Grabb’s Encyclopedia of Flaps Upper Extremities, Torso, Pelvis, and Lower Extremities

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FIGURE 440.4 Arc of rotation. The gluteal thigh flap will reach the pubis, deep perineum, sacrum, and ischium
medially. Laterally, the flap reaches the greater trochanter and the anterior superior iliac spine. Island pedicle
modifications (left side) have an extended reach because they lack a cone of rotation.
In perineal wounds, there is often a skin bridge separating the flap from the recipient defect. This bridge can be
incised to accommodate the flap, or a subcutaneous tunnel can be created. In either case, the flap can be
deepithelialized in any part for subcutaneous insertion (Fig. 440.5B). At the base of a peninsular flap, backcuts
are often necessary to facilitate transposition and insetting.
In most cases, the donor defect can be easily closed in primary fashion. If the width of the flap exceeds 7 to 10
cm, however, it may be necessary to close the defect with a split-thickness skin graft.
When using an island flap, the initial dissection is carried out as described for the peninsular flap (Fig. 440.6A). If
the descending branch of the inferior gluteal artery is readily identified and has a palpable pulse at the proposed
proximal margin of the flap, then a careful subfascial dissection of the neurovascular pedicle is performed to its
root. At the level of the inferior border of the gluteus maximus muscle, the pedicle will give off several large
branches. These branches are divided after careful identification of the main vascular trunk. Numerous vascular
perforators will be encountered as the pedicle is dissected from the undersurface of the gluteus maximus muscle,
requiring attentive care in dissection. In one-third of patients, the inferior gluteal vessels will not be palpable, and
skeletonization of the pedicle may be hazardous. In these situations, it is important to preserve the deep fascia
proximal to the skin island and incorporate the deep fascia, the overlying subcutaneous tissue, and a portion of
the gluteus maximus muscle as a composite pedicle (Fig. 440.7). This maneuver will ensure adequate perfusion
of the skin island. In some situations, it may be advantageous to detach the gluteus maximus muscle from its
origin to accommodate the mechanics of transposition. The flap is then transferred to the recipient defect.

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FIGURE 440.5 Elevation of the flap. A: After elevation of the flap, the gluteus maximus muscle can be detached
from its insertion and split if additional length is needed. B: The flap may be deepithelialized in any part for
transfer through subcutaneous tunnels or to fill large defects. C: The flap transposed to a perineal defect. Donor
sites less than 7 to 10 cm wide can be closed primarily.
When transposing island pedicle modifications of the flap, one must avoid twisting, kinking, or traction of the
neurovascular pedicle. This is particularly important when the rotation exceeds 90 degrees. The subcutaneous
tunnel through which the flap passes also must be large enough to avoid constriction of the vascular pedicle.
FIGURE 440.6 A: Perineal hernia following abdominal-perineal resection. B: After reduction of the hernia, the
fascial rim of the defect is patched with fascia lata (upper right). A gluteal island flap is elevated on its
neurovascular pedicle. C: The flap is transposed to the perineal defect.
CLINICAL RESULTS
We have employed the inferior gluteal thigh flap for closure of 60 wounds in 46 patients. There have been
two flap failures. One was due to failure to recognize that the inferior gluteal artery was already thrombosed.
The other loss, in an attempted
free flap, was due to venous thrombosis. Partial loss (including superficial epidermal slough) was noted in

three flaps. Of these, one was secondary to hematoma, and the second was due to venous congestion in a
severely skeletonized island pedicle modification. The third flap lost the distal 4 cm as a result of wound
infection. Two flaps have dehisced (ischial, trochanteric defects) with pseudobursa formation; in both these
cases, wound hematoma was identified as the underlying cause. Two more flaps had delayed healing due
to partial dehiscence. One wound infection was encountered 24 hours postoperatively and was manifested
by cellulitis of the flap (Streptococcus spp.). This resolved with intravenous antibiotics. One patient
experienced dysesthesia in an island pedicle flap transferred to close a trochanteric defect. This was
attributed to tethering of the nerve from a tight closure, a complication that could have been avoided by
planning a longer flap.
FIGURE 440.7 If the descending branch of the inferior gluteal artery is poorly developed, the proximal deep
fascia, subcutaneous tissue, and inferior portion of the gluteus maximus muscle are used as a composite
pedicle.
SUMMARY
The inferior gluteal artery skin flap can be used as either a standard or island flap to cover significant
perineal defects. Fascia can be included to repair hernial defects.
References
1. Hurwitz DJ. Closure of a large defect of the pelvic cavity by an extended compound myocutaneous flap
based on the inferior gluteal artery. Br J Plast Surg 1980;33:256.
2. Le Quang C. Two new free flaps developed from aesthetic surgery: II. The inferior gluteal thigh flap.
Aesthet Plast Surg 1980;4:159.

3. Hurwitz DJ, Swartz WM, Mathes SJ. The gluteal thigh flap: a reliable, sensate flap for the closure of
buttock and perineal wounds. Plast Reconstr Surg 1981;68:521.
4. Walton R. The inferior gluteal thigh flap. In: Mathes S, Nahai F, eds. Clinical applications for muscle and
musculocutaneous flaps. St. Louis: Mosby, 1982.
5. Hurwitz DJ, Walton RL. Closure of chronic wounds of the perineal and sacral regions using the gluteal
thigh flap. Ann Plast Surg 1982;8:375.
6. Haertsch P. The surgical plane in the leg. Br J Plast Surg 1981;34:464.

Chapter 441
Gracilis Muscle and Musculocutaneous Flaps to The Perineum
F. R. HECKLER
EDITORIAL COMMENT
This is an excellent flap, as demonstrated in this chapter. The reader is cautioned that in patients with
flabby inner thighs, it is not always possible to determine accurately the portion of the skin supplied by the
gracilis muscle. The muscle should first be identified and the skin territory then determined.
The gracilis muscle and musculocutaneous units are therapeutic mainstays for dealing with clinical problems
requiring reconstruction of the perineum, genitalia, medial thigh, groin, perirectal area, and lower buttock (see
Fig. 441.1).
The gracilis muscle, whether used as a simple muscle or compound musculocutaneous flap, has all the features
classically enumerated in describing favorable muscle-flap donor sites. (1) Transfer of the muscle to a new site
leaves no noticeable residual functional loss in the donor leg. (2) The skin segment available in the
musculocutaneous flap is considerable in size, but the donor defect can be closed primarily. Donor-site scars,
located as they are on the upper inner thigh, are relatively inconspicuous. (3) The vascular pedicle is consistent
in location, easily dissected, and of sufficient size and length to be attractive for free microvascular transfer. (4)
The single motor nerve is likewise easily accessible and may be divided without denervating adjacent leg
muscles, making the gracilis useful in distant transfers for reanimation of paralyzed areas.
INDICATIONS
The gracilis musculocutaneous unit and muscle flap are well suited for reconstruction of defects in the
perineum. When bulk is required, such flaps may be used alone or in combination.
The highly vascular nature of these flaps assists wound healing in the adverse bacteriologic environment of
the perineum and has been successful even in heavily irradiated fields. Gracilis flaps have been used in the
closure of persistent perineal sinuses (1, 2, 3, 4), repair of perineal hernias after pelvic exenteration (5), and
closure of massive postoperative or postirradiation perineal defects (6, 7) (see Figs. 441.4, 441.5, and
441.8).
Gracilis flaps have been used for correction of intractable vaginal prolapse (8). Several authors report
success using gracilis muscle transfer to substitute for a flaccid rectal sphincter (9, 10, 11, 12), whether the
dysfunction is neurologic or traumatic in etiology.
The vagina (13, 14) can be reconstructed using bilateral gracilis musculocutaneous flaps, and the use of
unilateral flaps for hemivaginectomy or partial vaginectomy also has been reported. Reconstruction is
preferably performed immediately following extirpative surgery, allowing primary wound closure, easier
postoperative management, and markedly diminished postoperative morbidity (see Fig. 441.5). Additionally,
neovaginal reconstruction allows the patient to retain a more normal self-image and the functional potential
for sexual intercourse. Postoperative examination for tumor recurrence in the pelvis is facilitated.
Fistulas between bladder, urethra, rectum, vagina, and skin can cause major morbidity. The majority of such
fistulas can be repaired using local tissues. Great problems exist, however, when fistulas occur in irradiated

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fields, when there is fistula recurrence after standard surgical repair, when the fistula is of unusual
magnitude, and when local tissues are inadequate in quantity for use in repair. Under such conditions, the
use of distant, well-vascularized gracilis flaps has proved to be most effective (4, 14, 15, 16, 17) (see Figs.
441.6, 441.7, 441.8).
A number of authors have reported additional uses for gracilis muscle and musculocutaneous flaps. They
have been used for subtotal penile reconstruction in sickle cell patients (18), total penile reconstruction (19,
20, 21, 22, 23), scrotal reconstruction (24), and groin and vulva repair (2, 17, 25).
ANATOMY
The gracilis muscle is part of the adductor muscle group in the medial thigh (Fig. 441.1). It is the most superficial
muscle of this group, originating from the medial segment of the inferior pubic ramus and lower half of the
symphysis pubis. The muscle belly is flattened in configuration and runs distally, lying between the sartorius and
adductor longus anteriorly, the adductor magnus on its deep surface, and the semimembranosus posteriorly. It
ends in a rounded tendon that passes behind the medial femoral condyle to insert on the medial surface of the
upper end of the body of the tibia.
FIGURE 441.1 Medial thigh anatomy as related to the gracilis flap. The dominant vascular pedicle passes
between the adductor longus (Al) and adductor brevis (AB) muscles to reach the gracilis 8 cm distal to the pubic
tubercle. The secondary distal pedicles enter the muscle at the junction of its middle and distal thirds [Sa,
sartorius (cut); pfa, profunda femoris artery; sfa, superficial femoral artery; 1, dominant gracilis vascular pedicle;
Gr, gracilis muscle; 2, distal vascular pedicle from superficial femoral). (From Heckler, ref. 14, with permission.]
The gracilis receives its vascular supply through a single dominant proximal artery and two or three more distant
minor pedicles. The dominant proximal vessel is derived from the profunda system, usually as a branch of the
medial femoral circumflex artery. It approaches between the adductor longus and adductor brevis muscles,
entering the deep aspect of the gracilis 8 to 10 cm distal to the pubic tubercle. This artery is accompanied by
paired venae comitantes. Each of the vessels has a diameter ranging from 1.2 to 1.9 mm.
At the junction of the middle and distal thirds of the gracilis, there are usually one or two additional vascular
pedicles entering the muscle. These vessels are branches of the superficial femoral artery and are about one-
third the size of the dominant proximal pedicle. An additional minor branch of the obturator artery enters the
gracilis near its origin.
The motor nerve of the gracilis is an anterior branch of the obturator nerve. The nerve accompanies the proximal
dominant vascular pedicle, entering the muscle near the entrance of the artery. Both motor and sensory fibers
are present, but transferred skin sensation in the gracilis musculocutaneous flap is modest at best.

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FIGURE 441.2 Areas of use for gracilis muscle and musculocutaneous flaps. The functional arcs of rotation for
the gracilis muscle and musculocutaneous flaps are outlined. The shaded area in the suprapubic region is
covered with difficulty by the gracilis musculocutaneous flap, since a full 180-degree rotation is required.
Excessive kinking of the vascular pedicle may occasionally result. This area is reached easily by the gracilis
muscle flap, which may simply be turned over rather than rotated. (From Heckler, ref. 14, with permission.)
FLAP DESIGN AND DIMENSIONS
The gracilis musculocutaneous territory consists of the segment of medial thigh skin directly overlying the
proximal two-thirds of the gracilis muscle and varying amounts of adjacent skin (Figs. 441.2 and 441.3).
Because the gracilis is a long, narrow muscle, it is quite possible to locate the skin island improperly, which will
result in skin necrosis.
A straight line is first drawn on the skin between the easily palpated adductor longus origin at the pubic tubercle
and the semitendinosus tendon at the knee. The line should be drawn on the medial thigh skin prior to putting
the patient in the lithotomy position, since in postures where the knee is flexed, the lax gracilis migrates
somewhat posteriorly and topographic skin landmarks may be unreliable. This is particularly true in obese
patients and patients with loose skin. The line should be drawn with the patient supine and with the leg straight
and slightly abducted.
The skin paddle should be designed posterior to the line. For practical purposes, a skin island can usually be
relied on with maximum dimensions of 8 cm in width and 22 cm in length.
FIGURE 441.3 Gracilis musculocutaneous territory. A straight line is drawn between the adductor longus tendon
at the pubic tubercle (x) and the tendon of the semitendinosus (x). The gracilis musculocutaneous territory lies
completely posterior to this line (Sa, sartorius; Gr, gracilis). (From Heckler, ref. 14, with permission.)
The survival of the skin overlying the distal third of the muscle is less reliable. Several possible reasons have
been suggested for this. (1) The sartorius in the distal thigh partially overlies the gracilis, separating it from the

overlying skin. (2) The majority of musculocutaneous perforators emerging from the gracilis are located
proximally, with few, if any, distally. (3) Approximately 60 percent of cadaver dissections will demonstrate a direct
cutaneous branch of the superficial femoral artery that at least partially supplies the skin in the area. Regardless
of which factor is primarily causative, wide clinical experience indicates that the skin overlying the distal third of
the muscle should not be included in the gracilis musculocutaneous flap. If the clinical situation demands
inclusion of this skin, the area should be carefully evaluated with intravenous fluorescein prior to flap inset (26).
OPERATIVE TECHNIQUE
Gracilis Muscle Flap
Since no skin paddle is planned, the skin incision may run the full length of the thigh. The saphenous vein and
nerve will be seen during the initial skin reflection and should be preserved. The gracilis is easily identified,
particularly in the distal thigh, where its rounded tendon is seen lying between the obliquely longitudinal muscle
fibers of the sartorius anteriorly and the wider, flat fascial expansion of the semimembranosus posteriorly.
Dissection proceeds from distal to proximal. The gracilis tendon is circumferentially dissected and divided.
Dissection in a proximal direction is in an essentially bloodless plane and proceeds rapidly. All vascular pedicles
to the gracilis approach from an anterior direction and enter the muscle on its deep surface. The minor, more
distal pedicles are ligated as they are encountered. The adductor longus is retracted as the proximal half of the
gracilis is dissected, allowing easy identification of the major neurovascular pedicle.
Absolute skeletonization of the vessels is usually not necessary and adds some element of risk in terms of vessel
spasm or injury. The dominant vascular pedicle is the center of the functional arc of rotation of the flap, and
further dissection adds only minimally to its functional reach.
The flap is transferred to the planned recipient site through either a subcutaneous or submuscular tunnel,
depending on the circumstances. This tunnel must be of appropriate dimensions to preclude vascular
compression of the muscle pedicle. The donor site is closed primarily in layers over a suction drain.
Gracilis Musculocutaneous Flap
It is easiest to begin the dissection distal to the skin paddle by first incising longitudinally along the topographic
line for a short distance. Initial dissection can then be carried out for localization of the gracilis without concern
for separating the cutaneous portion of the flap from the muscular portion. The rounded gracilis tendon is found
just above the knee, lying between the obliquely directed sartorius fibers and the flat semimembranous fascial
expansion.
The gracilis tendon should be circumferentially dissected and then placed under tension. The skin-paddle design
must then be reexamined to ensure that it has been properly located, centered over the longitudinal axis of the
gracilis muscle. Improper location of the skin-paddle design and subsequent partial separation of the skin and
muscle components of the musculocutaneous unit are, in my opinion, the most common causes of failure in use
of this flap.
Once correctness of flap design is ensured, dissection proceeds rapidly. The gracilis tendon is transected, and
the skin-island incisions are deepened to fascial level. Dissection proceeds in the avascular fascioareolar plane
between the adductor longus and gracilis. The more distal, minor vascular pedicles of the gracilis are divided as
they are encountered. The adductor longus is retracted anteriorly, and the critical dominant proximal pedicle of
the gracilis is easily seen running between the adductor longus and brevis, entering the gracilis 8 cm distal to the
pubic tubercle.
The skin edges are temporarily sutured to the muscle to prevent inadvertent disruption of the important
musculocutaneous perforating vessels, and the gracilis is dissected free posteriorly by dividing the

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semimembranosus fascia.
The proximal vascular pedicle is the center of the functional arc of rotation of the flap, and further dissection of
the muscle proximal to the major pedicle is therefore generally of no benefit. Incision and elevation of the gracilis
fascia proximally may occasionally be of aid in allowing easier rotation and relocation of the flap.
The donor site is closed primarily over a suction drain. Some tension is invariably present, but I have not needed
to resort to skin grafting the donor site in any of my patients, and scars have been acceptable.
General Perineal Reconstructions
When highly vascular flaps with bulk are needed to fill defects that have considerable depth, it is occasionally
helpful to fill such perineal cavities with a gracilis muscle flap and then to cover the surface with a gracilis
musculocutaneous flap from the opposite side (Fig. 441.4).
FIGURE 441.4 Patient with massive perineal fistulas and sinuses from inflammatory bowel disease. A: The
perineal defect communicates with a large rectocutaneous fistula, as well as a large urethrocutaneous fistula.
Preliminary diverting colostomy and suprapubic cystostomy have been performed. B: Gracilis muscle and
musculocutaneous flaps dissected and delivered to perineum. Muscle flap will be applied to help seal
urethroperineal fistula following closure. Muscular portion of musculocutaneous flap will be applied to seal
rectoperineal fistula following rectal closure, and skin will then be used to resurface area. C: Result 6 months
postoperatively at time of colostomy closure.
Correction of Intractable Vaginal Prolapse
In this condition, bilateral gracilis muscle flaps may be developed and tunneled behind the posterior vaginal wall.
The tendons are each sutured to the opposite adductor longus tendon under considerable tension. It has been
reported that gracilis muscles transferred in such a fashion provide reliable dynamic support for the lax vaginal
wall (14).
Anal Sphincter Reconstruction

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Voluntary control of gracilis motor function must be present. The gracilis muscle is mobilized, tunneled to the
perineum, and passed circumferentially around the rectum. It is then sutured to the opposite ischial periosteum.
The gracilis is not normally synergistic with the rectal sphincters, and considerable postoperative bowel habit
rehabilitation is required.
Vaginal Reconstruction
The patient is in the lithotomy position (Fig. 441.5). Bilateral gracilis musculocutaneous flaps are elevated and
passed through generous subcutaneous tunnels to the perineum. Here, the neovagina is constructed, suturing
the flaps to each other in pouchlike fashion, skin side in. The neovaginal pouch is deposited into the
perineopelvic defect, with the distal ends of the flaps becoming the neovaginal apex and the proximal flaps
becoming the vaginal orifice. A vaginal vault approximately 15 cm in depth results, with no tendency toward late
contraction and no need for obturation.
Urethrocutaneous Fistulas
It is safest to perform definitive fistula closure when local tissue reaction has regressed and infection is well
controlled (Fig. 441.6). To this end, initial temporary urinary diversion, fistula debridement, and urethral
marsupialization are performed. Definitive repair is usually done 4 to 6 months later.
The gracilis muscle is dissected and passed subcutaneously to the base of the penis. The musculocutaneous
flap is too bulky for inclusion in penile urethral repair. Therefore, if additional skin is required, a skin graft is
applied to the transferred muscle. Mucosal closure of the fistula is carried out, and the transferred muscle is
sutured over the mucosal suture line in watertight fashion. If inadequate mucosa for urethral reconstitution is
present, a skin graft is tubed over the urethral catheter and the muscle is then applied. Skin closure over the
muscle is performed using carefully mobilized local tissues or a skin graft.
Vesicovaginal, Rectovaginal, and Rectocutaneous Fistulas
Local infections and acute tissue reaction must first be controlled. This requires diversion of the urinary stream. A
preliminary diverting colostomy is, likewise, advisable for management of rectovaginal or rectocutaneous fistulas
(Fig. 441.7).

FIGURE 441.5 Vaginal reconstruction with bilateral gracilis musculocutaneous flaps. A: Gracilis
musculocutaneous flap designed on thigh for use in primary vaginal reconstruction following pelvic exenteration.
B: Bilateral gracilis musculocutaneous flaps tunneled to perineum. Posterior suture line already in place for
formation of vaginal pouch. C: Vaginal pouch completely inset. Distal ends of gracilis musculocutaneous flaps
form neovaginal apex, while proximal ends form neovaginal orifice. Abdominal surgery with formation of ileal loop
bladder and permanent colostomy progresses simultaneously with vaginal reconstruction. D: Reconstructed
vagina easily admits full length of vaginal speculum. (From Heckler, ref. 14, with permission.)
FIGURE 441.6 Muscle flap for urethrocutaneous fistula repair. The urethra is reconstituted by closing the
remaining urethral tissue or with local turnover flaps. If local tissue is inadequate, the urethra may be
reconstructed with a skin graft tubed over an indwelling catheter. The muscle flap is tunneled subcutaneously to
the repair site and interposed between the urethral repair and the overlying skin closure. If skin cover is
inadequate, a skin graft is placed on the outside of the muscle (m) in preference to using a musculocutaneous
flap, which is too bulky. (From Heckler et al., ref. 16, with permission.)

FIGURE 441.7 Closure of vesicovaginal fistula with gracilis musculocutaneous flap. The muscle or
musculocutaneous flap is interposed between the bladder and vaginal suture lines. The flap also can be
interposed between the rectum and vagina if this is the site of the fistula. If there is a vaginal mucosal deficit, the
musculocutaneous flap is chosen to supply additional skin (bl, bladder; m, gracilis muscle; Sk, cutaneous portion
of gracilis muscle flap; v, vagina). (From Heckler, ref. 14, with permission.)
FIGURE 441.8 Hemivaginal reconstruction for necrosis of posterior vaginal wall and large rectovaginal fistula
following therapeutic irradiation. A: Patient with necrosis of posterior vaginal wall and large rectovaginal fistula
following pelvic irradiation. Previous diverting colostomy has been performed. Excision of fistulous tract and
remaining posterior vaginal wall has been carried out. Unilateral gracilis musculocutaneous flap designed on
inner thigh. B: Reconstruction of rectum has been performed using available local mucosa. Cutaneous portion of
gracilis musculocutaneous flap reconstitutes posterior vaginal wall (seen between retractors), and gracilis muscle
is interposed between vaginal mucosal reconstitution and rectal reconstruction. C: Vaginal reconstruction allows
easy and full access with vaginal speculum, and rectal muscle is sutured over the bowel closure to seal it off,
and the skin segment allows tension-free skin closure.
A transvaginal approach will usually allow adequate exposure for excision of the fistula tract and mucosal

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closure, although a transabdominal approach may occasionally be required. The gracilis muscle flap is employed
if remaining vaginal mucosa is adequate for tension-free closure; otherwise, the musculocutaneous flap is used
(Fig. 441.8).
The muscle flap is dissected and tunneled to the fistula site in the usual manner and is interposed between the
rectal or bladder closure and the vaginal suture line. If the musculocutaneous flap is used where there is a lack
of vaginal tissue, it is best to dissect a skin paddle somewhat in excess of the size of the apparent defect.
Delivering excess tissue to the site of the fistula repair allows accurate trimming and precise fitting of the flap to
the defect. Extending the thigh donor incision proximally through the labia also will help greatly in accurate
insetting of the flap in the tight confines of the vagina.
In correction of major rectocutaneous fistulas, excision of considerable amounts of perianal or perineal skin is
often
required, owing to extensive fistulization, induration, and infection. Here, the musculocutaneous flap is most
useful. After debridement and closure of the enteral wall, the gracilis muscle is sutured over the bowel closure to
seal it off, and the skin segment allows tension-free skin closure.
CLINICAL RESULTS
My own clinical experience with gracilis flaps has been acquired from surgery performed on 53 patients.
There were 20 unilateral flaps and 33 bilateral flaps, for a total of 86 flaps. Forty-two musculocutaneous
flaps were used, with the remainder being simple muscle flaps. None of the flaps has failed. This success
rate is particularly gratifying because the gracilis musculocutaneous flap seems to have gained some
notoriety for relative lack of reliability.
SUMMARY
I feel that with proper care in flap design and dissection, gracilis muscle and musculocutaneous flaps are
quite reliable. They remain useful and versatile tools in the armamentarium of the reconstructive surgeon
who is called on to repair difficult wounds in the perineum.
References
1. Bartholdson L, Hulten L. Repair of persistent perineal sinuses by means of a pedicle flap of musculus
gracilis. Scand J Plast Reconstr Surg 1975;9:74.
2. Bostwick J III, Hill HL, Nahai F. Repairs in the lower abdomen, groin, or perineum with myocutaneous or
omental flaps. Plast Reconstr Surg 1979;63:186.
3. Baek SM, Greenstein A, McElhinney AJ, Aufses AH Jr. The gracilis myocutaneous flap for persistent
perineal sinus after proctocolectomy. Surg Gynecol Obstet 1981;153:713.
4. Ward MW, Morgan BG, Clark CG. Treatment of persistent perineal sinus with vaginal fistula following
proctocolectomy for Crohn's disease. Br J Plast Surg 1982;69:228.

5. Bell JG, Weiser EB, Metz P, Hoskins WJ. Gracilis muscle repair of perineal hernia following pelvic
exenteration. Obstet Gynecol 1980;56:377.
6. Page CP, Carlton PK Jr, Becker DW. Closure of the pelvic and perineal wounds after removal of the
rectum and anus. Dis Colon Rectum 1980;23:2.
7. Sorosky JI, Bass DM, Curry SL, Hewett WJ. Gracilis myocutaneous flap as a life-saving procedure in
control of necrosis following radiotherapy and radical surgery for pelvic malignancy. Gynecol Oncol
1982;13:405.
8. Dibbell DG. Dynamic correction of intractable vaginal prolapse. Ann Plast Surg 1979;2:254.
9. Pickrell K, Masters F, Georgiade M, et al. Rectal sphincter reconstruction using gracilis muscle transplant.
Plast Reconstr Surg 1954;13:46.
10. Landeen JM, Habal MB. The rejuvenation of the anal sphincteroplasty. Surg Gynecol Obstet
1979;149:78.
11. Kalisman M, Sharzer LA. Anal sphincter reconstruction and perineal resurfacing with a gracilis
myocutaneous flap. Dis Colon Rectum 1981; 24:529.
12. Maruyama Y, Ohnishi K, Hashimura C. Functional reconstruction of anal constriction using a gracilis
musculocutaneous flap. Acta Chir Plast 1983;25:76.
13. McCraw JB, Massey FM, Shanklin KD, et al. Vaginal reconstruction with gracilis myocutaneous flaps.
Plast Reconstr Surg 1976;58:176.
14. Heckler FR. Gracilis myocutaneous and muscle flaps. Clin Plast Surg 1980;7:27.
15. Graham JB. Vaginal fistulas following radiotherapy. Surg Gynecol Obstet 1965;120:1019.
16. Heckler FR, Aldridge JE Jr, Somprasong S, Jabaley ME. Muscle flaps and musculocutaneous flaps in the
repair of urinary fistulas. Plast Reconstr Surg 1980;66:94.
17. Larson DL, Bracken RB. Use of gracilis musculocutaneous flap in urologic cancer surgery. Urology
1982;19:148.
18. Heckler FR, Dibbell DG, McCraw JB. Successful use of muscle flaps on myocutaneous flaps in patients
with sickle cell disease. Plast Reconstr Surg 1977;60:902.
19. Orticochea M. The musculocutaneous flap method: an immediate and heroic substitute for the method of
delay. Br J Plast Surg 1972;25:106.
20. Orticochea M. A new method of total reconstruction of the penis. Br J Plast Surg 1972;25:347.

21. Hester TR, Hill HL, Jurkiewicz MJ. One-stage reconstruction of the penis. Br J Plast Surg 1978;31:279.
22. Wheeless CR, McGibbon B, Dorsey JH, et al. Gracilis myocutaneous flap in reconstruction of the vulva
and female perineum. Obstet Gynecol 1979;54:97.
23. Persky L, Resnick M, Desprez J. Penile reconstruction with gracilis pedicle grafts. J Urol 1983;129:603.
24. Westfall CT, Keller HB. Scrotal reconstruction utilizing bilateral gracilis myocutaneous flaps. Plast
Reconstr Surg 1981;68:945.
25. Parkash S. The use of myocutaneous flaps in block dissections of the groin in cases with gross skin
involvement. Br J Plast Surg 1982;35:413.
26. McCraw JB, Myers B, Shanklin KD. The value of fluorescein in predicting the viability of arterialized flaps.
Plast Reconstr Surg 1977;60:710.

Chapter 442
Transverse Gracilis Musculocutaneous Flap
N. J. YOUSIF
H. S. MATLOUB
R. KOLACHALAM
B. K. GRUNERT
J. R. SANGER
EDITORIAL COMMENT
The transverse reorientation of the skin flap has allowed far greater survival than trying to base the flap
along the length of the muscle. Survival is based on the anatomic dissection showing the transverse nature
of the blood supply to the overlying skin.
The transverse gracilis musculocutaneous flap can be utilized both for filling smaller osseous cavities and for
coverage of soft-tissue deficits. A transverse cutaneous paddle follows the direction of the blood vessels, rather
than that of the muscle fibers, allowing for maximum cutaneous perfusion, simplifying the dissection, and limiting
the effects of skin mobility seen in traditional flap patterns.
INDICATIONS
The traditional concept that the blood supply to the muscles and their overlying skin could be considered
nearly synonymous (1, 2, 3, 4) implied that complete muscle survival would naturally result in complete
survival of all the overlying skin. The gracilis muscle did not always conform to that supposition. Previous
vertical orientation of the skin component of the gracilis musculocutaneous flap (5, 6, 7, 8, 9, 10, 11, 12,
13), because of skin mobility, often allowed for elevation outside the skin territory of the muscle perforators.
Recent anatomic studies and analysis of the musculocutaneous vessels of the gracilis (14) reveal a strong
transverse tendency of the musculocutaneous vessels and demonstrate that only a small portion of the
gracilis muscle is necessary to encompass all the musculocutaneous or septocutaneous perforators from
the proximal pedicle.
ANATOMY
Cadaveric anatomic and latex injection studies have determined that the cutaneous vessels of the gracilis
consistently connect to the surrounding cutaneous vessels through dynamic interarterial gateways (14) (Figs.
442.1, 442.2, 442.3). This allows extension beyond the anatomic vascular territory in both transverse and vertical
directions (Fig. 442.4). The proximal pedicle enters the gracilis muscle 10 ± 2 cm below the pubic tubercle. The
dissections identify both septocutaneous and musculocutaneous perforators from the proximal gracilis pedicle.
These branches have a pronounced tendency to travel in a transverse direction, supplying the cutaneous
territory over the adductor longus and sartorius anteriorly, and extending for >5 cm beyond the posterior margin
of the gracilis muscle (Fig. 442.5). This allows a transverse design of the gracilis musculocutaneous flap, such
that the vascular perforators are invariably included in the cutaneous portion of the flap.

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FLAP DESIGN AND DIMENSIONS
When transversely oriented, the cutaneous paddle follows the direction of the blood vessels, rather than that of
the muscle fibers, and is centered over the main pedicle, i.e., about 10 cm below the pubic tubercle. This allows
for maximum
cutaneous perfusion by matching the cutaneous axis to that of its blood supply. The design also simplifies the
dissection, allowing more secure placement of the preoperative outline of the cutaneous paddle, and limiting the
variability due to skin mobility in the traditional flap pattern (11, 12, 13). The anterior limit of the ellipse shape
may overlie the surface marking of the superficial femoral artery, and the posterior limit is the posterior midline of
the thigh. The width of the cutaneous segment is determined by the amount of skin in the upper medial thigh that
would allow direct closure. Flaps have been transferred measuring 25 × 10 cm, with complete cutaneous
survival. Another advantage is that the location of the final scar may be more hidden.
FIGURE 442.1 A left lower extremity after elevation of the cutaneous flap. Two large musculocutaneous
branches from the proximal pedicle (arrow) of the gracilis muscle divide in the anterior subcutaneous tissue after
they exit the muscle. (From Yousif et al., ref. 14, with permission.)
FIGURE 442.2 Segmental subcutaneous vessels from the superficial femoral artery are noted to perfuse the skin
over the middle portion of the gracilis muscle (G). (From Yousif et al., ref. 14, with permission.)

FIGURE 442.3 In this dissection of a right lower extremity, a large septocutaneous branch (arrow) is seen
dividing into anteriorly- and posteriorly-directed vessels. In the dissection, no large musculocutaneous branches
were noted from the proximal pedicle of the gracilis muscle (G). (From Yousif et al., ref. 14, with permission.)
FIGURE 442.4 Design of the transverse gracilis flap centers the cutaneous paddle over the main pedicle of the
gracilis muscle. (From Yousif et al., ref. 14, with permission.)

FIGURE 442.5 The cutaneous perforators from the proximal pedicle of the gracilis muscle were characterized by
vectors beginning at their origin, following their course, and ending at the point where the vessel terminated in
the subdermal plexus. (From Yousif et al., ref. 14, with permission.)
SUMMARY
The musculocutaneous perforators from the proximal pedicle of the gracilis muscle tend to orient
themselves in a transverse direction. This allows for a transverse orientation of the cutaneous paddle of the
gracilis muscle and provides a flap that can be utilized for reconstructions that fill smaller osseous cavities
and restore soft-tissue losses.
References
1. Tansini I. Sopra it nuovo processo di amputatzione della mammella. Gazetta Med Ital 1906;57:141.
2. Bakamjian VY, Littlewood M. Cervical skin flaps for intraoral and pharyngeal repair following cancer
surgery. Br J Plast Surg 1964;17:191.
3. Owens N. A compound neck pedicle designed for repair of massive facial defects: formation, development,
and application. Plast Reconstr Surg 1955;15:369.
4. Orticochea M. The musculocutaneous flap method—an immediate and heroic substitute for the method of
delay. Br J Plast Surg 1972;25:106.
5. Mathes SJ, McCraw JB, Vasconez L. Muscle transposition flaps for coverage of lower extremity defects:
anatomic considerations. Surg Clin North Am 1974;54:1337.

6. McCraw JB, Massey FM, Shanklin MD, Horton DE. Vaginal reconstruction with gracilis myocutaneous
flaps. Plast Reconstr Surg 1976;58:176.
7. Vasconez L, Bostwick J III, McCraw JB. Coverage of exposed bone by muscle transposition and skin
grafting. Plast Reconstr Surg 1974;53:526.
8. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of independent myocutaneous vascular
territories. Plast Reconstr Surg 1977;60:341.
9. Mathes SJ, Nahai F. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: C. V. Mosby, 1979.
10. Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical
correlation. Plast Reconstr Surg 1981;67:177.
11. Labanter HP. The gracilis muscle flap and musculocutaneous flap in the repair of perineal and ischial
defects. Br J Plast Surg 1980;33:95.
12. Harii K, Ohmori K, Toni S. Free gracilis muscle transplantation with microneurovascular anastomoses for
the treatment of facial paralysis. Plast Reconstr Surg 1976;57:133.
13. Webster MHC, Soutav DS. Gracilis. In: Practical guide to free tissue transfer. London: Butterworths,
1986. Pp. 104-107.
14. Yousif NJ, Matloub HS, Kolachalam R, et al. The transverse gracilis musculocutaneous flap. Ann Plast
Surg 1992;29:482.

Chapter 443
Local Skin Flaps of The Penis
C. E. HORTON
I. B. KAPLAN
EDITORIAL COMMENT
The use of local tissue, particularly in this specialized area, is always preferable to the use of outside flaps
or skin grafts.
The function of the penis as a conduit for urine and sperm, as well as its erectile capability for sexual activity,
requires that it be covered with pliable, well-vascularized skin. Skin loss causing superficial genital scars can
usually be repaired with skin grafts of varying thickness. However, when underlying structures, most commonly
the urethra, need reconstruction, the area of surgery must be covered with normal, pliable, well-vascularized skin
in the form of flaps.
INDICATIONS
Tissue defects of the penis may be congenital or acquired. Acquired conditions include trauma, acute or
chronic infections, premalignant or malignant conditions, and burns that can cause structural loss in the
genital area. By far the majority of local flaps for reconstruction of the penis and urethra have been
presented in the voluminous literature dealing with the repair of congenital anomalies of the genital area,
viz., hypospadias and epispadias.
To date, more than 300 procedures have been described for the repair of hypospadias—the majority of
them using some form of local skin flaps for construction of the urethra and coverage of the penile shaft
after release of chordee. Urethral fistulas continue to be the most common complication of hypospadias
surgery, and repair of these and other acquired fistulas constitutes the most common reason for the use of
local penile flaps.
Because of the laxity of penile skin and its favorable blood supply, local flaps, either alone or in
combinations, can be ingeniously devised to repair and cover most penile defects. It is perhaps simplest to
classify local penile flaps as (1) scrotal, (2) penile shaft, (3) glanular, and (4) preputial.
OPERATIVE TECHNIQUE
Scrotal Flaps
The scrotum is a convenient source of the flaps for the penis and perineum, and possible flap designs are
boundless. Scrotal hair-bearing skin (1) has been abandoned as a means of urethral reconstruction because of
accumulations of calcareous deposits on the hairs, with the potential for obstruction and infection.
Scrotal flaps have been used as coverage of the ventral surface of the penis after urethroplasty (2, 3, 4, 5, 6)
(Figs. 443.1 and 443.2). Scrotal advancement (7) and transposition flaps (8) (Fig. 443.3) have long been used
for coverage of the base of the denuded penis.
A bipedicle scrotal flap (9) (Fig. 443.4) can be used to cover the entire penile shaft. The penis is buried in a bed

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under the scrotal skin, and the glans is extruded through a buttonhole placed in the dependent portion of the sac.
At a second procedure, the penis is freed from its scrotal bed by bilateral incisions diverging from the glans. The
scrotal flap now adhering to the dorsolateral penile shaft is closed along its ventral aspect, a Z-plasty being
incorporated to interrupt the linear closure.
Transposed flaps of scrotal dartos muscle (Fig. 443.5) have been used by the senior author to reinforce suture
lines over repaired urethral fistulas. The advantages of scrotal flaps include the ease and rapidity with which
they can be elevated, the fact that they are directly adjacent to the penis, and that the scrotal donor site can be
closed primarily without difficulty. Ideally, scrotal flaps should be used for the base of the penis, and not distally.
The disadvantages of scrotal flaps relate to the unsightly cosmetic appearance of the rugose hairy skin on the
penile shaft and to the torsional effect that larger flaps produce on the erect organ. Additionally, these flaps will
not reach the penile tip without much difficulty.
Penile Shaft Flaps
One-stage hypospadias repairs (10, 11, 12, 13, 14, 15) using penile shaft skin flaps based on the hypospadic
meatus have achieved recent popularity (12, 13, 14). In one technique (Fig. 443.6), a lateral flap of ventral skin
based on the meatus and extending distally onto the inner surface of the prepuce is tubed over a catheter and
brought out to the penile tip. A subcutaneous “mesentery” can be left to vascularize the urethral flap along its
length.
FIGURE 443.1 A-F: Cecil-Culp coverage of ventral urethra with scrotal flaps after urethral reconstruction.

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FIGURE 443.2 A-F: Wehrbein-Smith urethroplasty with tubed scrotal flap.
FIGURE 443.3 A-C: Scrotal transposition flap.

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FIGURE 443.4 A-F: Bipedicle scrotal flap.
FIGURE 443.5 A-D: Dartos flap transposed to cover repaired ventral urethral fistula.

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FIGURE 443.6 A-F: DesPrez-Persky urethroplasty using ventral penile skin extending onto the inner prepuce as
a vascularized flap.
The “flip-flap” procedure (14, 15) (Fig. 443.7) involves the construction of a new distal urethra from a triangular
flap of skin based on the meatus and “flipped” distally to form the ventral and lateral sides of the urethra, the roof
being completed by a V-shaped glanular flap.
Penile Shaft Flaps for Repair of Urethral Fistulas
Penile urethral fistulas have taxed the ingenuity of surgeons for decades. Various local flaps have been
described both for closure of the fistula itself and for coverage of the repair. Turnover or “hinge” flaps based on
the side of the fistula (16) and then flipped over like a trapdoor have been used to place an epithelial lining on
the urethral side of the fistula. A dermal flap (17) incorporating an epidermal flap has been designed as a “cork”
to plug a fistulous hole in the urethra (Fig. 443.8).
Various procedures have been described to achieve a twolayer closure over a fistula. After repair of the fistula, a
deepithelialized flap is mobilized and advanced from one side of the fistula and covered by a full-thickness flap
mobilized from the opposite side.
A turnover flap based on a subcutaneous mesentery adjacent to a strictured urethra has been described (19)
(Fig. 443.9). Recently, a one-stage urethroplasty (20) for urethral strictures has been described using a
transverse distal island of penile skin constructed on a subcutaneous pedicle and used as a patch or tube to
reconstruct the urethra (Fig. 443.10).

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FIGURE 443.7 A-E: Horton-Devine “flip flap.”
FIGURE 443.8 A-F: Heckler-Mathes dermal flap with epidermal “cork” for urethral fistula repair.

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FIGURE 443.9 A-D: Turnover flap based on subcutaneous mesentery.
FIGURE 443.10 A-E: Penile skin island flap on subcutaneous dartos pedicle.

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FIGURE 443.11 A-E: Transposition flap to cover repaired shaft fistula.
Transposition/Advancement Flaps and Z-Plasties
The elasticity of the penile skin can be used to cover the distal portion of the penile shaft by the simple expedient
of mobilizing the penile skin widely to the base of the penis and then unfurling the tube of rolled back penile skin
to cover the distal defect.
FIGURE 443.12 A-D: Double Z-plasty used to lengthen deficient ventral skin after chordee resection.
Simple rotation flaps can be designed on the penile shaft skin to cover repaired urethral fistulas (16) (Fig.
443.11). A repaired fistula near the base of the penile shaft is more simply covered with a transposed scrotal flap
(16).
Z-plasties can be used to lengthen penile skin and to interrupt linear skin closures between the penile shaft and
the scrotum (22) (Fig. 443.12).

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FIGURE 443.13 A-D: V-shaped glans flap for meatal stenosis.
Glans Flaps
The V-shaped glans flap has been used in both primary hypospadias repair (23) and to correct meatal stenosis,
either as a result of previous hypospadias repair or as a result of cicatricial narrowing secondary to local
inflammation (Fig. 443.13). The dorsal roof of the meatus is incised and allowed to spread open, and the V-
shaped glans flap is advanced into the dorsal meatotomy incision in a Y-to-V fashion.
FIGURE 443.14 A-D: U-shaped distal shaft skin flap for meatoplasty.
The glanular “wing” flaps first described by these authors are used to cover a newly created distal urethra and to
reshape the flattened spadelike glans and give it a more normal conical appearance. Prior to this midline glans
flap design, meatal stenosis was a common occurrence when repaired hypospadic urethras were brought to the
tip of the penis.
A meatoplasty using a U-shaped skin flap can be taken from the underside of the shaft-glans junction (24) (Fig.
443.14). After the meatal stricture has been slit open into healthy urethra, the tongue of skin is sewn into the
defect.

FIGURE 443.15 A-H: Hodgson-Toksu preputial “tumble” flap.
Preputial Flaps
Flaps of preputial skin are useful for coverage of glans defects (25). The double lining of the prepuce means that
the inner surface can still be used when burns and other surface injuries destroy the outer surface. This preputial
double lining can be separated into its inner and outer layer quite simply by blunt dissection and can be
advanced proximally to cover the entire shaft of the penis in some cases, being sutured to the residual
penoscrotal skin or used as an advanced scrotal flap at the base of the penile shaft (26).
Transferring the excess dorsal preputial hood is a well-accepted means of resurfacing the ventral portion of the
penile shaft in hypospadias surgery. The preputial skin is extended and brought to the ventral surface either by
the buttonhole technique (27, 28) or by the longitudinal preputial splitting technique (29), or by simply shifting the
unfolded, trimmed preputial skin around the lateral aspect of the penis (30). The lateral transfer technique is
especially useful to correct minor degrees of penile torsion in association with distal hypospadias.
The double-layered prepuce has been used to create vascularized flaps for a neourethra and coverage of the
ventral penis (31, 32, 33).
The “tumble flap” (Fig. 443.15) uses the central area of the inner leaf of the prepuce, formed into a tube and left
attached to the dorsal preputial skin by subcutaneous attachments. A button- hole flap is used to transfer
prepuce, along with the tubed vascularized skin, to the ventral surface of the penis, where it is used to
reconstruct the urethra proximal to the tip of the penis.
A transverse preputial island flap (Fig. 443.16) of the inner preputial skin is separated with a subcutaneous
tissue pedicle from the dorsal penile skin and spiraled around to the ventrum. This tubed vascularized flap is
then anastomosed to the proximal urethra delivered to the tip of the glans by a coring technique and covered by
Byars-type preputial flaps.
SUMMARY

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The various local flaps available for penile defects have been outlined and their differing indications
discussed.
FIGURE 443.16 A-G: Duckett transverse preputial island flap.
References
1. Rochet B. Nouveau procédé pour refaire le canal pénien dans l'hypospadias. Gaz Hebd Med Chir
1899;4:673.
2. Cecil AB. Hypospadias and epispadias: diagnosis and treatment. Pediatr Clin North Am 1955;2:711.
3. Culp OS. Experiences with 200 hypospadias: evolution of a therapeutic plan. Surg Clin North Am
1959;39:1007.
4. Wehrbein HL. Hypospadias. J Urol 1943;50:335.
5. Smith DR. Surgical treatment of hypospadias. J Urol 1955;73:329.
6. Arconti JS, Goodwin WE. Use of scrotal skin to cover wound defects in the groin and pubic area. J Urol
1956;75:292.
7. Robinson DW, Stephenson KL, Padgett EC. Loss of coverage of the penis, scrotum, and urethra. Plast
Reconstr Surg 1946;1:58.

8. Horton CE, McCraw JB, Devine CJ, Devine PC. Secondary reconstruction of the genital area. Urol Clin
North Am 1977;4:133.
9. Cassen PR, Bonnano PC, Converse JM. Penile skin replacement: indications and techniques. In: Heusten
JT, ed. Transactions of the Fifth International Congress of Plastic and Reconstructive Surgeons. Melbourne,
Australia: Butterworth, 1971.
10. Duplay S. De l'hypospadias périnéo-scrotal et de son traitement chirurgical. Arch Gen Med 1874;23:513.
11. Browne D. Hypospadias. J Postgrad Med 1949;25:367.
12. DesPrez JD, Persky L, Kiehn CL. One-stage repair of hypospadias by island flap technique. Plast
Reconstr Surg 1961;28:405.
13. Broadbent TR, Woolf R, Toksu E. Hypospadias: one-stage repair. Plast Reconstr Surg 1961;27:154.
14. Horton CE, Devine CJ. One-stage repair of hypospadias: a combined approach and plastic procedure.
Norwich, NY: Eaton Laboratories, Medical Film Division, 1960.
15. Bevan AD. A new operation for hypospadias. JAMA 1917;68:1032.
16. Horton CE, Devine CJ, Graham JK. Fistulas of the penile urethra. Plast Reconstr Surg 1980;66:407.
17. Horton CE. Urethral fistulas. In: Horton CE, ed. Plastic and reconstructive surgery of the genital area.
Boston: Little, Brown, 1973;402.
18. Walker D. Outpatient repair of urethral fistulae. Urol Clin North Am 1981;8:582.
19. Orandi A. One-stage urethroplasty. Br J Urol 1968;40:717.
20. Quartey JKM. One-stage penile/preputial cutaneous island flap urethroplasty. J Urol 1983;129:284.
21. Horton CE, Devine CJ. Chordee without hypospadias. In: Horton CE, ed. Plastic and reconstructive
surgery of the genital area. Boston: Little, Brown, 1973;384.
22. Arneri V. Reconstruction of the male genitalia. In: Converse JM, ed. Reconstructive plastic surgery, 2d
Ed. Philadelphia: Saunders, 1977;3907.
23. Horton CE, Devine CJ. Hypospadias. In: Gibson T, ed. Modern trends in plastic surgery. London:
Butterworth, 1966;268-284.
24. Blandy JP, Tressider GC. Meatoplasty. Br J Urol 1967;39:261.
25. Happle R. Surgical treatment of erythroplasia of Queyrat. Plast Reconstr Surg 1977;59:642.

26. Bruner J. Traumatic avulsion of the skin of the external genitalia. Plast Reconstr Surg 1950;6:334.
27. Theirsch C. Behandlung der epispadias. Arch Heilkunde 1869;10:20.
28. Nesbit R. Plastic procedure for correction of hypospadias. J Urol 1941; 45:699.
29. Byars LT. Functional restoration of hypospadias deformities. Surg Gynecol Obstet 1951;92:147.
30. Horton CE, Devine CJ. Hypospadias. In: Converse JM, ed. Reconstructive plastic surgery, 2nd ed.
Philadelphia: Saunders, 1977;3857.
31. Hodgson NB. A one-stage hypospadias repair. J Urol 1970;104:281.
32. Toksu E. Hypospadias: a one-stage repair. Plast Reconstr Surg 1970; 45:365.
33. Duckett JW. Transverse preputial island flap technique for repair of severe hypospadias. Urol Clin North
Am 1980;7:423.

Chapter 444
Glans Skin Flap
G. F. SHUBAILAT
EDITORIAL COMMENT
This is an excellent technique to provide the urethral opening at the tip of the glans.
In the treatment of hypospadias and epispadias, the objectives of a good repair are to straighten the penis by
correcting the chordee and to reconstruct a neourethra with its external meatus opening at the tip of the conical
glans, resulting in a normal- appearing and normally functioning organ (1).
ANATOMY
The dorsal artery of the penis provides most of the blood supply to the cavernous spaces of the spongy glans
penis. The rest is derived from the deep artery and the artery to the bulb. Venous drainage is through the
unpaired dorsal vein of the penis.
The skin of the glans is supplied by the dorsal nerve of the penis, a branch of the pudendal nerve S2-4. The
erectile tissue is supplied by the autonomic cavernous nerves that arise from the lumbar sympathetic ganglia (2).
FLAP DESIGN AND DIMENSIONS
To fulfill the criteria involved in the treatment of hypospadias and epispadias, the use of a V-shaped incision on
the glans to develop one midline flap to line one side of the neourethra and two lateral flaps to produce a more
conical glans has been described and popularized (3). The flap has been used in a single-stage technique for
the primary repair of all types of hypospadias and epispadias (4) and has been adapted as the final stage of
other once-popular multistaged repairs (5).
A triangle is marked with its apex in the midline at the coronal sulcus and its sides diverging distally to a wide
base located at the tip of the penis. These markings are made on the ventral skin in hypospadias and on the
dorsal skin in epispadias. The coronal sulcus is marked, thus defining two lateral glanular wings (Fig. 444.1A).
OPERATIVE TECHNIQUE
A traction suture of 4-0 silk is applied to the glans. I have stopped infiltrating with xylocaine and epinephrine. I
use a Penrose tube as tourniquet to the base of the shaft to allow me to operate in a bloodless field. Hemostasis
is secured at the end of the operation, before final closure of the skin flaps. The two lateral and midline glanular
flaps are dissected free. An incision is made in the midline, starting at the coronal sulcus and extending
proximally to the existing meatus, splitting it for a distance of 0.5 cm into the urethra. The skin edges are
undermined, and any existing fibrous bands causing the chordee are excised (Fig. 444.1B). Straightening of the
penis is confirmed by inducing a simulated erection (6).
The three flaps are now ready to be incorporated into the different techniques for repair of the various types of
hypospadias and epispadias.
The operative steps in distal penile hypospadias repair are depicted in Figure 444.1C-I. In more severe types of
hypospadias, the existing meatus is mobilized to a more proximal position on the shaft, leaving a defect that is
too wide for the midline glanular flap to reach. To bridge this defect, in the uncircumcised patient or where there

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is adequate preputial skin left, I have improved my results and decreased the incidence of stricture and fistula by
constructing a vascularized island flap that is tubed and moved ventrally on its vascular pedicle to reconstruct a
new urethra in defects up to 5 cm. In the already circumcised patient, a tube of free full-thickness preputial skin is
constructed over a catheter splint of appropriate caliber (Fig. 444.2). The proximal end of the free or vascularized
tube is anastomosed obliquely to the existing meatus. Distally, the midline glanular flap is fitted into the seam of
the tube like a tongue in a groove. The glanular wings are then approximated over the tube, and the rest of the
preputial skin is rotated to cover the ventral skin defect.
The same operative principles apply in the treatment of epispadias (Fig. 444.3A-C).
In the treatment of distal glanular stricture with resultant proximal fistulas, a secondary ventral turnover flap can
be developed to widen and reconstruct the strictured segment and incorporate it with the glanular flaps (Fig.
444.4A-E). In more proximal strictures a vascularized island preputial patch flap has been very successful and
reliable in restoring the normal wide caliber in the strictured segment.
In the least severe type, where an external meatus of adequate caliber opens dorsally at the coronal sulcus of a
patulous glans and the absence of chordee is confirmed by simulated
erection, the midline glans flap can be modified and used as a bipedicled flap. It is left in continuity with the floor
of the existing meatus, and a proximal ventral turnover flap is used to reconstruct the roof of the neourethra (as
demonstrated earlier in our treatment of distal glanular urethral strictures with coronal fistulas).

FIGURE 444.1 A: The three glanular flaps and ventral turnover flap outlined. B: Flaps elevated and chordee
excised. C: V-shaped median flap fitted into the dorsal meatotomy. Ventral turnover flap raised. D: Turnover flap
sutured to both sides of the median flap constructing the neourethra. E: The lateral glanular wings interdigitated
over the neourethra and sutured together and to the free distal edge of the turnover flap. F: The prepuce is
unfolded and mobilized. G: Prepuce is rotated to cover ventral defect. H: Operation completed. I: Final result.

FIGURE 444.2 Glans flap depicted. A free preputial tube graft is shown bridging the defect.
In repairs of distal lesions, the urine is diverted with a silicone Foley catheter through the repair for 2 to 3 days. In
more severe types, we discontinued using perineal urethrostomy, and we always use suprapubic Cystocath
drainage for 10 days and a perurethral catheter for splintage and as a safeguard standby drainage in case the
suprapubic drainage blocks.
FIGURE 444.3 Epispadias. A: Preoperative. B: End of one-stage operation. C: A three-month result.
The fluffed pressure dressing is soaked off after 2 days. Some surgeons use cold sterile compresses frequently.
A urinary antiseptic should be administered while the catheter is in place. Lubrication and dilatation of the new
meatus are carried out thrice daily using the nozzle of an ophthalmic antibiotic tube after the removal of the
catheter.
CLINICAL RESULTS
In our series of 800 cases with different types of hypospadias where the glans flap was used in one-stage
repair, I was the main surgeon in 500 cases. Primary healing was attained in 96% of repairs of distal penile
types. Since I have introduced the vascularized preputial island pedicled flap in one-stage repairs of severe
types of proximal hypospadias cases as an alternative to a free preputial skin graft, the incidence of
strictures and fistulas was reduced from 23% early in the series to 11%. While stricture is a common cause
of fistula formation, the latter can occur due to hematoma formation under the very delicate and thin skin
causing breakdown of the suture line or sloughing of skin edges. It is my experience that very few acute
fistulas heal spontaneously by reintroducing a catheter. Established fistulas and strictures are preferably
repaired after a time lapse of 6 months. Dehiscence of the wound occurred in 3% of our early 62 reported

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cases. This was either due to a child forcibly pulling out the catheter or due to infection (which we found to
be more common in adult cases due to the increased sebaceous and sweat gland activity in the operated
areas). Meatal stenosis can be managed by V-Y meatoplasty.
SUMMARY
The glans flap as originally described by Horton and Devine (3) was successfully incorporated into all my
techniques of dealing with different types of hypospadias and epispadias and their complications in a large
series of patients over the last 23 years.
FIGURE 444.4 A: Distal stricture and fistula. B: Stricture released open. C: Secondary turnover and lateral
glanular flaps developed. D: Neourethra constructed over Foley catheter. E: Completed repair.
References
1. Shubailat GF, Ajluni NJ. Experience with the glans flap operation for distal penile hypospadias. Plast
Reconstr Surg 1978;62:546.
2. Gardner E, Gray DJ, O'Rahailly R. In: Temer H, ed. Anatomy. Philadelphia: Saunders, 1975;503.

3. Horton CE, Devine CJ. Hypospadias. In: Gibson T, ed. Modern trends in plastic surgery. London:
Butterworth, 1966;268-284.
4. Horton CE, Devine CJ, Adamson JE, Carraway JH. Hypospadias, epispadias and exstrophy of the
bladder. In: Grabb WC, Smith JW, eds. Plastic surgery. Boston: Little, Brown, 1979;855-868.
5. Bialas RF, Horton CE, Devine CJ. The adaptability of the glans flap in hypospadias repair. Plast Reconstr
Surg 1977;60:416.
6. Horton CE, Devine CJ. Simulated erection of the penis with saline injection: a diagnostic maneuver. Plast
Reconstr Surg 1977;59:670.

Chapter 445
Prepuce Skin Flap
R. HAPPLE
EDITORIAL COMMENT
In an uncircumcised penis, the prepuce is a ready source of local flap material that can be used for a variety
of purposes.
The prepuce skin flap, as described in this chapter, is unique because it need not be moved from its natural
position and consequently has no pivot point. This flap serves to cover large defects of the glans penis and is
especially suitable for the surgical treatment of penile precancerous lesions. The prepuce skin flap can obviously
be used only if the foreskin is still present. However, in view of the fact that precancerous lesions of the penis
very seldom occur in circumcised men, this problem rarely arises.
INDICATIONS
The prepuce skin flap is used mainly in the treatment of erythroplasia of Queyrat (1) (Fig. 445.3) or Bowen's
disease (2) (Fig. 445.4). Moreover, patients suffering from lichen sclerosus et atrophicus of the penis may
be relieved of pain and discomfort by use of this flap technique (3). However, if one of these diseases has
involved the urethral meatus, other operative measures are required in combination with this flap.
FLAP DESIGN AND DIMENSIONS
The extent of the area to be excised is first outlined on the glans penis. The prepuce is then stretched over the
glans, and the flap is outlined in correspondence to the expected defect on the glans (Fig. 445.1A and B), with its
base running parallel to the coronary sulcus. The remaining circumference of the external part of the prepuce is
resected following the coronary sulcus.
OPERATIVE TECHNIQUE
The flap is raised by blunt dissection from the internal part of the prepuce (Fig. 445.1C), and the prepuce is
removed by resecting its internal part along the coronary sulcus. The excision of the lesion on the glans is made
next (Fig. 445.1D), and the defect is covered by the prepared skin flap. The remaining wound edges are sutured
along the coronary sulcus (Fig. 445.1E).
If the entire surface of the glans has to be reconstructed, the flap comprises the total circumference of the
external part of the prepuce. In this case, triangular incisions are made at the distal part of the flap in order to
adapt it to the conical shape of the glans.
If a penile precancerosis has extended to the adjacent surface of the foreskin, the prepuce skin flap can be
raised in the same way as described before, because the external and internal parts of the prepuce can easily be
separated by blunt dissection (Fig. 445.2).
A great deal of oozing is prevented by preliminary infiltration of the glans with a solution containing a
vasoconstrictive drug.

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CLINICAL RESULTS
The success rate of this flap is very high, provided meticulous hemostasis has been maintained. In my
experience, patients do not suffer any functional deficit after this operation, even after removal of the entire
surface of the glans. Apparently, sexual function does not depend on the presence of the normal skin of the
glans penis.
SUMMARY
The prepuce skin flap is an ideal source of tissue in resurfacing defects of the glans penis.
FIGURE 445.1 A-E: Closure of a defect of the glans by means of a prepuce skin flap.
FIGURE 445.2 Removal of a precancerous lesion involving the glans and the adjacent surface of the
internal part of the prepuce.
FIGURE 445.3 Prepuce skin flap for the treatment of erythroplasia of Queyrat. A: The defect is outlined on
the glans. B: The flap is sutured onto the defect, and the remaining wound edges are closed along the

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coronary sulcus. C: Final result.
FIGURE 445.4 Prepuce skin flap for the treatment of Bowen's disease involving adjacent areas of the glans
and the prepuce. A: Prior to surgery. B: Final result.
References
1. Happle R. Surgical treatment of erythroplasia of Queyrat. Plast Reconstr Surg 1977;59:642.
2. Happle R. Zur operativen Behandlung des Morbus Bowen an der Glans penis. Hautarzt 1972;23:125.
3. Happle R. Chirurgische Behandlung des Lichen sclerosus et atrophicus penis. Dermatol Monatsschr
1973;159:975.

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Chapter 446
Deepithelialized Overlap Skin Flap of The Penis
E. D. SMITH
A penile skin flap is sutured over a deepithelialized flap to provide a strong cover for both primary hypospadias
repair (1, 2, 3, 4) and closure of fistulas (5, 6). This procedure also avoids superimposing another suture line
over the urethral closure.
INDICATIONS
Except for enlarging the distal glanular orifices, for which only meatotomy and hemicircumcision are
suitable, this technique can be used to repair any degree of hypospadias. In many techniques of repair, the
suturing of the outer skin involves edge-to-edge apposition. This is a potentially weak junction, especially if,
in addition, that suture line is superimposed over a deeper line of urethral closure.
FLAP DESIGN AND DIMENSIONS
In the overlap technique, skin closure is achieved by the apposition of two raw surfaces together, produced by
shaving of skin from one side (full thickness) and overlapping the flaps like a double-breasted suit. Tissue
adherence by granulation tissue repair is very rapid and solid, depending as it does on
a broad surface of good vascularity. Further, the flat plate of overlapping skin has two laterally placed suture
lines, so that suture lines are not superimposed.
FIGURE 446.1 A-E: First stage of repair, including skin transfer, correction of chordee, and meatotomy (see text
for description). (From Smith, ref. 1, with permission.)
The preliminary transfer of preputial skin right to the tip of the glans in the first stage ensures that the urethral
tube will be constructed by a single epithelium in continuity, without any “break” or anastomosis between
changes of epithelium from one section to another (as occurs in techniques involving buried strips, free grafts, or
pedicle tubes for part of the length only). Such preliminary transfer also provides sufficient skin for a firm overlap
of deepithelialized layers over the whole length of the repair.
There are no skin appendages (hair follicles or sweat glands) in preputial or penile skin, so the dermis will not
reepithelialize beneath the double layer. The principle of overlapping skin could be applied to the final stages of
any number of techniques (4).
OPERATIVE TECHNIQUE

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The hypospadias repair is performed in two stages. The objective of the first stage is twofold: (1) the correction
of all elements of chordee, and (2) the transfer of the prepuce to the tip of the ventral surface of the glans to
establish viable skin for the subsequent urethral reconstruction. The second stage involves fashioning a
complete skin tube to the tip of the penis, supported by overlapping skin layers and denuded of epithelium on
one side to allow “double breasting” of raw surfaces.
First-Stage Repair
When the patient is 3½ years of age, the first stage of the repair is performed (Fig. 446.1). First, the dorsal
prepuce is cut longitudinally to the coronal groove (Fig. 446.1A). The preputial flaps are denuded of their inner
layer (which is discarded) and rotated from the dorsal to the ventral side (Fig. 446.1B).
An area on the glans on either side of the central blind groove is denuded of epithelium to beyond the tip of the
glans (Fig. 446.1C). At this point, the two raw areas are joined by a transverse incision (line with arrows in Fig.
446.1C), which allows total release of all the penile skin and access to all the elements contributing to chordee
(skin release, Buck's fascia, and central chordee band).
Chordee elements may extend well proximal to the orifice. After this is completed, the preputial flaps are sutured
dorsally and laterally (points B and C in Fig. 446.1E) into the coronal groove. As seen ventrally, the dark areas
represent the inner, denuded surface of the prepuce.
The preputial flaps are then applied ventrally to the glans and sutured right to the tip distally (AA', EE', etc.).
Proximally, the skin flaps join the midline to compensate for any deficiency of skin after correction of the chordee
(Fig. 446.1D). A liberal meatotomy is performed. The extent of the mobilized and sutured prepuce is illustrated
(Fig. 446.1E).
Figure 446.2 shows the end result of the first stage ventrally. The penis is straight, and there is continuous skin
from the orifice to the tip of the glans. No catheter is used.
Second-Stage Repair
Three months after the first stage has been completed, the second phase of the repair is undertaken (Fig.
446.3). A deep ventral U-shaped incision is made from the penile orifice to the tip of the glans, producing a thick
layer of skin (Fig. 446.3A).
This central strip should be 12 mm wide. A complete skin tube is fashioned by inverting the raw edges and
bringing them together ( AA) with continuous 4-0 nylon sutures placed over a temporary no. 10 or 12 French
catheter (Fig. 446.3B). The needle should not penetrate the skin, only the subcutaneous tissue.

FIGURE 446.2 The end result of the first stage, with solid skin continuously from urethral orifice to tip of glans
penis. (From Smith, ref. 3, with permission.)
FIGURE 446.3 A-G: The second stage of repair (see text for description). The deepithelialization is shown in
parts D through F. (From Smith, ref. 1, with permission.)
Further support for this tube is provided by interrupted 5-0 chromic catgut sutures, drawing more subcutaneous
and fascial sutures over the primary suture line (Fig. 446.3C). The lateral skin flaps are undermined, and a deep
incision is made on either side of the tube, halfway through the glans. This maneuver allows the tube to slip into
the substance of the glans, which is closed over the tube as the outer layers of skin are being overlapped (Fig.
446.3E and F).
A 3-mm-wide strip of skin is then shaved from one lateral flap to provide a raw surface (Fig. 446.3D). This is
accomplished, using scissors, by creating two or three narrow strips that commence proximally. The first strip

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should commence laterally, not at the medial edge (Fig. 446.4A).
The medial edge of the shaved skin is then sutured beneath the opposite flap, commencing at the level of the
coronal groove (Fig. 446.3E). This suture line is not superimposed on the primary suture line of the skin tube,
which is now completely covered by the skin flap (Fig. 446.4B and C).
Subsequently, the opposite flap is swung over the raw area and sutured (AA), including the glans tissue at the
glans level, in order to project the skin tube into the substance of the glans (Fig. 446.3F). Tissue adherence of
the denuded areas is very strong, and no suture lines are superimposed. If there is tension, a dorsal relieving
incision is made (Fig. 446.3G). Finally, a suprapubic stab cystotomy (not illustrated) is performed for urinary
diversion for a period of 12 days.
Use in Fistula Closure
The principle of the overlap flaps also may be applied to the repair of a hypospadias fistula (5, 6). The edges of
the fistula are excised, and the urethral mucosa is first closed separately with inverting 5-0 chromic catgut
sutures. The penile skin is undermined, and one side is “shaved” for at least 3 mm beyond either end of the
fistula. The skin is then overlapped to bring the raw flaps together.
CLINICAL RESULTS
Of 480 repairs performed, the rate of postoperative fistula formation was 2.3 percent.
SUMMARY
The principle of a deepithelialized overlap flap has been a major contribution to the prevention and
treatment of fistulas in hypospadias repairs.

FIGURE 446.4 A: Creation of the “shaved” area on one side. A small strip is commenced proximally (arrow)
with scissors. This first strip should commence laterally, not on the medial edge. B: A skin strip is excised
and discarded (upper arrow). The lower arrow shows the raw surface of the first strip. Two or three further
strips are then excised, until the full width of raw area is achieved. C: The shaved lateral flap (artery forceps
used only to obtain the photograph). D: Medial edge of shaved area sutured (5-0 chromic catgut) beneath
opposite lateral flap, covering the primary urethral tube. E: Opposite lateral flap brought over the shaved
area. (A and B from Smith, ref. 3, with permission. C through E from Smith, ref. 1, with permission.)
References
1. Smith ED. A deepithelialized overlap flap technique in the repair of hypospadias. Br J Plast Surg
1973;26:106.
2. Smith ED. Multiple-stage hypospadias repair. In: Whitehead ED, Leiter E, eds. Current operative urology.
Hagerstown, MD.: Harper & Row, 1984.
3. Smith ED. Hypospadias. In: Holder TM, Ashcroft KW, eds. Pediatric surgery. Philadelphia: Saunders,
1980.
4. Belman AB. The Broadbent hypospadias repair. Urol Clin North Am 1981; 8:483.

5. Walker RD. Outpatient repair of urethral fistulae. Urol Clin North Am 1981;8:573.
6. Lau JTK, Ong GB. Double-breasted technique for the repair of urethral fistulas after hypospadias surgery.
Br J Urol 1982;54:111.

Chapter 447
Inguinal Skin Flap for Urethral Reconstruction
S. ZENTENO ALANIS
EDITORIAL COMMENT
This procedure might be completed in one stage if a rectangular flap based medially is used. The flap is
then rolled toward the midline, allowing for both the proximal and distal urethral repairs.
Obtaining adequate function in urethral reconstruction of congenital or acquired defects presents multiple
problems. None of the techniques currently described is ideal. Urethral reconstruction has been undertaken
using flaps, pedicle tubes, free grafts, or combined methods (1, 2, 3, 4, 5, 6, 7, 8, 9, 10). Seeking to avoid the
disadvantages of the various procedures, I have been using a technique that employs a tubed flap to reconstruct
urethral segments (11).
INDICATIONS
The advantages of this technique are as follows:
1. Because of flap elasticity, tissues do not suffer retraction, as they do in free grafts.
2. If the anastomoses are done as indicated, it is possible to avoid severe strictures.
3. The skin of this region is hairless.
FIGURE 447.1 Diagrammatic representation of the inguinal skin flap used for urethral reconstruction. The
distal end of the flap can be anastomosed to either the proximal or distal urethral defect, depending on
the defect and the design of the flap.
4. There is ample tissue to reconstruct sizable defects in the urethra.
5. There is no need for grafting in the donor area.
FLAP DESIGN AND DIMENSIONS
A flap is designed in the inguinoscrotal area measuring 10 to 12 cm long and about 4 to 5 cm wide. The base of
the flap should be placed as close as possible to that part of the urethra which is to be reconstructed (Fig.
447.1).