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Shaw et al. Plast Aesthet Res 2021;8:52 https://dx.doi.org/10.20517/2347-9264.2021.53 Page 3 of 11

[15]
preserve sexual function and may be favored in patients of younger age . In addition, de novo persistent
[16]
erectile dysfunction is rare following anterior urethroplasty (~1%) .
Flap characteristics
There are four primary factors that characterize the ideal flap. Flaps should be (1) hairless; (2) accustomed
[17]
to the aqueous environment; (3) adaptable; and (4) cosmetic . Each factor will be discussed briefly, with
more depth provided in the discussion of individual flaps.

Hairless
Flaps should be derived from non-hair bearing skin. Hair in chronic contact with urine will lead to bacterial
urethral colonization, stone formation, and inflammation. Accordingly, penile prepuce and distal penile
shaft skin are preferred over the proximal penile shaft and scrotal skin.

Aqueous environment
Choice of urethral augmentation should preferentially favor tissue that is accustomed to or adaptable to the
aqueous environment. Skin not accustomed to this environment will become inflamed and will be prone to
squamous metaplasia. Chronic inflammation and metaplastic changes are concerning for both stricture
recurrence and malignant transformation. This includes skin that is already diseased with active
inflammatory processes (e.g., LS).

Adaptable
Ideal flaps should provide adequate urethral caliber in varying locations and be mobile enough to treat
strictures in variable locations in the urethra. This includes skip lesion strictures. While non-hair bearing
skin can be found elsewhere in the groin, none is as adaptable as penile skin.

Cosmesis
The creation of suture lines that approximate anatomic skin markings is an important consideration in the
choice of the flap. Concomitant skin conditions such as vitiligo should also be considered for the choice of
flap location. Additionally, the possibility of debilitating another structure is another consideration for flaps,
particularly for use in tissue transfer.

SCROTAL AND GENITAL ROTATION FLAPS
Scrotal and various rotational flaps (e.g., anterior thigh) were popularized prior to the wide use of penile
skin flaps and BMG. Now primarily of historical importance, these flaps tend to fail to meet one or more of
the four factors necessary for flap success. Scrotal flaps were widely used at one point, but the incorporation
of hair-bearing skin into the urethra leads to unacceptable long-term outcomes with stones and
infections [18-24] . Other flaps, including the incorporation of thigh skin which may not be hair-bearing, had
comparatively short pedicles and were not appropriate in the reconstruction of the penile urethra. With rare
exceptions, these skin flaps have been abandoned for use as the urethral replacement.

The use of non-skin pedicled rotational flaps (i.e., gracilis) as an interposition layer for fistula reconstruction
[25]
and in combination with grafting continues to be actively used and investigated . For example, rotational
gracilis flaps have been combined with BMG to manage complex bulbar strictures . A full discussion of
[26]
these cases is outside the scope of this review.