A novel full-thickness skin graft technique for the surgical management of congenital buried penis in children

Abstract

Buried penis in children presents significant surgical challenges, particularly in severe cases involving skin deficiency and fascial abnormalities. Traditional fixation (TF)-based techniques often yield suboptimal cosmetic and functional outcomes. This study evaluated a novel full-thickness skin graft (FTSG) technique using inner preputial skin for congenital buried penis. A retrospective analysis was conducted on boys aged 4–7 years who underwent surgical management between January 2020 and December 2024 at the Department of Urology, Children’s Hospital of Fudan University, National Children’s Medical Center (Shanghai, China). Patients were divided into FTSG (n = 132) and TF (n = 141) groups. The FTSG technique achieved greater penile length at 6 months (mean ± standard deviation [s.d.]: 3.52 ± 0.51 cm vs 3.21 ± 0.59 cm, P < 0.001) and 12 months (mean ± s.d.: 3.88 ± 0.61 cm vs 3.39 ± 0.69 cm, P < 0.001) postoperatively, with lower rates of skin contracture (0.8% vs 6.4%, P = 0.020) and retraction (1.5% vs 7.8%, P = 0.015), compared to TF group. Operative time in FTSG group was slightly longer than that in TF group (mean ± s.d.: 70.92 ± 9.10 min vs 65.70 ± 8.66 min, P < 0.001) without additional burden. Parental satisfaction for penile size and morphology was higher (P < 0.001 for both) in FTSG group than TF group, while voiding satisfaction was comparable (P = 0.239). These findings suggest that an FTSG using inner preputial tissue is a safe and effective alternative to TF techniques for children with severe congenital buried penis, providing improved penile exposure, enhanced cosmetic outcomes, and a reduced risk of recurrence. Longer-term studies are warranted to evaluate graft adaptation during penile growth and puberty.

INTRODUCTION

Buried penis is a congenital condition in which a normally developed penile shaft is concealed beneath the skin of the abdomen or scrotum, typically due to insufficient penile skin, abnormal fascial attachments, or inadequate anchorage in the pubic region.1 Although uncommon, congenital buried penis can result in long-term psychosocial distress, difficulty with hygiene maintenance, and increased parental anxiety if not surgically corrected at an early age.2 The condition shows considerable anatomical variability, and despite several proposed classification systems, no universally accepted framework exists, complicating surgical decision-making in pediatric practice.

Traditional surgical approaches for congenital pediatric buried penis typically involve penile degloving combined with dorsal dartos flap advancement or fascial fixation.3 While these methods are generally effective for mild-to-moderate cases, outcomes are often less satisfactory in severe presentations, particularly when significant skin deficiency or fascial dysplasia is present. In such cases, relying solely on local tissue redistribution may lead to inadequate exposure, skin contracture, penile retraction, and suboptimal cosmetic results.4

By contrast, acquired buried penis in adults, often secondary to obesity, inflammation, or prior surgery, is increasingly managed with full-thickness skin graft (FTSG). These grafts provide durable, tension-free coverage with superior color and texture matching compared with local flaps or split-thickness grafts.5 However, despite their theoretical advantages, FTSGs have rarely been applied in children with congenital buried penis, likely because of concerns about graft viability and the technical challenges posed by smaller anatomical fields. While short-term follow-up can assess graft survival and perioperative feasibility, the long-term adaptability of these grafts to penile growth during childhood and puberty remains uncertain, representing a key limitation in current pediatric evidence. To our knowledge, few studies have systematically evaluated the use of FTSG in this specific population.6

To address this clinical gap, we developed a novel surgical technique combining complete degloving, excision of dysplastic fascial layers, and reconstruction of the ventral penile shaft using a diamond-shaped inner preputial FTSG. This approach aims to achieve adequate penile exposure and a cosmetically satisfactory outcome, particularly from the parental perspective, while minimizing tissue edema, recurrence, and contracture. In this retrospective study, we compare the clinical outcomes, complication profiles, and parental satisfaction of this graft-based method with those of traditional fixation techniques in a cohort of children with severe congenital buried penis.

PATIENTS AND METHODS

Patients

This retrospective cohort study was conducted in the Department of Pediatric Urology at the Children’s Hospital of Fudan University, National Children’s Medical Center (Shanghai, China). From January 2020 to December 2024, a total of 273 boys aged 4 years to 7 years were included. All patients were diagnosed with congenital buried penis, characterized by poor penile exposure due to abnormal skin fixation or deficient penile shaft coverage, without obesity-related fat pad burial or prior penile surgery. The clinical diagnosis was based on physical findings such as poorly developed penopubic and penoscrotal angles, excessive preputial coverage, and insufficient visible penile shaft length.

Patients were excluded if they had any of the following: a history of penile or preputial surgery, hypospadias, disorders of sex development, systemic diseases requiring immunosuppressive therapy, or acquired buried penis due to obesity, post-circumcision scarring, or trauma.

All procedures were performed by experienced pediatric urologists. The choice of surgical technique was determined by the degree of penile skin deficiency and the extent of fascial abnormalities. In the earlier phase of the study, traditional repair was primarily performed using a modified Sugita procedure incorporating fascial fixation, whereas in the more recent 2 years, the FTSG technique was increasingly adopted, particularly for children with severe ventral skin deficiency. Consequently, both procedures were employed during the study period. Two senior pediatric urologists managed all cases: XLF performed 75 procedures using the FTSG technique and 54 procedures using the traditional fixation (TF) method, while another senior urologist (Dr. Hong-Quan Geng from Department of Urology, Children’s Hospital of Fudan University, National Children’s Medical Center) performed 57 FTSG and 87 TF procedures. The distribution of patients between groups was not strictly balanced across surgeons but largely reflected the gradual adoption of the new method in clinical practice. Based on the surgical approach used, the patients were divided into two groups: 132 underwent the novel FTSG technique (FTSG group) and 141 underwent traditional correction using the modified Sugita procedure (TF group).

This study was conducted in accordance with the principles of the Declaration of Helsinki and was approved by the Ethics Committee of the Children’s Hospital of Fudan University, National Children’s Medical Center (Approval No. [2025]127). Written informed consent was obtained from the parents or legal guardians of all participants. Written informed consent for the publication of anonymized clinical data and images was also obtained from the patients’ legal guardians. Permission for data use and publication was granted by the Ethics Committee of the Children’s Hospital of Fudan University, National Children’s Medical Center, and all data were anonymized prior to analysis. The datasets generated and analyzed during the current study are available from the corresponding authors upon reasonable request. All data were collected from the Children’s Hospital of Fudan University, National Children’s Medical Center.

Surgical technique

All procedures were performed under general anesthesia with the patient in the supine position, following standard sterile preparation and draping. In the TF group, a modified Sugita procedure with fascial fixation was performed. The penis was completely degloved to release dysplastic fascial tissue and concealed attachments. The inner preputial plate was then divided into two wings and rotated ventrally to cover the ventral shaft. The skin incision was made in a circumferential, circumcision-like ring, and the dermis of the dorsal penile root skin was anchored to the tunica albuginea at the penile base.

In the FTSG group, a 3.0-cm longitudinal incision was made along the ventral midline of the penis to expose the operative field and enlarge the preputial orifice (Figure 1a). Preputial adhesions were released by blunt dissection. A circumferential incision was then made approximately 0.8 cm proximal to the coronal sulcus, preserving the inner preputial mucosa for later graft preparation (Figure 1b).

Figure 1.

Surgical steps of the full-thickness skin graft (FTSG) technique for congenital buried penis in children. (a) Ventral midline incision (approximately 3.0 cm) with widening of the preputial orifice. (b) Inner preputial mucosa excised approximately 0.8 cm proximal to the coronal sulcus; penile degloving performed along Buck’s fascia with removal of dysplastic fascia. (c) Tunica albuginea fixed to the dermis at the penile base using 4-0 absorbable sutures. (d) Dorsal midline incision and longitudinal splitting of penile skin; bilateral preputial flaps rotated ventrally. (e) Inner mucosa resected from the lateral flaps and preserved, remaining layers sutured, and penoscrotal angle refined. (f) Full-thickness graft harvested from the preserved inner mucosa. (g) Graft tailored to the ventral defect. (h) Redundant skin trimmed. (i) Graft sutured to the penile shaft and dorsal-stretch dressing and waterproof film applied to immobilize the graft.

The penile shaft was degloved along Buck’s fascia down to the base, and dysplastic fascial tissue was excised to achieve complete exposure and release of concealed attachments (Figure 1c). Fixation sutures were then placed between the tunica albuginea and the dermis at the penile base to prevent retraction.

In the FTSG group, a midline incision was made along the dorsal penile skin, followed by longitudinal splitting and ventral rotation of the preputial flaps (Figure 1d). Adjacent scrotal skin was mobilized to reconstruct a natural penoscrotal junction (Figure 1e). An FTSG was then harvested from the preserved inner preputial mucosa and trimmed to match the shape and dimensions of the ventral defect (Figure 1f and 1g). The graft was sutured to the surrounding penile skin using interrupted absorbable sutures.

Contour refinement was achieved by trimming redundant dorsal or scrotal skin (Figure 1h), followed by the application of a dorsal-stretch dressing and immobilization of the penis in an extended position using a transparent waterproof film (Figure 1i). A silicone Foley catheter was inserted and maintained for urinary drainage. The graft site was kept immobilized for 6 days, after which the dressings were removed, while the Foley catheter was typically removed earlier, after about 4 days. Patients were followed up at 1 month, 3 months, 6 months, and 12 months postoperatively.

Parental satisfaction assessment

Parental satisfaction was assessed 12 months postoperatively using a structured 5-point Likert scale (1: very dissatisfied, and 5: very satisfied). The questionnaire evaluated three domains, including penile size, penile morphology, and voiding function, and was adapted from the validated Pediatric Penile Perception Score to suit the context of congenital buried penis repair.7 The complete questionnaire is provided in Table 1.

Table 1.

Parental satisfaction questionnaire

Domain	Question (for parents)	Scale (1–5)
Penile size	Are you satisfied with your child’s penile size after surgery?	1–5
Penile morphology	Are you satisfied with the penile appearance and morphology?	1–5
Voiding function	Are you satisfied with your child’s voiding status?	1–5

Parents were asked to rate their satisfaction at 12 months postoperatively using a 5-point Likert scale: 1: very dissatisfied; 2: dissatisfied; 3: neutral; 4: satisfied; and 5: very satisfied

Statistical analyses

All data were analyzed using SPSS software version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (s.d.) and were compared using independent-samples t-tests. Categorical variables are presented as counts and percentages. Between-group comparisons were performed using Chi-square tests when the expected frequency was ≥5. Fisher’s exact test was used when the expected frequency was <5. A two-tailed P < 0.05 was considered statistically significant.

RESULTS

Baseline characteristics were comparable between the two groups, including age (mean ± s.d.: 5.9 ± 1.1 years vs 6.1 ± 1.2 years, P = 0.145), weight (23.70 ± 6.30 kg vs 24.20 ± 6.60 kg, P = 0.526), and preoperative penile length (mean ± s.d.: 1.42 ± 0.31 cm vs 1.48 ± 0.29 cm, P = 0.085), as shown in Table 2. The operative time was slightly longer in the FTSG group compared to the TF group (mean ± s.d.: 70.92 ± 9.10 min vs 65.70 ± 8.66 min, P < 0.001), although the absolute difference was modest. The hospital stay was also longer in the FTSG group compared to the TF group (mean ± s.d.: 5.95 ± 1.21 days vs 5.09 ± 1.05 days, P < 0.001). The catheter retention times were similar between groups (mean ± s.d.: 4.07 ± 0.75 days vs 4.01 ± 0.85 days, P = 0.579), as shown in Table 2.

Table 2.

Patient’s baseline characteristics and perioperative data

Item	FTSG group (n=132)	TF group (n=141)	P
Age (year), mean±s.d.	5.9±1.1	6.1±1.2	0.145
Weight (kg), mean±s.d.	23.70±6.30	24.20±6.60	0.526
Preoperative penile length (cm), mean±s.d.	1.42±0.31	1.48±0.29	0.085
Operative time (min), mean±s.d.	70.92±9.10	65.70±8.66	<0.001
Hospital stay (day), mean±s.d.	5.95±1.21	5.09±1.05	<0.001
Catheter retention time (day), mean±s.d.	4.07±0.75	4.01±0.85	0.579
Penile length at 6 months (cm), mean±s.d.	3.52±0.51	3.21±0.59	<0.001
Penile length at 12 months (cm), mean±s.d.	3.88±0.61	3.39±0.69	<0.001
Lymphedema, n (%)	13 (9.8)	16 (11.3)	0.688
Incision infection, n (%)	3 (2.3)	4 (2.8)	1.000
Scrotal hematoma, n (%)	2 (1.5)	5 (3.5)	0.449
Skin contracture, n (%)	1 (0.8)	9 (6.4)	0.020
Penile retraction, n (%)	2 (1.5)	11 (7.8)	0.015
Skin necrosis (partial), n (%)	1 (0.8)	1 (0.7)	1.000
Need for second surgery, n (%)	0 (0)	3 (2.1)	0.248

All outcome measures and complications listed were assessed postoperatively. s.d.: standard deviation; FTSG: full-thickness skin graft; TF: traditional fixation

Penile length at both 6 months and 12 months postoperatively was significantly greater in the FTSG group than that in the TF group (mean ± s.d.: 3.52 ± 0.51 cm vs 3.21 ± 0.59 cm at 6 months, P < 0.001; 3.88 ± 0.61 cm vs 3.39 ± 0.69 cm at 12 months, P < 0.001; Table 2). The surgical steps of the FTSG procedure are illustrated in Figure 1. Immediate postoperative appearance in the FTSG group showed satisfactory penile exposure and smooth graft integration, with Figure 2 demonstrating the improved cosmetic outcome and restoration of the penoscrotal angle.

Figure 2.

Preoperative (left and middle images) and postoperative (right image) appearance of congenital buried penis shown from coronal and sagittal-oblique perspectives.

The overall incidence of postoperative complications was low in both groups (Table 2). However, the FTSG group showed significantly lower rates of skin contracture (1 [0.8%] vs 9 [6.4%], P = 0.020) and penile retraction (2 [1.5%] vs 11 [7.8%], P = 0.015). No secondary operations were required in the FTSG group, whereas 2.1% of patients in the TF group underwent reoperation (P = 0.248). Other complications, including lymphedema, incision infection, hematoma, and partial skin necrosis, were rare and showed no significant differences between the groups (all P > 0.05).

At the 12-month follow-up, parental satisfaction scores were significantly higher in the FTSG group than those in the TF group for both penile size (mean ± s.d.: 4.52 ± 0.55 vs 3.85 ± 0.76, P < 0.001) and penile morphology (mean ± s.d.: 4.55 ± 0.57 vs 3.77 ± 0.86, P < 0.001), while satisfaction with voiding function was comparable between groups (mean ± s.d.: 4.27 ± 0.56 vs 4.18 ± 0.66, P = 0.239), as shown in Table 3. Representative postoperative outcomes in the FTSG group are shown in Figure 3, illustrating a smooth, tension-free ventral contour, well-integrated graft, and a natural penoscrotal angle without retraction or necrosis.

Table 3.

Parental satisfaction scores at 12 months postoperatively

Satisfaction domain	FTSG group (mean±s.d.)	TF group (mean±s.d.)	P
Penile size	4.52±0.55	3.85±0.76	<0.001
Penile morphology	4.55±0.57	3.77±0.86	<0.001
Voiding status	4.27±0.56	4.18±0.66	0.239

s.d.: standard deviation; FTSG: full-thickness skin graft; TF: traditional fixation

Figure 3.

Postoperative penile appearance at 1 month following full-thickness skin graft (FTSG). The ventral shaft exhibits no swelling, tension, or retraction. The graft demonstrates good integration with the surrounding skin, and the penoscrotal angle is well defined and cosmetically satisfactory.

DISCUSSION

Buried penis in children is a frequently underdiagnosed yet clinically significant condition that presents not only cosmetic challenges but also potential psychological burdens if left untreated. The condition has been classified according to fascial integrity, skin availability, and scrotal configuration, with surgical correction typically indicated in moderate-to-severe cases.8 Traditional repair techniques, such as dorsal dartos flap rotation, fascial fixation, and scrotoplasty, have shown varying success; however, recurrence, skin contracture, and penile retraction remain common, particularly in children with poor native tissue elasticity or severe fascial dysplasia.9 Recent histological studies have demonstrated altered expression of smooth muscle myosin heavy chain isoforms in the dartos fascia of patients with buried penis, suggesting a structural basis for fascial insufficiency.10 Radwan et al.11 further proposed that surgical technique selection should be individualized based on the anatomical level of involvement, underscoring the importance of reconstructive flexibility. Despite this, most pediatric approaches continue to rely on rearrangement of local tissues, while tissue replacement strategies such as FTSG application, commonly employed in adult acquired buried penis, have rarely been explored in children.

To our knowledge, this study is among the few systematic evaluations of FTSG application in a pediatric population. Compared with conventional fixation-based techniques, FTSGs offer true anatomical tissue replacement rather than simple tissue redistribution. Although they only described three adult cases, Klein et al.12 noted that in patients with substantial skin loss, native tissue rearrangement often leads to tension, wound dehiscence, or retraction, whereas grafting provides tension-free, full-shaft coverage with superior esthetic integration. In our cohort, the inner preputial plate served as an ideal donor site, offering excellent dermal thickness, elasticity, and pigmentation match. Falcone et al.13 similarly supported the use of FTSG, demonstrating improved satisfaction scores and lower reoperation rates in patients with complex penile defects. More recently, Staniorski et al.14 reported outcomes from 103 adults undergoing high-complexity buried penis reconstruction with routine use of FTSGs, showing low revision rates despite frequent minor wound complications, and identifying frailty as a key predictor of adverse outcomes. Nonetheless, evidence from adult reconstructive series indicates that split-thickness skin grafts and FTSGs can yield comparable results in certain settings, suggesting that graft selection should depend on defect characteristics and surgeon experience.15 In addition to dartos advancement and fascial fixation, rotational preputial flaps have been widely used in hypospadias surgery as a reliable option for ventral coverage. Although well vascularized, these flaps carry drawbacks such as postoperative edema and long-term bulkiness of the inner preputial skin, which can compromise cosmetic outcomes.16 Moreover, flap rotation under limited tissue conditions may introduce excessive tension, increasing the risk of contracture or retraction during follow-up. In hypospadias repair, the primary objective is functional urethral reconstruction, and cosmetic outcomes are often secondary.17 By contrast, for congenital buried penis, caregiver expectations place greater emphasis on penile appearance. To meet these cosmetic demands, we considered FTSGs more suitable because they provide tension-free resurfacing and avoid the risk of flap-related bulkiness or contour distortion.

Although the FTSG procedure requires additional steps, such as graft harvesting and inset design, the operative time was only slightly longer than that of TF techniques. The difference, approximately 5 min, was modest and did not impose any additional intraoperative burden or affect workflow efficiency. With adequate surgical expertise, the technique can be seamlessly integrated into standard pediatric practice. Mechanistically, our approach aligns with contemporary reconstructive principles. Klein et al.12 identified the superficial fascial system as a critical anatomic and mechanical layer, and its disruption in buried penis pathology often necessitates strategies beyond simple fascial suspension. By securing the FTSG directly over the exposed Buck’s fascia, our method takes advantage of a highly vascularized, stable surface that promotes graft integration. Staniorski et al.14 further reported that meticulous bed preparation and graft fixation markedly reduced contracture rates and improved long-term pliability. This biological rationale may account for our low incidence of skin necrosis, retraction, and scarring. Moreover, Hosseinpour et al.6 recently reported favorable outcomes using FTSG in 25 pediatric patients with concealed penis, reinforcing its feasibility in children and complementing the findings of our larger cohort.

Our design also incorporated functional contouring. The diamond-shaped graft provided uniform shaft coverage and aided in restoring a natural penoscrotal angle. Wang et al.18 demonstrated that penile shape and the smoothness of the ventral transition are key predictors of caregiver satisfaction, often outweighing voiding status in perceived outcome importance. Although penile length at 6 months and 12 months was statistically greater in the FTSG group, the absolute differences were small (within a few millimeters) and may not represent a meaningful clinical advantage. These results should therefore be interpreted with caution. This may explain why, in our study, parental satisfaction regarding penile appearance was significantly higher in the graft group, while satisfaction with voiding function remained comparable between groups.

Surgical safety remains a primary concern. Staniorski et al.14 reported that wound tension and inadequate resurfacing were strong predictors of early complications and revision in adult patients undergoing buried penis reconstruction. In our pediatric cohort, excision of dysplastic fascia combined with anatomical graft replacement resulted in lower rates of penile retraction and virtually eliminated the need for secondary surgery. A recent study has emphasized that preoperative frailty indices, such as the Modified Frailty Index, can predict postoperative complications in buried penis surgery, underscoring the importance of comprehensive risk stratification during surgical planning.19 Despite ongoing technical refinements, clinical experience with concealed penis repair suggests that optimized local tissue rearrangement alone may not prevent recurrence or ensure satisfactory penile contour in all cases.20

Notably, the FTSG technique allows for greater anatomical customization. Radwan et al.11 highlighted the importance of tailoring surgical strategies to individual anatomy, particularly in multilevel cases. Our approach aligns with this principle by providing a reconstructive option that is not constrained by local skin redundancy. It can be applied flexibly in children with prior failed surgeries, significant skin contracture, or extensive fascial disorganization.21

From a psychological standpoint, early correction of concealed or buried penis has been linked to improved parental reassurance and reduced psychosocial burden later in childhood.22 Rybak et al.23 further observed that normalization of visible penile length and contour after surgery is directly associated with reduced stigma and improved social functioning. The higher satisfaction scores observed in our graft group may therefore reflect both anatomical success and psychological benefit.

While our findings are encouraging, this study has several limitations. It is a retrospective, single-center analysis with limited long-term follow-up. As Delgado-Miguel et al.9 emphasized, surgeries performed before puberty must be evaluated longitudinally to assess growth accommodation and pubertal skin adaptation. Moreover, while preputial grafting proved ideal in our cohort, circumcised children or those with prior preputial scarring may require alternative donor sites. Inguinal or abdominal skin has been proposed in adult studies, although its suitability for children warrants further investigation. Future research should include multicenter, prospective trials with extended follow-up and objective outcome measures, such as validated caregiver-reported instruments, penile length monitoring, and standardized photographic evaluation. Cui et al.24 highlighted the importance of collaborative databases in pediatric genital surgery to enable consistent technique comparison and long-term impact assessment. Furthermore, advancements in biologic dressings and postoperative immobilization techniques may further improve graft integration and minimize shear-related graft loss, particularly in younger children.

In summary, our study introduces a feasible, safe, and effective adaptation of FTSGs for the management of severe buried penis in children. While the technique draws from established adult reconstructive frameworks, it addresses a distinct pediatric challenge that true skin deficiency cannot be resolved through local tissue rearrangement alone. With careful patient selection, meticulous graft preparation, and secure anatomical fixation, this approach may offer durable advantages in both cosmetic outcomes and complication reduction. Given the lack of prior large-scale pediatric data on this method, our findings provide an important foundation for broader clinical adoption and future multicenter validation.

AUTHOR CONTRIBUTIONS

HW and YY contributed equally to this work and share first authorship. HW was responsible for the study design, data coordination, and manuscript drafting. YY participated in the statistical analysis, figure preparation, and data interpretation. JJL contributed to postoperative infection monitoring, collection of complication-related data, and critical manuscript revision from an infectious disease perspective. JLY supervised the overall study, coordinated institutional collaboration, and performed critical manuscript revision. XLF supervised the surgical procedures, performed part of the operations, and ensured surgical data accuracy. All authors read and approved the final manuscript.

COMPETING INTERESTS

All authors declare no competing interests.