In this unedited surgical video, Dr. Snodgrass and Dr. Bush of the Hypospadias Specialty Center demonstrate a difficult reoperative case. This patient had a form of 'distal-proximal' hypospadias, where the hypospadiac meatus is simultaneously near the corona and near the scrotum. These are usually proximal hypospadias cases associated with significant ventral penile curvature, in addition to the severe skin shortage on the underside of the penis. In addition, this patient had another risk factor for significant skin issues: a single dorsal midline whorl of skin. This finding is quite rare in hypospadias, and the doctors refer to it as the 'gnome hat' configuration. They have found it significantly increases the complexity of skin reconstruction for 2 reasons: first, there is only a single hump instead of the usual 2, so skin from the dorsal surface that is wrapped around as a ventral flap is not symmetric, leaving one side of the penis significantly short of skin, and the other with an excess; and secondary, there appears to be inherent problems with the vascularity of the penile skin in patients with this configuration. The surgeons have noted a substantial increased risk of postop skin necrosis which typically happens between days 7-14 after surgery. This has been so notable, that now when the doctors of the Hypospadias Specialty Center see this configuration, they recommend HBOT therapy to decrease (but not totally eliminate) the risk of such significant skin problems. Unfortunately, this patient underwent a 2 stage Bracka repair at another institution despite all these high risk features, and not surprisingly healed with very substantial skin flap and near complete skin graft loss. Dr. Bush and Dr. Snodgrass perform a redo STAC 1 procedure with extensive skin reconstruction as a first step, straightening the persistent ventral penile curvature and beginning the skin rehabilitation. If all heals well, they will return in 6 months for an oral graft, and then 6 months later for tubularization of the oral graft.