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

Figure 6. Diagrammatic illustration of the combined buccal mucosa graft and dorsal penile skin flap technique for pediatric hypospadias
(from Djordjevic et al. [32] ). A: Severe hypospadias with chordee. B: The short urethral plate is divided. Tunica albuginea is plicated
dorsally to straighten the penis. C: A longitudinal skin flap is harvested from dorsal penile skin. Two lateral skin flaps will be used for
penile body covering. D: The flap is buttonholed and transposed ventrally. Buccal mucosa is grafted and quilted to the tunica albuginea
starting from urethral meatus up to the tip of the glans. Previously, glans was incised in the midline and its two wings were extensively
mobilized. E: The flap was anastomosed with buccal mucosa graft to create neourethra. All suture lines are covered with well-
vascularized subcutaneous tissue of the flap. Glans is closed without tension. F: Penile skin reconstruction is done using available penile
skin.

Figure 7. Scrotal hypospadias. (A) The short and undeveloped urethral plate is visible. (B) The flap is transposed ventrally. Buccal
mucosa graft is fixed starting from the native urethral meatus to the tips of corporal bodies. (C) A well-vascularized island skin flap is
created from the dorsal penile skin. A hole is made at the base of the flap (from Djordjevic et al. [32] ).

Double graft
[37]
A double-faced dorsal plus ventral onlay urethroplasty described by Palminteri et al. was applied in nearly
obliterative strictures where an isolated graft would be clearly insufficient to achieve adequate lumen caliber
without urethral transection. The strictured segment was opened on the ventral aspect, followed by a
midline incision of the exposed dorsal urethral plate and then followed by dorsal and ventral augmentation
[38]
using two OMGs . In cases where a severe penile curvature was present, Djordjevic et al. [39,40] started to
repair the chordee by ventral tunica albuginea incision and grafting. In patients with a penile length less
than 2.5 cm, preoperative topical hormonal therapy was instituted for a period of three weeks.