A 20-Year Experience with Tissue Expansion for Large Cervical Fascial Defects: An Algorithm Based on Different Clinical Flap Designs.

Over the past 20 years, we have designed various types of expanded cervical flaps for large facial defects and achieved excellent tissue matching. This study was performed to propose a treatment strategy for flap selection for the reconstruction of different facial units. The authors retrospectively reviewed the application of cervical expanded flaps for facial rehabilitation in our department between January 2003 and January 2023. The study included 122 patients with unilateral (62.3%) and bilateral (37.7%) facial deformities ranging from the zygomatic arch to the chin. The median area of the tissue defect was 15.2 × 8.5 cm2 (ranging from 6 × 4 cm2 to 27 × 12 cm2). The expansion period ranged from 61 to 175 days (mean: 86.5 days). Maximum and minimum sizes of pre-expanded cervical flaps were 30 × 13 cm2 to 7 × 5 cm2. All the flaps could be summarized into type 1, an advanced expanded cervical flap; type 2, a wing-shaped expanded cervical flap with overlapping tissue expansion; and type 3, an expanded single-lobed transposition flap rotated based on the anterior neck. Cervical flaps reliably meet the reconstructive requirements for different facial units, especially for large cutaneous defects in the clinic. The selection of these flaps can be planned preoperatively according to the location and size of the defect or lesion.

Deep inferior epigastric vessels for free scapular flap phalloplasty.

We aimed to present our 20-year experience of using the deep inferior epigastric vessels as recipient vessels for free scapular flaps phalloplasty and evaluate the outcomes. Penile reconstruction was performed using a free scapular flap between 2000 and 2020 by the same surgical team. Deep inferior epigastric vessels were used in all the cases. The surgical techniques and outcomes were described. Overall, 73 patients used the deep inferior epigastric artery (DIEA) as the recipient artery. Regarding the recipient veins, 2 veins were anastomosed in 72 (98.6%) patients, 1 deep inferior epigastric vein (DIEV) was used in 1 patient, 2 DIEV in 14, 1 DIEV + superficial inferior epigastric vein (SIEV) in 13, 1 DIEV + superficial circumflex iliac vein (SCIV) in 38, great saphenous vein (GSV) + SCIV in 4, and GSV + SIEV in 3. The mean age and body mass index of the study cohort was 28 years and 24.3 kg/m2, respectively. The shortest follow-up time was 7 months. Eleven patients had flap-related complications. Three patients were readmitted to the operating room within 24 hours, and 2 of them underwent salvage procedures with venous revision. Two patients lost the entire flap. One patient with 3-cm distal portion necrosis required surgical intervention. Three patients experienced urethral necrosis. DIEA is a suitable receptor artery for inflow. The DIEV, SIEV, and SCIV are available options for venous drainage according to the patient anatomical characteristics. The GSV can be an excellent backup for outflow and salvage procedures.

Blood Supply of the Temporal Flap Pedicled With Orbicularis Oculi Muscle: Anatomy and Its Clinical Implications.

BACKGROUND: Traumatic injury or tumor resection can lead to eyelid defects, nasal defects, and cheek defects. The temporal flap pedicled with orbicularis oculi muscle (OOM) can be used to repair these defects. This cadaver-based anatomic study aimed to evaluate the blood supply of this flap and investigate its clinical implications. METHODS: Twenty hemifaces from 10 cadavers were used in this study. The number of arteries supplying OOM of the flap, the diameter of the artery entering OOM, and the maximum width of OOM were recorded. All data were presented as mean±SD values and analyzed using Student t -test. A P value<0.05 was considered statistically significant. RESULTS: Of these 10 specimens, 7 were males and 3 were females. The average age was 67.7 years (range, 53-78 y). The number of arteries supplying OOM was 8.5±1.4 in the male and 7.8±1.2 in the female. The diameter of the zygomatico-orbital artery was detected as 0.53±0.06 mm in the male and 0.40±0.11 mm in the female. The maximum width of OOM was detected as 2.5±0.1 cm in the male and 2.2±0.1 cm in the female. Males had significantly larger average values than females in the diameter of zygomatico-orbital artery and maximum width of OOM ( P =0.012, P <0.001, respectively). However, the number of arteries supplying OOM did not differ significantly between sex ( P =0.322). CONCLUSIONS: We conclude that the blood supply of the temporal flap pedicled with OOM is abundant and reliable. The findings provide surgeons with valuable anatomic knowledge for repairing facial defects with this flap.

Using an Expanded Cervical Flap With an Overlapping Tissue Expansion Technique to Resurface Middle and Lower Facial Defects.

BACKGROUND: Extensive facial burn scars are a tragedy for patients and often pose a great challenge to surgeons because of the high esthetic and functional demands. For patients with healthy skin in the neck region, a cervical flap is highly recommended for facial resurfacing; however, the skin on the midline of the neck often needs more expansion than that on either side, especially for the treatment of large facial defects. The sufficient longitudinal soft tissue in the anterior neck ensures a normal neck shape as well as a normal range of cervical extension, rotation, and lateral flexion. To overcome this, we developed an expanded cervical flap with an overlapping tissue expansion technique to gain more length centrally. METHODS: First, 2 tissue expanders were embedded in the anterior neck region overlapping each other at the midline of the neck. After adequate inflation of the expander, the expanded flap was dissected and rotated to repair defects in the middle and lower face. The anchor position of the flap was placed on the horizontal line of the thyroid cartilage to restore the cervicomental angle. RESULTS: Sixteen patients were treated with this method in this single-center study. All defects affected the middle and lower face, with an area ranging from 135 to 185 cm 2 , and were caused by a massive facial burn. Among them, 12 patients suffered ectropion of the lower lip, 3 suffered limited mouth opening due to scar contraction, and one patient had a cervicomental adhesion. The area of the expanded flap was approximately 163 to 266 cm 2 . The average period of expansion was 89.5 days. Patients were followed up after the operation, with the follow-up period ranging from 6 to 12 months. In all cases, good defect coverage was achieved, with primary closure of the donor sites and a good postoperative cervical configuration. CONCLUSION: We conclude that the expanded cervical flap with the overlapping tissue expansion technique proved to be a reliable method for facial skin reconstruction with functional and aesthetic improvement.

Facial Defects With Infraorbital and Zygomatic Area Reconstruction Using an Expanded Flap Based on the Orbicularis Oculi Muscle: A Long-Term Follow-up.

OBJECTIVE: Reconstruction of facial soft-tissue defects may pose a dilemma for plastic surgeons, as the flaps must be reliable to obtain a natural appearance while minimizing donor site morbidities. This clinical study describes a reconstructive method for infraorbital and zygomatic defects using a pre-expanded rotation flap based on the orbicularis oculi muscle (OOM). METHODS: The surgeries were subdivided into 2 stages. In the first stage of the operation, a 100 to 200 mL expander was placed underneath the temporal area through a hairline incision. In the second stage, after adequate inflation of the expander, the pre-expanded rotation flap based on the OOM of the lower eyelid was raised from lateral to medial to cover the facial defects. RESULTS: In this single-center study from February 2010 to February 2017, 16 patients underwent facial defect reconstruction using the pre-expanded flap based on the OOM. All of the defects were located at the infraorbital and zygomatic regions, and their sizes ranged from 3.0 4.0 to 7.0 14.0 cm. The causes of these defects included postburn scars (37.5%), melanocytic nevus (50%), and hemangiomas (12.5%). In all cases, good coverage was provided for the defects that were in the medial cheek or lower eyelids. There were no flap losses of any kind. There were no major complications, and all minor incidences were treated by minimal procedures. The patients were followed up after surgery, with the follow up ranging from 6 months to 108 months. The follow-up data included postoperative consultations, the defect size, the need for further procedures and the degree of satisfaction. CONCLUSION: The pre-expanded rotation flaps in the lateral facial area based on the OOM can ideally and safely be applied for facial defect reconstruction owing to their reliable blood supply and excellent texture match.

Congenital aphallia associated with congenital urethrorectal fistula: A rare case report.

RATIONALE: Aphallia is an extremely rare congenital malformation of unknown cause, with few reports in the literature. It is usually associated with other urogenital and gastrointestinal anomalies and is believed to be a result of either the absence of a genital tubercle or chromosome polymorphism. Herein, we describe an extremely rare case of congenital aphallia with congenital urethrorectal fistula and describe our treatment for this patient. PATIENT CONCERNS: An 8-year-old boy was brought to our hospital by his parents because of congenital absence of the penis. The child was male per karyotype and had excess heterochromatin on chromosome 9 (46 XY with 9 qh+). No urethral orifice was identified, and urine passed rectally since birth; thus, urinary tract outlet obstruction led to urine reflux from the anus to the epididymis for a long time. The boy had to be placed on prophylactic antibiotics because he developed urinary tract infection and epididymitis almost every day. DIAGNOSIS: Congenital aphallia (46 XY normal male karyotype) associated with congenital urethroretal fistula. INTERVENTIONS: We performed urethral exteriorization via perineal urethroplasty and urethrorectal fistula repair. The parents approved for phallic reconstruction when the boy reached puberty. OUTCOME: A new external urethral orifice was created on the lower scrotum. The urinary reflux was corrected, and the epididymitis symptoms disappeared. The urethral fistula was then closed. At 8 months follow up, the patient was no longer on antibiotics and had no symptoms of urinary tract infection or epididymitis. CONCLUSIONS: Compatible treatment should be adopted to address urinary tract drainage and infection. Management requires a stepwise approach to address needs as they arise. Neophalloplasty should be performed by an experienced team in early adolescence.

Significance and Surgical Options for Nontranssexual Phalloplasty: A Retrospective Single-Center Analysis of 166 Patients.

OBJECTIVE: This study aimed to evaluate the long-term outcomes of phalloplasty and explore the clinical significance and selection of methods for penile reconstruction. METHODS: The same surgical team performed primary phalloplasty in 166 nontranssexual patients using different surgical approaches between September 2000 and September 2020. All patients had at least 6 months of follow-up. Surgical techniques, complications, and outcomes were retrospectively recorded. RESULTS: A total of 166 patients with indications such as penile trauma (n = 68 [41%]), amputation injury (n = 15 [9%]), iatrogenic (n = 13 [8%]), penile aplasia (n = 54 [32%]), genital ambiguity (n = 15 [9%]), and Peyronie disease (n = 1 [0.6%]) underwent different techniques of phalloplasty. Four patients (2.4%) had total flap necrosis, and 17 (10%) had partial flap necrosis. The total urethral complications rate was 32.5% (54 of 166); however, all the patients were able to void while standing after successful corrective surgery. CONCLUSIONS: Individualized selection of appropriate penile reconstruction methods tailored to the cause of penile defect, patients' personal needs, thickness of donor site, and the blood supply of the flap are conducive to achieving satisfactory treatment results, reducing complications, and improving patient satisfaction. We believe that a scapular flap has certain advantages in nontranssexual patients, whereas other flaps also have their own indications.

Scrotal septal flap and two-stage operation for complex hypospadias: A retrospective study.

BACKGROUND: Complex hypospadias is a surgical challenge. AIM: To present the long-term outcomes of two-stage repair of complex hypospadias using a scrotal septal flap. METHODS: This was a retrospective study of patients with complex hypospadias who were operated on between January 1st, 2001, and January 1st, 2019, at a single hospital using a scrotal septal flap (two-stage surgery) or prepuce flap (one-stage surgery; control group). In the scrotal group, the urethra was first repaired using oral mucosa; in the second stage, a scrotal septal flap was used as a second imper-meable layer. Maximal/average urinary flow rates after surgery were compared. All patients were followed for ≥ 6 mo (range: 6-96 mo). RESULTS: Ninety-seven patients were included (46 in the scrotal group and 51 in the prepuce group). The maximal urinary flow rate was 15.4 ± 2.1 mL/s in the scrotal group and 14.3 ± 3.0 mL/s in the control group (P = 0.035). The average urinary flow rate was 8.4 ± 2.3 mL/s in the scrotal group and 7.5 ± 1.5 mL/s in the control group (P = 0.019). The proportion of patients achieving good therapeutic effects was higher in the scrotal group than in the control group [24 (52.2%) vs 16 (31.4%), P = 0.042; 34 (73.9%) vs 25 (49.0%), P = 0.014]. The scrotal flap two-stage surgery was independently associated with a higher maximal urinary flow rate (OR = 2.416, 95%CI: 1.026-5.689, P = 0.044) and with a higher average flow rate (OR = 2.484, 95%CI: 1.054-5.854, P = 0.038). CONCLUSION: In complex hypospadias, a scrotal septal flap could be a versatile and reliable option for resurfacing the penis.

Risk Factors for Urethrocutaneous Fistula Repair After Hypospadias Surgery: A Retrospective Study.

OBJECTIVES: We review our experience in urethrocutaneous fistula (UCF) repair after hypospadias surgery to investigate the risk factors for unsuccessful outcome. METHODS: Two hundred eleven patients had undergone UCF repair in our department from January 2005 to December 2015. This study included 185 patients who were followed up for more than 6 months. The age of patients, size, site and number of UCFs, number of UCF repairs, urethral complications other than UCF, and postoperative infection were included as potential risk factors. Binary logistic regression analysis was used for multivariate analysis. Odds ratio (OR) and 95% confidence intervals (CIs) were calculated. Stratified analysis and assessment of additive interaction were performed to have a better understanding of the relation between the risk factors. RESULTS: Urethrocutaneous fistula repairs failed in 38 patients (20.5%) at first attempt. In the univariate analysis, size of UCFs (P = 0.012), times of UCF repair (P = 0.008), and postoperative infection (P = 0.044) were statistically related with the outcome of surgery. In the multivariate analysis, only the size of UCFs (P = 0.030; adjusted OR, 2.42; 95% CI, 1.09-5.36) and times of repair (P = 0.008; adjusted OR, 3.09; 95% CI, 1.35-7.07) were identified as risk factors for unsuccessful outcome. We had consistent results in the stratified analysis. No additive or multiplicative interaction between the 2 risk factors was found. CONCLUSIONS: Our study suggested that UCF repairs after hypospadias surgery were easier to fail if one of the UCFs was larger than 2 mm or it had been repaired repeatedly. But when both factors existed, the increase of the risk was not statistically significant. The age of patients, site and number of UCFs, complications other than UCF, and postoperative infection were not significantly related to the success rate of UCF repair.

Pre-Expanded Submental Island Flap for Resurfacing Middle and Lower Facial Defect.

Resurfacing large facial defect is a continuing challenge for plastic surgeons. Skin graft or free flap is hard to obtain satisfactory results or is beyond the skill of most surgeons. The authors performed 13 expended submental island flaps to resurface middle and lower facial defects and achieved satisfactory results. In the first stage operation, the authors implanted one soft tissue expander in the anterior neck region which was expanded over an average of 3 months. In the second stage operation, the authors elevated the expanded submental island flap to resurface facial defect. For the patients who request aesthetic results and allow 2-stage operation, our method provides more satisfactory results. This technique does not require any special skills and is well within the skill of most plastic surgeons.

[Functional evaluation of a "two in one" urethroplasty for hypospadias].

OBJECTIVE: To assess the functional result of a "Two in One" urethroplasty which combined oral mucosa graft and local flap. METHODS: 17 patients with hypospadias underwent a "Two in One" urethroplasty, which combined buccal mucosa and local flap for urethral reconstruction. Uroflowmetry was performed 1 day before and 1 year after operation. The urine flow rate, voided volume and urine flow curves were detected using a rotating sensor. The results of maximum urine flow rate (Qmax) were expressed as percentiles and compared to the Toguri value from normal children. RESULTS: Before corrective operation, 12 of 17 patients (70.6%) produced a plateau urine flow curve. 5 patients (29.4%) produced a very low flow curve. The average maximum flow rate was (7.89 +/- 2.29) ml/s per second compared to Toguri values, 12 of 17 patients (70.6%) had a Qmax below the normal 5th percentile. After a "Two in One" urethroplasty, a hell-shaped curve was obtained in 10 patients (58.8%). The maximum flow rate was (11.30 +/- 3.01) mL/s per second. 7 of 17 patients (41.2%) had a Qmax above the normal 25th percentile, 8 patients (47.1%) had a Qmax between the normal 25th percentile and 5th percentile, only 2 patients (11.8%) had a Qmax below the 5th percentile. CONCLUSIONS: The functional result of the "Two in One" urethroplasty is ideal. The maximum urine flow rate of the patients increases after the operation.

[Which vessel, the artery or the vein is more important in vascular supercharge: an investigation of vascular changes on rat abdominal supercharging flap models].

OBJECTIVE: The study was to reveal the vascular changes in three different supercharging flap models. From this study, we want to investigate which vessel, the artery or the vein is more important in elongating perforator flap survival and why. METHODS: Twelve rats were divided into three experimental groups. The left side flaps in all groups were pedicle using xiphoid perforator as control group. The right side flaps were supercharging experimental group. Group I, flap supercharged based on artery and vein of pubis perforator. Group II, flaps supercharged based on artery of pubis perforator. Group III, flaps supercharged based on vein of pubis perforator. Near-infrared fluorescent angiography was performed using SPY imaging system pre-and-aft operation and all angiography videos were compared and analyzed. RESULTS: Showed in angiography video of SPY, in control group and vein supercharging group, blood supply could be observed the immediately reducing, and almost be disappeared the amount of perfusion to distal area. It shows relatively constant necrosis in the distal side of control group and vein supercharging group, and the necrosis of vein supercharging group smaller than these of control group. In artery, vein supercharging group and artery supercharging group, blood perfusion could be observed separately perfusion in the upper and low area of flap. There are complete survival showed on the artery supercharging group and artery and vein supercharging group. CONCLUSIONS: These findings indicated that congestive flap necrosis attribute to insufficiency of arterial blood. Arterial inflow was demonstrated more important for improved survival of distal flap than venous outflow.

[Penile augmentation and elongation using autologous dermal-fat strip grafting].

OBJECTIVE: To investigate the effect of autologous dermal-fat strip grafting in penile augmentation and elongation. METHODS: From May 2004 to December 2010, 24 patients underwent penile enhancement with free dermal-fat strip grafting. Through suprapubic incision, the superior suspensory ligament and part deep suspensory ligament are cutted off to lengthen the penis. The resulted dead space is filled with the autologous dermal-fat strip (6.0-9.5 cm in length, 1.2-1.5 cm in width and 0.6-0.8 cm in depth) to enhance the penis. RESULTS: Primary healing was achieved in 23 cases. Incisional fat liquefaction happened in one case which healed after dressing change. The penile appearance was satisfactory both at rest or erection. The penile length and circumference increased by 2.5-4.8 cm (average, 3.2 cm) and 1.8-3.0 cm (average, 2.4 cm), respectively. 18 patients were followed up for 3 months to 5 years. All the patients were satisfactory on the cosmetic and functional results. No complication happened. CONCLUSIONS: It is safe and effective for penile augmention and elongation with autologous dermal-fat strip grafting and disconnection of penile suspensory ligament.

Infraorbital and zygomatic reconstruction using pre-expanded rotation flap based on the orbicularis oculi muscle.

Infraorbital and zygomatic reconstruction procedures pose challenges to plastic surgeons because of the close location of the operation to the eyes and nose. Failed flap design can lead to distortion of the adjacent organs and tissue, particularly for larger defects. Flaps based on the orbicularis oculi muscle (OOM) can be easily rotated from the lateral or temporal region to cover the infraorbital and zygomatic area. We use a soft-tissue expander to enlarge the size of this flap for larger defect repair. Out of a total of 12 patients whose infraorbital or zygomatic defects ranged from 2.0 × 3.0 cm to 4.0 × 5.0 cm, 11 experienced a successful repair without complications. The size of the pre-expanded rotation flap ranged from 3.0 × 4.0 cm to 5.0 × 7.0 cm. The pre-expanded rotation flap based on the OOM has the advantages of an excellent colour and thickness match to the infraorbital and zygomatic areas, a reliable blood supply, abundant tissue and negligible donor-site morbidity. It has thus become our favourite technique for infraorbital and zygomatic reconstruction.

[Applied anatomy of cervico-acromial crossing skin flap].

OBJECTIVE: To investigate the applied anatomy of the blood supply of the cervicoacromial crossing flap and its feasibility in clinical application. METHODS: 5 fresh adult and 10 forman fixed adult cadaver specimens were used. The arteries, veins, cutaneous arteries, subdermal vascular network, and vascular network of the superficial layer of deep fascia in the cervico-acromial area were observed and studied under the microscope. The frontier border of the cervico-acromial area is clavicle, the posterior border is the spine of scapula, the outer border is acromion and the inner border is cervical base. RESULTS: (1) The perforator branches concentrate at the front edge of trapezius muscle; (2) The vessel network around the front edge of trapezius muscle is abundant. Among the anastomosis, two or three anastomosis which across the area from the base of the neck to acromion can be observed in the axial of every cervico-acromial area. Abundant vessel network can be observed in the superficial layer of deep fascia. CONCLUSIONS: The blood supply of the cervico-acromial flap is abundant, which constains constant perforator point. The cervico-acromial crossing skin flap can be applied with the rich blood supply and abundant vessel network in the superficial layer of deep fascia.

[Application of tunica vaginalis flap for multi-fistulas after urethroplasty in hypospadias].

OBJECTIVE: To discussed a new technique for multi-fistulas after urethroplasty in hypospadias. METHODS: 8 cases with postoperative multi-fistulas, which were not successfully repaired by previous treatment, were reoperated with tunica vaginalis flap combined with urethral stent and elastic dressing. The multi-fistulas were located between glan and scrotum. The number of fistulas was 3-7 (median, 5). RESULTS: Primary healing was achieved in all the 8 cases. The micturition and esthetic result were satisfied. 5 cases were followed up for 8-10 months with no recurrence of fistula. There was also no dysuria and penile curvature. CONCLUSIONS: Tunica vaginalis flap combined with urethral stent and elastic dressing is an effective technique for multi-fistulas after urethroplasty. It is easily performed with reliable result.

[Tubed oral mucosa for staged treatment of congenital hypospadias in infancy].

OBJECTIVE: To discuss the treatment of congenital hypospadias in infancy. METHODS: After correction of chordee, the tubed oral mucosa was used to prefabricate urethra in penis as free graft. The urethral anastomosis was performed at the second stage. The scrotum fascia flap, pedicled with scrotal artery, was transferred to cover the penile defect. RESULTS: From Jan. 2007 to May 2010, 42 cases were treated. The tubed oral mucosa was 3.0-4.0 cm in length, and 0.6-0.8 cm in diameter. The maximum size of scrotum flap was 1.5 cm x 3.0 cm. Urethral fistula happened in two cases due to necrosis at the distal end of scrotal flap, which was healed spontaneously after dressing for 1-2 weeks. Primary healing was achieved in all the other cases. After operation, the 26 cases have been visited for 6 months to 3 years, no urethra fistula , narrow and the penis curved. There is an universal urinate for oneself and a good form. CONCLUSIONS: The tubed oral mucosa can be used to prefabricate urethra, which is anastomosed at the second stage. The tubed oral mucosa combined with scrotal fascial flap which has a reliable blood supply, is very suitable for hypospadias in infancy.

[Anatomy correction of penile epispadias].

OBJECTIVE: To investigate the pathological characters and anatomic correction of penile epispadias. METHODS: The urethra was formed by local urethra plate mucosa flaps. The contracture on dorsum of penis was released by cutting off the superficial suspensory ligament to reposition the penile and urethral sponge. RESULTS: From Jun. 2004 to Dec. 2010, 26 cases with penile epispadias were treated. 18 cases were followed up for 6 months to 5 years. 10 cases were treated successfully with good cosmetic and functional results. Urinary incontinence happened in 8 cases, which healed after tightening operation. CONCLUSIONS: The anatomic correction of penile epispadias can recover the normal anatomic structure, resulting good cosmetic and functional results.

[Application of temporal-zygomatic expanded flaps pedicled with orbicularis oculi muscle for sub-orbital defects].

OBJECTIVE: To investigate the therapeutic effect of temporal-zygomatic expanded flaps pedicled with orbicularis oculi muscle (00M) for sub-orbital defects. METHODS: 16 cases with sub-orbital defects were treated. The expanders were implanted at temporal-zygomatic region at the first stage. At the second stage, temporal-zygomatic expanded flaps pedicled with OOM were designed and transferred to repair the suborbital defects. RESULTS: All the expanded flaps survived completely. 11 cases were followed up for 3 months to 3 years. The flaps had no contracture with a good match of color and texture with surrounding tissue. The scar was also inconspicious. CONCLUSIONS: The temporal-zygomatic expanded flaps can be used for large size defects below orbit. It is very flexible, leaving minimal morbidity for the whole face.

[Staged treatment of the severe hypospadias in adult].

OBJECTIVE: To report the treatment of serious hypospadias in adults with free graft of tubed mouth mucosa and scrotal fascia flaps. METHODS: The tubed mouth mucosa was free grafted to fabricate the distal segment of urethra. It was anastomosed to the urethra at the second stage. The scrotal fascia flap was used to cover the penile wound. The biggest flap was 3 cm in width and 6.5 cm in length. RESULTS: From Jan. 2002 to Dec. 2007, 76 adults with severe hypospadias were treated. Infection happened in 4 cases. 2 cases had urethral fistula due to the partial flap necrosis which was healed automatically within 2-4 weeks. All the other patients healed primarily. CONCLUSIONS: It is a good method for the treatment of serious hypospadias in adults with scrotal fascia flaps and free graft of tubed mouth mucosa which is anastomosed to the urethra at the second stage.