Adult Buried Penis Repair with Escutcheonectomy and Split-Thickness Skin Grafting
Marshall C. Strother MD; Alexander J. Skokan MD; Matthew E. Sterling MD, Paris D. Butler MD, MPH; R. Caleb Kovell MD
FIRST PUBLISHED: June 27, 2018 – The Journal of Sexual Medicine
Adult buried penis occurs when surrounding tissue (e.g., redundant tissue and scar tissue) engulfs the penis, often impairing a man’s ability to retract tissue and expose the glans.
Obesity is the most common risk factor, and hygiene can become a problem. Urine and other moisture can become entrapped, leading to chronic inflammation, scarring, infection, and loss of viable genital skin.
Once skin loss occurs, the primary treatment is surgery. Surgery is indicated when men start having trouble with voiding, hygiene, sexual function, and penile self-examinations.
Before surgery, a complete history and physical examination is conducted, including a sexual function assessment. The pannus and genital skin should also be examined.
Patients may have better outcomes if they quit smoking 4 to 8 weeks before surgery. Antiplatelet and anticoagulant medications are usually stopped before surgery and for five days following.
A collaboration between a plastic surgeon and a urologic surgeon is recommended, as other problems (e.g., urethral stricture or hidradenitis) may be found during the procedure.
A basic description of the procedure follows. Complete details and corresponding color photographs are available here.
Excision of Diseased Penile and Scrotal Tissue
- The patient is positioned supine, and after the usual surgical preparation, the borders of the diseased tissue are carefully marked.
- The glans is then exposed, beginning with a longitudinal dorsal or ventral slit in the cicatrix. The maximum viable amount of glans tissue is preserved to minimize changes in penile sensation.
- With the glans exposed, a Foley catheter is inserted, and a glans holding stitch of 2-0 monofilament nonabsorbable suture is placed.
- All diseased skin on the glans and penile shaft and scrotum is then completely excised.
- Diseased underlying dartos fascia may also be excised, being careful not to compromise the suspensory ligament or neurovascular bundles of the penis.
- The length and girth of the penile shaft is measured in preparation for coverage with a split-thickness skin graft. This is performed with the stay suture held with sufficient tension to straighten the penis but not enough to significantly stretch the tissue, which will overestimate the size of the graft needed.
Escutcheonectomy and Skin Graft Harvest
- The boundaries of the escutcheonectomy are then marked in a modified trapezoidal or “bat wing” configuration.
- Care is taken to avoid excessive resection and leave sufficient tissue for a tension-free primary closure of abdominal skin to the base of the penis. If sufficient healthy skin is present within the boundaries of resection, the escutcheon itself may be used as the donor site for the forthcoming penile skin graft. The graft may be taken at this point or marked out and then taken later as described below. When the skin of the escutcheon is unhealthy, the skin graft should be procured from one of the thighs in the standard fashion.
- The lateral escutcheonectomy incisions are then made, connecting inferiorly to the area of the previously excised penile skin tissue. The area of the escutcheon to be excised is then carefully undermined up to the inferior border of the rectus fascia. If the skin graft was not harvested previously, then traction is applied inferiorly and laterally on the escutcheon, the skin is coated in mineral oil, and a graft of thickness of 0.012 to 0.020 inches is taken with a mechanical dermatome.
The split-thickness skin graft is then placed on a moistened gauze on the back table for future use. The escutcheonectomy is then completed at the superior marking.
- Before the abdominal flap tissue is advanced caudally, a closed suction drain is placed into the subcutaneous space.
- The closure is then performed in a layered fashion. Scarpa’s fascia of the flap is secured to the suspensory ligament and to Buck’s fascia lateral to the neurovascular bundle with interrupted 2-0 absorbable suture.
- The dermis is secured to the dartos or Buck’s with 3-0 sutures of the same type.
- The lateral edges of the escutcheonectomy site are temporarily reapproximated with skin staples to facilitate alignment.
- Closure is completed with deep dermal interrupted absorbable 3-0 suture, followed by a running skin closure with 3-0 polypropylene, and the staples are removed.
- Scrotal tissue is then reapproximated as necessary according to the extent of scrotal skin that was excised earlier in the procedure. The scrotal skin is reapproximated with interrupted 5-0 chromic gut.
- The scrotal skin and inferior margin of the abdominal flap are then secured circumferentially (in a “turtleneck” fashion) to the Buck’s or dartos fascia at the base of the penis with simple interrupted 5-0 fast-absorbing gut suture to prevent skin retraction and facilitate union of the scrotal skin with the penile skin graft.
Placement of Penile Skin Graft
- The rectangular graft is wrapped circumferentially around the shaft of the penis such that the seam is located on or just adjacent to the ventrum, recreating a raphe-like appearance.
- The graft is secured to the penile shaft with 5-0 plain absorbing gut suture. Additional running 5-0 plain gut is then used to secure the skin graft to the inferior border of the penile glans, penile base, and in numerous places throughout the middle of the graft to prevent shearing.
- With the skin graft firmly in place, it is then fenestrated in several places using a no. 15 blade or iris scissors to prevent hematoma or seroma accumulation.
- The entire graft site and penile wound is then coated with antibiotic ointment and circumferentially wrapped with large, nonadherent gauze. The negative pressure wound vacuum sponge is then placed around the entirety of the penis and Foley catheter.
- Maintenance of the penis in a stretched position can be facilitated by bringing the ends of the glans holding stitch through the holes of a sterile clothing button and then tying these down so the button is held against the outside of the occlusive vacuum dressing. Suction is applied at −125 mm Hg.
Postoperative Care and Follow-Up
- The patient’s negative pressure wound vacuum dressing and Foley catheter are maintained for 3 to 5 days after surgery. The patient is allowed out of bed to a chair during this time but should not ambulate, and therefore he usually requires continuous hospitalization during this period.
- On the fifth postoperative day, the dressing and Foley catheter are removed. The vacuum dressing is replaced by copious antibiotic ointment, antibiotic-impregnated gauze, and a dry rolled gauze wrap, which are changed daily for the next 10 days.
- At this point the patient is usually able to manage dressing changes at home, so he is discharged after thorough evaluation and education by social work, physical therapy, occupational therapy, and wound care nursing.
Patient satisfaction rates for this technique are consistently greater than 80% to 90%.
Rates of improvement in sexual function fall in a range between 50% and 75%, as buried penis is often not the only factor involved in patients’ sexual dysfunction.
Several other points were discussed (text from original paper):
- There is wide variability reported in the frequency with which viable penile skin is found that can be preserved, obviating the need for a split-thickness skin graft for penile coverage.
- Some authors advocate preservation of the dartos fascia of the penis, which is separated from the overlying diseased skin. This theoretically preserves mobility of the skin over the penile shaft and may provide a better vascular bed for graft take. Others believe the dartos layer is usually involved by the same inflammatory process that affects the overlying skin, making the preservation of the dartos layer both very difficult and of questionable desirability. We generally favor the latter approach and have found that, although mobility of the shaft skin is indeed significantly reduced, this rarely results in bother or impaired sexual function.
- In cases where the abdominal skin near the base of the penis is not inflamed, it is possible to make the inferior margin of the escutcheonectomy several centimeters above the base of the penis, preserving a strip of healthy tissue between the excised penile skin and the escutcheonectomy. This strip is then retracted as much as possible to maximize exposed penile length.
- Another use of healthy suprapubic skin is the harvesting of the graft from the escutcheon itself, which we describe here. This has the distinct advantage of eliminating the morbidity of a separate donor site.
- An alternative method to avoid the morbidity of a skin graft is to forgo grafting entirely and suture the abdominal skin directly to the corona of the glans. This technique restores directed voiding and some sexual function.
- Finally, we use plain gut sutures and a negative pressure dressing to attach and bolster our split-thickness skin graft.
Surgeons may be concerned that the STSG (split-thickness skin graft) will not “take.” However, the authors did not see any reports of a graft take of less than 80% in a literature review.
Superficial wound dehiscence and local wound infections occur at a rate of 10% to 20%.
Failed repairs occur at similar rate but can usually be resolved with a second procedure.
Take Home Message
With rising obesity rates worldwide, acquired buried penis is likely to become more prevalent. Escutcheonectomy with STSG is associated with high patient satisfaction, return of function, and better quality of life. Further research is needed to improve outcomes.