):1195–1198. doi:10.1016/j.urology.2007.01.065

12. Gupta NK, Sulaver R, Welliver C, et al. Scrotoplasty at time of penile implant is at high risk for dehiscence in diabetics. J Sex Med. 2019;16(4):602–608. doi:10.1016/j.jsxm.2019.02.001

13. Rezaee ME, Swanton AR, Gross MS. Current findings regarding perioperative complications in benign scrotal surgery. Urology. 2022;169:23–28. doi:10.1016/j.urology.2022.06.043

14. Machol JA 4th, Langenstroer P, Sanger JR. Surgical reduction of scrotal massive localized lymphedema (MLL) in obesity. J Plast Reconstr Aesthet Surg. 2014;67(12):1719–1725. doi:10.1016/j.bjps.2014.07.031