We would like to congratulate the authors on their recent publication, “Limited Panniculectomy for Adult Buried Penis Repair.”1 This is a challenging clinical condition that has become more prevalent, most commonly because of the increasing number of overweight and obese male adults.
As the authors of multiple articles on the management of buried penis, we have focused on patient selection, surgical technique, and quality-of-life improvement2–4 in this unique patient population. We feel it necessary to review several key concepts useful for maximizing outcomes in the management of buried penis that were not highlighted in the most recent publication. As for all complex clinical conditions, immaculate patient selection and multidisciplinary care are ideal for a successful result. When evaluating a patient with a buried penis, historical data, including changes in patient weight, evaluation/optimization of coincident medical conditions (e.g., diabetes, hypertension, sleep apnea), travel history, urologic complaints (e.g., urinary tract infections, voiding difficulties, history of circumcision), a thorough sexual history (e.g., erectile function, pain associated with erection, sexually transmitted disease history), and a detailed social history (e.g., smoking, alcohol, drug use, social support network), should be elicited at the initial patient encounter. As the authors highlight, examination of the abdominal and suprapubic fat is an essential component in the surgical plan for buried penis correction. Another critical component is the genital examination for identification of penile soft-tissue contracture requiring surgical release or the need for penile lengthening. In line with a thorough initial history and physical examination, multidisciplinary care with urology is essential. This cooperative approach aids not only in proper patient selection but also in surgical planning and execution, and allows for a tailored approach to each patient.2
The authors’ description of a limited panniculectomy adds another component for the correction of the buried penis. Depending on the orientation and distribution of excess skin and soft tissues of the lower abdomen and mons pubis, modifications of the trapezoid design may be of benefit.4 Penile soft-tissue contracture release has evolved to its current state that uses denuding of the penile shaft superficial to the Buck fascia with preservation of the dorsal penile neuromuscular bundle. We agree with the authors that the skin defect is best reconstructed with a split-thickness skin graft because it lacks hair follicles, graft take rates are high, and the donor site does not require any form of reconstructive procedure. Distinct from the authors’ use of an occlusive foam/elastic dressing, we recommend the use of negative-pressure wound therapy at 75 mmHg for 5 days.
In summary, a multidisciplinary approach to the management of the buried penis with careful consideration of the overall medical condition of the patient, evaluation and surgical correction of contributors to the buried penis (e.g., lower abdomen, mons pubis, and genital soft tissues), and the application of bolstered skin grafts can optimize outcomes in this patient population that translates to a significant improvement in their overall quality of life.4
The authors have no financial interest to declare in relation to the content of this communication.
Ivo A. Pestana, M.D.
Plastic and Reconstructive Surgery
Wake Forest University
Duncan B. Hughes, M.D.
Detlev Erdmann, M.D., Ph.D., M.H.Sc.
Division of Plastic, Reconstructive, Maxillofacial, and
Duke University Medical Center
1. Figler BD, Chery L, Friedrich J, Wessells H, Voelzke BB. Limited panniculectomy for adult buried penis repair. Plast Reconstr Surg. 2015;136:10901092.
2. Pestana IA, Greenfield JM, Walsh M, Donatucci CF, Erdmann D. Management of “buried” penis in adulthood: An overview. Plast Reconstr Surg. 2009;124:11861195.
3. Blanton MW, Pestana IA, Donatucci CF, Erdmann D. A unique abdominoplasty approach in management of “buried” penis in adulthood. Plast Reconstr Surg. 2010;125:15791580.
4. Hughes DB, Perez E, Garcia RM, Aragón OR, Erdmann D. Sexual and overall quality of life improvements after surgical correction of “buried penis”. Ann Plast Surg. 2016;76:532535.
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