Penile Enlargement Surgery-Fact or Illusion?

Yoram Vardi; Lior Lowenstein

Disclosures

Nat Clin Pract Urol. 2005;2(3):114-115. 

Genital size has been a source of anxiety for men throughout history. It has various social and psychological ramifications, such as social maladjustment, fear of relationships, and lack of self-confidence. Many men feel a need to enlarge their penis in order to improve their self-esteem, or to satisfy and impress their partners. 'Phallic identity'—the tendency of males to seek their identity in their penis, with an emphasis on the belief that bigger is better—and 'phallocentrism'—the idea that the penis is central to identity and symbolically empowered—are deeply embedded myths that are likely to persist.[1]

In recent years, surgery to augment penile length or girth has become increasingly common, especially in private settings. Lack of standardization of this controversial procedure has led to a wide variety of poorly documented surgical techniques, with unconvincing results. Since the early 1970s, when it was first described by pediatric urologists in boys with microphallus and bladder exstrophy,[2,3] media attention, increased demand for cosmetic surgery, and widespread advertising have contributed to the rising popularity of penile augmentation. The fact that, between 1991 and 1998, 10,000 men underwent penile augmentation in the US alone, is evidence of this phenomenon.[4] Interestingly, the main concern of the majority of men having this kind of surgery is flaccid penile size, the so-called 'locker room syndrome', when men feel considerably inadequate despite normal penile length and girth.[5] Standard penile length and girth in the flaccid state range from 8.2 to 9.7 cm, and 1.6 to 2.7 cm, respectively.[5,6] It is important that a distinction be made between surgery with the esthetic aim of improving penile appearance, and surgery for functional abnormalities. In this Viewpoint, we will discuss only cosmetic penile procedures.

There are three main procedures for elongation of the penile shaft. Pubis liposuction entails the reduction of pubic fat and is performed primarily in obese persons when the protruding belly conceals the penis. Pubis liposuction can virtually increase penile length by 2 cm when measured from the pubis bone to the end of the glans penis. Another technique involves release of the suspensory ligament, a very controversial procedure in which the suspensory ligament of the penis is detached from the symphisis pubis and both corpora are advanced by traction of the penis using various methodologies, such as vacuum devices, weights, or specialized traction devices. It is important to emphasize that the release of the suspensory ligament does not itself cause length gain. Another common procedure for penile elongation is the advancement of an infrapubic skin flap onto the penis. The rationale for this technique is to protrude the external portion of the penis via a skin flap, or via a VY plasty at the base of the penis. Of the various procedures for skin advancement, it seems that the best results are obtained with the double-Z-plasty technique.[7]

Unfortunately no reliable data are available regarding the criteria for success or complication rates of these techniques. A few reports indicate that release of the suspensory ligament can decrease the angle of elevation of the erect penis.[7] Paradoxical penile shortening can also occur, as a result of spontaneous reattachment of the ligament to the pubis bone.[8] Skin advancement can cause severe deformities, including unnatural hair growth proximal to the penile stump. Utilizing a large flap can impair blood supply, leading to poor wound healing, possible dehiscence, and in some cases hypertrophic scarring.[8]

The issue of penile girth enhancement is even more controversial than penile lengthening. We could not find any recommended indication for this procedure in the literature. Wessels et al. ,[9] in their guidelines for penile augmentation, did not propose any guidelines for girth enhancement owing to the lack of an esthetic rationale. Penile girth can be increased by subcutaneous placement of different tissues (e.g. free fat or dermis grafts), or by cavernosal augmentation with saphenous vein grafts.[6] Autologous fat injection has been attempted, but results were unsatisfactory. Reabsorption and formation of fat globules lead to lumps and sporadic areas of swelling that distort penile shape. One report estimated that only < 30% of injected fat persisted after 1 year.[10,11] Enlargement of the corpora cavernosa via bilateral venous graft implantation has been described by Austoni et al.[6] Longitudinal incision of the tunica albuginea from the pubis to the glans along the lateral aspect of each corpus cavernosum is followed by placement of a segment of saphenous vein. Despite significantly increasing penile diameter during erection, this technique should be considered experimental. In our opinion it is an extremely aggressive and invasive procedure for the treatment of what is essentially a psychological problem.

Over the past 15 years a number of plastic and urologic surgeons have attempted to enhance the penile length and girth of healthy men for purely cosmetic reasons.[4] It is our conviction that men who are dissatisfied with the appearance of their genital organ should think very carefully before requesting procedures that are experimental and high risk, especially in cases where the penis is normal. A better option might be to seek the counsel of psychologists: often men simply need to be reassured that they are 'normal', or need advice on how to better satisfy their partner without resorting to cosmetic surgery. Unfortunately, however, there will always be people willing to undergo 'beautifying' surgical procedures in an attempt to feel better. It is the responsibility of every professional involved in sexual medicine to provide balanced and well-supported advice on these issues.

At present there are insufficient data to establish the safety and effectiveness of the techniques discussed herein. Many factors should be considered when evaluating these procedures: whether or not we can really enlarge or elongate the penis; which surgeries are the most successful and why; who the patients paying thousands of dollars for extra inches on a flaccid penis are, and why they feel compelled to do so; how their surgery affects the sexuality (particularly erectile function) and self-image of the patients; and whether or not anxiety and depression levels are reduced after surgery. Research should be directed towards nonsurgical options. We need to perform randomized trials, establish a standard method for measurement of penile length, and develop validated instruments for assessing subjective experience and perception of penile size. Until data on these issues are available, surgeries intended to change penile size or girth should only be used in conjunction with penile implant insertion, and in rare cases where reconstruction is required.[12,13]

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