Foreskin Restoration

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What is foreskin restoration using the regional peno-scrotal flap technique?

Foreskin Restoration by using Regional Peno-Scrotal Flap Technique

There are many established techniques for using regional fasciocutaneous flaps in reconstructive surgery across various parts of the body. A fasciocutaneous flap is a type of composite flap that includes skin, subcutaneous tissue, and the underlying fascia, all supplied by a consistent vascular network (fasciocutaneous perforators).

Peno-Scrotal flaps are a valuable and frequently used technique for penile and urethral reconstruction due to the scrotum's excellent vascularity, thin and elastic skin, and the genito-pudendal nerve distribution matches the genital region well. The design is based on the specific vascular supply of the area.

Key Principles of Scrotal Flap Design

  • Vascular Anatomy: The scrotum has a very rich blood supply primarily from the external pudendal arteries (anterior face) and the perineal arteries (posterior face). This robust network, especially within the dartos muscle and fascia, allows for reliable, pedicled flap designs.
  • Aesthetic and Functional Match: Scrotal skin offers excellent color, thickness, and elasticity match for the penis or perineum.
  • Flap Types: Various designs are used depending on the defect, including unilateral, bilateral anterior, two-stage, bipedicled, and island dartos flaps.

Common Regional Peno-Scrotal Flap Techniques for Foreskin Restoration

1. Single stage surgery:

Scrotal Advancement Flaps which starts from the ventral aspect of the penile skin

For smaller defects in the adjacent area, direct advancement of local scrotal tissue can be performed. This is feasible when the desired foreskin restoration is up to 6cm.

Considerations

  • Hair Removal: Scrotal skin is hair-bearing, which is a key aesthetic consideration. Patients may require laser hair removal post-operatively if used for penile resurfacing.
  • Staging: While many modern techniques aim for a single-stage reconstruction,traditional methods sometimes involve a 2-stage approach where the "nude" penis is temporarily buried in the scrotum to allow the skin to vascularize before being fully reconstructed in a second procedure.

Scrotal flap techniques offer durable and highly effective options for genitourinary reconstruction, leveraging the unique properties of the local tissue.

2. Bilateral Anterior Scrotal Flaps (for Penile Resurfacing or Trapped Penis Correction):

Used to cover significant penile skin defects caused by trauma, infection (like Fournier's gangrene), or foreign body injections.

  • Design: Two flaps are elevated from the anterior surface of the scrotum, each based on its respective external pudendal artery supply.
  • Procedure: The flaps are rotated to cover the dorsal and ventral aspects of the penile shaft, creating a new skin envelope. The scrotal donor site is then closed primarily.
  • Advantage: Provides a robust, well-vascularized, and redundant skin envelope suitable for a functional erection and an acceptable cosmetic appearance.

Foreskin Restoration

18 January 2026 Kim Jin Hong MD PhD

Single stage foreskin restoration surgical design diagram

Single Stage Surgery

Two stage foreskin restoration surgical technique diagram

Two Stage Surgery

1. Single Stage Surgery – Preoperative Design

  • d : Diameter of the penile shaft during erection
  • A to B : Half circumference of the Penile shaft girth
  • B to C : similar length of A to B
  • A to B = π X d / 2 = 1.5 X d. If d is 4 cm, A to B is 6 cm
Single stage foreskin restoration preoperative measurement diagram
  • After advancement of the ventral aspect penoscrotal flap, eventual penoscrotal web creation can not be avoided
  • Removing penoscrotal web is the final phase of single stage surgery
  • Penoscrotal web correction by multiple Z-plasty is visible at the next case photos
Penoscrotal web correction during single stage foreskin restoration

Single Stage Surgery: Postop Result

  • A’ to B’ is the elongated skin length, which will not change regardless of erect and flaccid state
  • A’ to B’ is the half length of the girth
  • D=3 cm => A’ to B’ =4.5 cm
  • D=4 cm => A’ to B’ = 6 cm
  • The half length of the midline suture line will be hidden inside of the new preputial skin
Postoperative result after single stage foreskin restoration surgery

Circumcision Restorations

by using mobilization of the Regional Peno-Scrotal Flap together with subsequent Penoscrotal-Web correction

Circumcision restoration using regional peno-scrotal flap technique

2. Two Stage Surgery

  • When the patient’s desired foreskin length gain is more than 6 cm, it is better to choose 2 stage surgical corrections
  • After making circumcisional incisions and degloving of the penile skin at the subdartos’ fascial layers, fully stretched scrotal skin layer preparation is helpful for accurate measurement and designing on the future donor site on the scrotum
Two stage foreskin restoration surgical planning diagram
  • The ventral aspects of scrotal sac is prepared after subdartos’ dissection for implantation of the denuded penile shaft
  • The wounds will be closed by absorbable suture materials
  • The red dotted marking is indicating the penile shaft and future incision lines for the flap harvesting after 6 months
Scrotal flap preparation for second stage foreskin reconstruction
  • Lateral view : the red line indicates the flaps from the ventral aspects of scrotum

For the treatment of trapped penis problem that is secondary to:

  • 1) circumcision design that was too short
  • 2) shortage of penile skin during or after the removal of foreign body granuloma in the penile skin
  • 3) just for reversing the circumcision status because of body dysmorphophobia (Body Dysmorphic Disorder), the most commonly selected surgical procedure is regional flap technique, using adjacent tissues such as penile and scrotal skin.
Regional flap design for trapped penis correction surgery

The benefits of regional flap techniques are:

  • Matching skin color
  • Erogenic sensitivity
  • Elasticity during full erection of the penile shaft
  • Abundant vascularity
  • Plenty of tissue volume

When the desired gap of penile skin length is less than 6 cm, it is advisable to choose single stage procedure.

Case One

This patient was 32 years old, 172 cm tall, and weighed 118 kg. He had been circumcised at the age of 12. He experienced long-term dissatisfaction with his body image. His penile length was 11 cm and girth was 12 cm during full erection. The pre-calculated expected gain was half the girth length using a single-stage surgical procedure — approximately 6 cm gain.

When the desired gain of penile skin length exceeds 6 cm, it is advisable to achieve the result in two stages, or select a composite flap design to enable a single-stage surgery using an extended scrotal flap.

Two-stage foreskin restoration surgical planning diagram

Case Two

The featured 52-year-old patient had undergone neonatal circumcision and experienced a shortage of penile skin, causing pressure on the penile shaft during full erection. Over time, this led to ventral scrotal and dorsal pre-pubic webbing.

As he preferred to keep all native penile skin in its original position, he opted for a two-stage surgical procedure. This involved embedding the penile shaft into the anterior scrotum after degloving, followed by tissue separation six months later. These procedures can be performed under local anesthesia with sedation, spinal anesthesia, or general anesthesia, depending on patient preference.

Two-stage foreskin restoration surgical planning diagram

Case Three

The healthy 47-year old patient suffered from trapped penis secondary to neonatal circumcision. His shortage of penile skin was much more serious than Case 1.

In this challenging case, it was most advisable to choose spinal or general anesthesia rather than local anesthesia, because of the long operation time and the wide area of the surgical fields.

The surgical design for him was harvesting three discrete flaps from the hairless part of the scrotum and reassemble them at the distal part of the penile shaft at the circumcision line. We can finish the surgery within a single stage but it requires six hours of surgery epidural anesthesia.