Penile Size and Penile Enlargement Surgery: A Review

B.E. Dillon; N.B. Chama; S.C. Honig

Disclosures

Int J Impot Res. 2008;20(5):519-529. 

In This Article

Penile Augmentation Procedures

When speaking of penile enhancement surgery, one must distinguish between those procedures that increase penile circumference, penile length and plastics procedures to change skin surrounding the penis.

The Sexual Medicine Society of North America has drafted a position statement on penile lengthening and girth enhancement surgery. It reads as follows:

'The Society for the Study of Impotence has found no peer reviewed, objective or independently-monitored studies, or other data, which prove the safety or efficacy of penile lengthening and girth enhancement surgery.

Therefore, penile lengthening and girth enhancement surgery can only be regarded as experimental surgery.

The Society is aware of complications and adverse outcomes that should be clearly disclosed to patients considering such surgery.

The Society believes that those government agencies charged with the regulation of medical practice and the enforcement of laws prohibiting false or unsubstantiated advertising claims should give careful attention to claims made with regard to these surgical procedures.' (www.smsna.org)

One of the earlier papers aimed at penile girth enhancement was reported in 2002, by Austoni et al. Thirty-nine patients underwent elective enhancement surgery for hypoplasia of the penis or functional penile dysmorphophobia. Penile dysmorphophobia is defined as a condition in those men whose penis are normal, but request an augmentation procedure as a result of an altered perception of the organ. Penile dysmorphophobia can be both a functional issue and an aesthetic issue.[27,28] The procedure was carried out by using a saphenous vein graft. Incisions were made in the tunica albuginea from apex of the corpora to the crura and saphenous vein patches were placed.[27] At 9 months postoperatively, there was no statistically significant increase in flaccid penile circumference, but there was a statistically significant increase in erect circumference. Erect diameter (location on shaft not specified) preoperatively was 2.85 cm, whereas the average erect diameter postoperatively was 4.21 cm. The authors indicated that there were no 'major complications'.[27]

Fat injection into the penis is the mainstay of girth enhancement procedures. The goal of fat injection into the dartos layer of the penis is uniform enhancement of penile circumference. In 2006, Panfilov[29] described his method of injecting the penis with autologous fat. In his protocol, 200-250 cm3 of a physiologic solution containing adrenalin (1:800 000) and 0.02 xylocaine (50 ml xylocaine 1% per 1 l solution) was instilled into two 2-3 mm incisions on the upper inner thigh. After approximately 50 min, the fat was harvested. Fat was injected in four 1 mm incisions around the penis at the 1, 5, 7 and 11 o'clock positions. For each incision anywhere from 10 cm3 to 16 cm3 of fat is injected. After injections, the penis is 'kneaded' to even out the injections. At 1 year of follow up, 77 patients were highly satisfied, 8 patients were fairly satisfied and 3 patients were not satisfied. One patient had too much fat injected into his foreskin, and 2 patients had excessive loss of fat.[29] Table 2 summarizes these studies.

Alter has written extensively regarding his experience with penile enhancement surgery.[29,30,31] In particular he has described the use of dermal fat grafts for penile girth enhancement. According to the author, dermal fat grafts are superior to autologous fat injections because less than 50% of fat survives in autologous fat injections whereas, dermal fat grafts had been used with success in plastic surgery.[30] Dermal fat grafts are taken from the groin area below the swimsuit line, or from the gluteal creases. Alter states that circumferential placement of a dermal fat graft is the preferred technique, with the size of the dermal fat graft based on the measurement of the penis on full stretch from the pubopenile junction to the distal corona. The urethra is usually left uncovered. Penile weights are used after approximately 1 month, postoperatively, to prevent shrinkage and graft contraction.[30]

It is reported that circumference is increased between 1 and 2 inches, using the aforementioned procedure. The procedure is rather lengthy (several hours), but results in a uniform increase in girth, without nodularity. Edema resolves with 6 weeks, whereas normal texture is regained in 4-6 months. It should be noted, however, that there can be severe complications that include, but are not limited penile shortening, asymmetry and curvature due to fibrosis if the graft does not take uniformly.[30,31]

With the advent of tissue engineering, there are a number of new mechanisms to perform circumferential enhancement. In 2006, Perovic et al.[32] reported their series of 84 patients who had penile circumferential enhancement using a biodegradable scaffold. Age ranges of their subjects were 19-54 years, and indications for augmentation were penile dysmorphic disorder or failed penile enhancement surgery. After fibroblast cells were harvested from scrotal biopsies, they were grown to a volume of 2 × 107, and then seeded on a tube-shaped polylacti-co-glycolic-acid scaffold. After 24 h of incubation, the penis was degloved and scaffold was transplanted between dartos and Buck's fascia.[32] At 24 months median follow up, mean increase in girth was 3.15 cm (1.9-4.1 cm) in the flaccid state and 2.47 cm (1.8-3.0 cm) in the erect state. Complications included infection in three patients, penile skin necrosis in two patients and seroma in five patients. All patients were able to be treated conservatively.[32]

A more novel technique used in penile girth enhancement has been the use of AlloDerm. AlloDerm is 'an acellular dermal matrix derived from donated human skin', which is available in sheets. Although most of the data for AlloDerm are anecdotal, recently, they have been widely used in penile girth enhancement. The AlloDerm sheets are placed above Buck's fascia. The reported minimal scar is one advantage of this technique for penile girth enhancement.[33]

The mainstay of penile lengthening procedures are a combination of release of the suspensory ligament of the penis with an inverted V-Y penopubic skin advancement (Figure 2).[34] Most surgeons recommend cutting the suspensory and fundiform ligament in combination with the use of postoperative penile weights. There is minimal evidence-based data in the literature documenting pre- and postoperative lengths.

(a) Location of incision. (b) Post operative schematic showing cut ligament and skin realignment. Inverted V-Y skin plasty at penile base with release of suspensory ligament. Reprinted with permission from British Journal of Urology.

Shirong et al.[35] performed penile elongation surgeries in patients who had congenital microphallus. They defined microphallus as an erect length of less than 8 cm, or in men with traumatic injuries. They performed 52 procedures over a 7-year period, in men aged 23-52 years. The procedure consisted of cutting the suspensory ligaments, beginning with the superficial ligaments and if more length was needed, the deep suspensory ligaments were partially cut. A scrotal flap was used to cover the exposed corpora, and in some cases a V-Y suture was used on the ventral side to avoid traction and allow better cosmesis.[35] Only 20 patients were followed postoperatively, and increase in length was seen from 3.5-6.5 cm. There was an average decrease in length of 0.5-1.5 cm within the first 6 months of the procedure.

It is often standard protocol that after transection of the fundiform and suspensory ligaments, penile weights (at least 10 pounds) are used. Penile weights are hung from the corporal ridge, once the patient has recovered from the initial procedure. The weights prevent reattachment of the suspensory ligament and should be worn intermittently throughout the day. Some men opt to use progressivelyheavier weights for anywhere from months to years, which act as tissue expanders.[30,31] In addition, Alter has suggested the placement of fat (dissected off the spermatic cord) between the suspensory ligaments and bone to prevent adherence to the pubic bone resulting in penile shortening.[29,30]

Recently, Shaeer et al.[36] reported a variation on the skin reconstruction and fat placement to prevent postoperation shortening. They recommend placing a pubic fat flap between the penis and the pubic bone after the suspensory ligament is released. In addition, they report a combination of a 'T closure' in addition to the V-Y advancement.[36]

In 2000, Perovic described his technique for penile elongation. Nineteen patients, aged 18-52 years were included in the study. Inclusion criteria were limited to patients who 'thought their penis was too short for sexual satisfaction'. All patients had anatomically normal penis, but short erect lengths between 6 and 10 cm. Patients who had a penile length greater than 10 cm, were excluded. Perovic's procedure involved completely disassembling the penis into two components: the glans cap with the urethra attached on the ventral aspect and the neurovascular bundle on the dorsal aspect, and the corpora. An autologous piece of rib cartilage was then shaped and sutured in a place inserted between the corpora and the glans. Thirteen patients noted an increase in length between 2 and 3 cm, whereas the remaining six had an increase between 3 and 4 cm. No infections or erosions were noted, and the cartilage remained roughly the same size as at the time of implantation. Fifteen patients reported painless intercourse at 3 months. Five patients noted a dorsal curvature that was corrected with a vacuum device.[37]

Paniflov[29] described his technique for penile elongation in 2006. He described incomplete cutting of the fundiform ligament of the penis. This allowed for the elongation of the extracorporeal part of the penis. Then, a 'V-Y plasty' was used to elongate the penile skin at the base.[29] The average penile length preoperatively was 8.75 cm (6.5-10 cm), which was increased to a mean of 11.14 cm at 12 months postoperatively. Few objective outcome data were reported and no complications were reported.

Complications of penile lengthening procedures may be significant. There is minimal short- and long-term patient satisfaction data. Penile shortening is the major complication, usually resulting from the freely hanging penis reattaching to the pubic bone higher on the corporal bodies. This complication may be minimized by the placement of fat as described previously. Other complications include loss of sensation, angling of the penis downward (due to lack of support) and hypertropic scarring of wounds.

A discussion of penile lengthening would be incomplete without the mention of penile reconstruction for bladder exstrophy epispadias. After the exstrophy is repaired these patients are often left with deformities of their penis, mainly a shortened penis or an upward-tethered penis. This is thought to be a result of a congenitally shortened anterior corpus cavernosum.[26] These deformities can lead to significant psychological and social issues in adulthood. A number of techniques have been described on how to reconstruct the epispadic penis. Cantwell was one of the first to describe the repair of epispadias in his 1895 article in the Annals of Surgery.[38] Since then many others have developed their own novel techniques as well as modified Cantwell's procedure. In 1971, Kelley and Eraklis[2] separated the corpora from the ischiopubic ramus in a patient with exstrophy of the bladder to gain length. One of the more common techniques used to correct exstrophy epispadias is the modified Cantwell-Ransley repair, a staged repair. This repair emphasizes penile chordee correction, urethral reconstruction, glandular reconstruction and penile skin closure. In 2000, Surer et al.[39] reported their 10-year experience using this technique in 93 patients. Of the subjects, 79 had classic exstrophy and 14 had complete epispadias. A primary repair was performed in 65 of the patients who had classic bladder exstropy and 12 who had epispadias. A secondary repair was done in 14 patients who had classic bladder exstrophy and 2 who had complete epispadias. The authors found that more than 90% of the patients had a functionally usable penis (at 68 months of followup). Complications from the procedure included urethrocutaneous fistula in 19-23%, urethral strictures in 9% and minor skin separation in 6%. They ultimately concluded that the modified Cantwell-Ramsley procedure yields excellent results both cosmetically and functionally.[39]

A 'hidden' penis usually occurs secondary to overlying skin or abdominal fat. As described by Alter, this may result from 'aging, obesity, overly aggressive circumcision, abdominoplasty with aggressive release of dartos fascia attachments to Scarpa's fascia or penile lengthening using an ill-advised large pubic V-Y advancement flap'.[40] This is compared to a 'buried' penis where the penile shaft is underneath the surface of the prepubic skin. Buried penis often results from obesity and/or radical circumcision. In 1999, Alter and Ehrlich described a novel technique for correction of the hidden penis in adults. The authors stressed, that prior to embarking on the procedure, the etiology of the concealment must be identified correctly to fix the condition properly.

The amount of penile skin must be assessed to assure that there is sufficient amount to perform the procedure. When concealment is due to overhanging suprapubic skin, the skin is excised in an elliptical fashion, which will allow for visibility of the penis. It is important to taper the fat cephalad and laterally, which will prevent an unsightly appearance. The subdermal tissue of the suprapubic skin is then tacked to the rectus fascia which maintains the upward position of the resected skin (Figure 3).[40]

Technique of tacking subdermal penopubic junction to rectus fascia with multiple rows of polyester sutures. Reprinted with permission from Journal of Urology.

Sometimes a suprapubic lipectomy or liposuction is performed if a large suprapubic fat pad is present. On occasion, release of the penile suspensory ligaments may be performed to allow for additional penile length. Even after the suprapubic fat issues are addressed, there is still a tendency of the corpora to retract into the scrotum. In order to prevent the retraction, a midline incision is made at the penoscrotal junction, and dissection carried down to the spongiosum and tunica albuginea. Two tacking sutures are placed on either side of the urethra from the tunica albuginea to the ventral penoscrotal subdermal tissue (Figure 4). These sutures prevent retraction of the penis into the scrotum.[40]

Technique of bilateral tacking of subdermal penoscrotal junction to periuretheral tunica albuginea. Reprinted with permission from Journal of Urology.

As implantation of a penile prosthesis has been perceived by some as resulting in penile shortening,[41,42] Miranda-Sousa et al.[43] developed a novel technique of releasing the penoscrotal web to give the appearance of a longer penis. The procedure was done in patients undergoing penile prosthesis implant for erectile dysfunction. Ninety patients, with a mean age of 62 years, underwent placement of a penile prosthesis. Group 1 consisted of 43 patients who had penile prosthesis placement (39 received Coloplast inflatable penile prosthesis and 4 received semi-rigid penile prosthesis) along with ventral phalloplasty with takedown of penoscrotal web. Group 2 contained 37 men who had Mentor Titan inflatable prosthesis placed through a standard penoscrotal incision. After the degree of penoscrotal webbing is determined by placing the penis on traction and distracting the scrotum in the midline, an asymmetric 'V' incision is made on each side of the web. A diamond shaped piece of scrotal skin is removed and closed in a modified Heineke-Michulz type fashion. In Group 1, 42 of 43 (98%) men reported good overall satisfaction; 84% reported an overall increase in their perception of penile length, whereas 12% reported no change and 4% reported decrease in penile length. The authors reported that the difference in patients reporting an increase in length vs those reporting a decrease in length reached statistical significance. In group 2, 31 of 37 (84%) patients reported penile shortening, which also reached statistical significance. Complications associated with the procedure were uncommon and minor (two wound hematomas and three superficial infections in group 1, and one wound separation in group 2). Operative time in group 1 was roughly 12 min longer than that in group 2. Most importantly, there were no prosthetic infections in either group.[43]

In 2007, Alter[44] published his surgical technique for the correction of penoscrotal web, in which he defines the penoscrotal web as 'an obtuse attachment of scrotal skin onto the ventral shaft, which shortens the functional and visual ventral penile length.' He attributes most penoscrotal webs to aggressive circumcision in which too much ventral penile skin is excised, however the penoscrotal web can also be congenital. Alter uses the 'Z-plasty' technique to correct penoscrotal web. Using this technique, the midline raphe is used for the central limb of the Z plasty, and then a 60° angle Z-plasty is performed. According to Alter, 60° allows for a theoretical gain in length of 75%. Skin incisions are made along the Z-plasty through skin and superficial dartos fascia, and skin closed with a 4-0 or 5-0 moncryl. He does caution that closing the Z-Plasty can cause circumferential narrowing of the penis.[44] More recently Chang and Liu published their technique for the correction of the penoscrotal web. Chang and Liu[45] reported that despite being effective, Z-plasty can be technically difficult. The authors offer a V-Y advancement flap technique for the correction of penoscrotal web. They described making a V incision at the penoscrotal junction, and this flap is then mobilized, using caution to preserve blood supply so as to not devascularize the flap. This flap was then advanced upwards and closed in a Y configuration using 4-0 chromic suture. This same technique was repeated 1.5 cm below the previous suture line to completely correct the web. The authors added that the ideal angle of 'V' should be approximately 60° with a length of 1 cm to gain maximum length. Using an angle greater than 60° can restrict length, however, an angle too small can compromise blood supply.[45]

Many of the previously quoted studies do not discuss complications. Penile enhancement surgery is a highly risky procedure. There is no standard surgical technique, and much of the performed procedures are experimental with minimal objective pre- and postoperative data. In patients who have autologous fat transfer for girth enhancement, complications include loss of injected fat and irregularity at the injection site, scar thickening with keloid formation and scrotalization.[46,47] These complications are usually seen when the V-Y flap techniques is employed.[46,47] Sexual dysfunction and further penile shortening are also reported complications of these penile enhancement procedures.

In 1997, Alter[46] nicely reviewed the complications from penile enhancement surgery. Alter reoperated on 19 men over a 2-year interval, all of whom had penile enlargement surgeries by other physicians. In all 19 men, cutting the suspensory ligaments and advancing the skin in the V-Y advancement flap was performed in an attempt to achieve penile lengthening. Penile girth enhancement was accomplished by autologous fat injections. Patients presented various complaints such as hypertrophic scars, low hanging penis and penile lumps. In 12 of 19 patients, either complete or total reversal of the V-Y advancement flap was performed. In addition, 12 of the men had removal of subcutaneous fat nodules. Alter attributed most of the poor results to flap viability secondary to vascular supply, or to a thick V-Y flap. Often a complete reversal of the V-Y flap was either impossible, or undesirable. Elevation of the V flap was performed, aligning hair-bearing skin on the flap to the scrotum to maintain blood supply and scrotal dog ears were excised.[46]

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