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Dávila et al. Plast Aesthet Res 2022;9:31 https://dx.doi.org/10.20517/2347-9264.2021.133 Page 3 of 12

gold standard for substitution urethroplasty [9,10] . Several factors were responsible for the acceptance of
OMGs as the best urethral substitute, including ready availability and easy manipulation, resistance to
infection, affinity for a humid environment, a thick epithelium and a thin lamina propria, quick
inosculation, and superior medium-term outcomes, which are equivalent to full-thickness cutaneous
grafts .
[10]
Several techniques have been described, each with its own peculiarities. However, there are few comparative
studies. There are three different approaches to the onlay augmentation technique: ventral, dorsal, and
dorsolateral. The ventral route has the theoretical advantage of being faster and without the need for
urethral dissection . However, it needs to be located proximally to the anterior urethra, in the bulbar
[11]
urethra. The dorsal route has the advantage of leaving the graft well fixed to the corpus cavernosum,
eventually allowing better graft take . The dorsolateral approach is an attempt to provide an alternative to
[6]
the other two approaches.

Types of flaps and flap techniques
The ideal flap should be: (1) hairless; (2) accustomed to a wet environment; (3) versatile; (4) cosmetically
[12]
appealing; and (5) produce minimal donor site morbidity . These characteristics provide a good
adaptation of the flap when it is incorporated into the urethra, ensuring good caliber and fluidity for urine
transport.

Historically, several flaps were commonly utilized in penile urethroplasty. Until the widespread utilization
of penile cutaneous flaps and OMGs as techniques of choice, scrotal flaps were popular options. Despite the
historical importance of these scrotal flaps, the incorporation of hair-bearing skin into the urethra led to
unacceptable long-term outcomes due to stones and infections . Other flaps which were non-hair-bearing,
[12]
including thigh skin, had shorter pedicles and, therefore, were not appropriate for penile urethroplasty .
[12]
However, for urethral fistula closure and reconstruction with interpositions layers in combination with
grafting, the use of non-cutaneous pedicled rotational flaps (i.e., gracilis muscle) continues to be actively
used and investigated .
[13]

PATIENT SELECTION AND SELECTION OF THE RIGHT TECHNIQUE
The preoperative evaluation of the patient is essential before deciding on the smallest procedure to be
performed. For this purpose, the patient must be considered as a whole, including age and comorbidities, as
they can interfere with both intraoperative and postoperative periods. These comorbidities, such as
smoking, the patient’s ability to be in lithotomy, previous surgeries, and diabetes mellitus, among others,
[10]
may impact on peripheral blood supply and compromise effective healing and surgical success . Another
fundamental aspect when selecting the surgical incision site is the evaluation of the skin and tissues, always
taking into consideration the care that the patient should have postoperatively [14,15] .

Physical examination to assess the integrity of the penile/genital skin and concomitant wounds, fistulas, or
abscesses is also important in selecting the proper locations for flaps and grafts. The use of skin affected by
lichen sclerosus (LS) should not be advised for urethral reconstruction. Currently, there is a high tendency
to use oral mucosa graft, causing flaps to lose popularity as a conventional reconstructive option [3,6,8,9,14,15] .

COMBINED TISSUE TRANSFER
The combined tissue transfer is an option for severe urethral stricture or congenital penile anomalies. The
concepts mainly consist in a graft dorsally fixed on the penis covered by a pedicled penile skin flap.