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Publication Penile – 3

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Penile Augmentation : Myths and RealitiesDepartment of Urology, University of California, San Francisco, USA


The size, shape and function of the penis has received much attention throughout history. Although most men feel confident about their potency many still remain insecure about their penile size. Men often joke about enlarging the penis and many wrongly assume that the larger the size the more effective the function.
Society’s approach to sexual issues, including penis size and appearance, is becoming progressively more open. Recently, the media have popularised the idea of penile augmentation and have made it an attractive choice for many susceptible men. Penile lengthening surgery is not a new topic as it used to be a goal in the treatment of a variety of urological conditions, including epispadias, Peyronie’s disease, traumatically acquired defects and the retracted phallus in patients with spinal cord injury (1, 2). However, only recently has lengthening been proposed as a cosmetic procedure for a normal penis (3).

History of Penile Enlargement Surgery

Men desiring genital enhancement usually suffer from a significant feeling of inadequacy even though the flaccid penis appears normal in length and girth. Inadequate erect penis size is a less common complaint but can be more disabling, even if sexual partners never imply size inadequacy.
Many techniques have been attempted to achieve a larger and cosmetically acceptable penis; however, many devastating complications have been reported, eg debilitating silicone granuloma of the penis and scrotum, paraffinoma of the penis and unsuccessful or even crippling effects of not only autologous fat injection but a variety of surgical procedures as well (4).
On the other hand, many authors have described their success in achieving penile enlargement. For micropenis, Kelly and Eraklis (5) reported a technique of detaching the corpora entirely from the ischiopubic rami while preserving the neuromuscular structures. Johnston (1) described the lengthening of the congenital or short penis in epispadias patients by partially detaching the crus from the ischial ramus and covering the exposed penis with a split thickness skin graft.
For patients with a concealed or buried penis, Horton et al (6) have reported on their method of suprapubic lipectomy, tacking of the suprapubic and proximal penile skin to the pubis and excising the fundiform ligaments or restraining bands of Scarpa’s fascia and performing a large lower abdominal Z-plasty. Rigaud and Berger lengthened the penis by making multiple tunica albuginea incisions and inserting an inflatable penile implant in patients with Peyronie’s disease.
Enlargement surgery with a modified V-Y advancement technique for normal-appearing penises was first reported by Long in 1990. Roos and Lissoos (7) subsequently reported their experience with a modification of this technique and claimed an average erect length increase of 4 cm with a low complication rate.

Augmentation Phalloplasty

During a recent meeting of the Phalloplasty Surgeons, the following issues were presented and discussed :

Preoperative work-up

Like any patient undergoing other elective penile surgeries, a detailed medical, social, psychological and sexual history is of paramount importance. Many patients who seek penile enlargement surgery suffer from significant feelings of inadequacy. Therefore, patient’s motives, expectations and psychological health should be thoroughly evaluated, preferably by a psychologist or psychiatrist familiar with the surgery. A severely depressed, disturbed, psychotic or unrealistic patient must not undergo surgery.
On physical examination, flaccid and erect penile length, as well as girth and any sexual dysfunction should be recorded. Erect length can be measured after an intracavernous injection of papaverine or alprostadil. Alternatively, a stretched length can be recorded to approximate the erect length.
Malpractice is a major concern, and lawsuits have been filed by many disgruntled patients after penile enlargement surgery. Every patient should be advised that these operations are still investigational. The procedures, alternatives, risks and possible complications should be discussed in detail. The patient is required to sign an extensive consent form after the discussion.

Issues related to penile length

Suprapubic skin incision : Inverted VY-plasty and its modifications, such as M- or W-incisions, were used by many surgeons to lower penile position after cutting the suspensory ligament and thus « increase » the penile length. A large VY-plasty is responsible for most of the reported complications such as wound dehiscence, delayed healing, hypertrophied scarring and hair-bearing skin on the penis. Other surgeons use a small transverse, Z, double Z, or scrotal incision to release the suspensory ligament and then instruct the patient to apply penile weights for several months to increase the length.
Release of suspensory ligament : All surgeons cut the fundiform ligament, which is an extension of the Scarpa’s fascia. Controversy exists regarding the release of the suspensory ligament (Figure 1). Some surgeons only cut the superficial portion of the ligament while others try to detach the root of the penis from the pubic bone as much as possible. Many are not familiar with the anatomy of the penile hilum and therefore argue that it is too risky for a small gain. It is to be noted that cutting the suspensory ligament alone may actually shorten the penis due to scarring in the dead space created. Various materials and tissues have been used to fill the gap such as Gore-tex ®, silicone, rectus fascia, free fat or a dermal fat graft. Others use penile weights or VY-plasty to maintain the lowered penile position.
illustrationFig 1 • Penile lengthening using (a) cutting of the suspensory ligament and (b) a V-Y suprapubic skin advancement technique Penile weights : Several penile weight devices are currently available. Patients are instructed to apply weights to the penis about 1 week to 1 month after surgery. The weights are increased as tolerated and are applied several hours a day for several months. The optimal time, duration and weight is unknown. It is also unclear whether the patient needs to apply weight continuously or if the treatment may be stopped after several months. The effect on penile ultrastructure and erectile function is unknown. One man used penile weights alone without surgery and claimed that his penile length increased by more than 2.5 cm after 9-12 months of application. He also reported that penile length decreased after weight application was discontinued and argued for continuous application.

Issues related to penile girth

The major drawbacks of free fat transfer are reabsorption and granuloma formation which can create irregular subcutaneous lumps. A well constructed dermal fat graft is more reliable in evenly enhancing the penile girth though it is more invasive and time consuming to perform.
Free fat transfer : The fat globules are obtained by liposuction of the abdomen, thighs or buttocks. The preparation and injection methods as well as injected volume vary. Some prefer to inject 20-30 ml at a time and to repeat several times while others inject up to 80 ml and do not repeat. Several surgeons feel strongly that massage and « smoothing out » of the injected fat, followed by wrapping of the penis with dressing such as an elastic bandage, is essential in keeping the fat even in the desired locations. The amount of fat that survives after one year is estimated at 30-50% and most of the patients are told of the need to repeat injections. Even with all the precautions stated above, uneven reabsorption and migration do occur, which may result in asymmetry, curvature, or nodules.
Dermal fat graft : A dermal fat graft is a composite of de-epithelialised skin and underlying fat. This type of graft « takes » or survives easily and enables accurate graft placement. The size of the graft needed is determined by measuring the circumference and the stretched length of the penis from the coronal sulcus to the base. The grafts are taken from the groin, or from one or both gluteal creases, and are sutured directly onto the Buck’s fascia. Some prefer not to include the corpus spongiosum while others wrap the entire circumference with grafts (8).

Results

For penile lengthening, claims of 8 – 10 cm increases are greatly exaggerated. Many patients do not gain any length and a 2.5 cm gain is considered a success. Nevertheless, in some patients, penile descent and increased convexity of the penile base may give an illusion of a longer penis in the flaccid state. During erection any increase in length is negligible but a drop of erectile angle of about 30° is common. Most of the complications are related to VY-plasty. These include proximal penile humps with hair-bearing skin, « dog ears », scrotalisation, hypertrophic scars from delayed wound healing and dehiscence.
Increases in penile girth of 2.5 – 5.0 cm are achievable with free fat transfers or dermal fat grafts. However, free fat injections have a high incidence of complications due to migration and reabsorption, which can result in asymmetry, curvature, cysts or nodule formation. On the other hand, dermal fat grafts seem to have a lower complication rate if they are performed by experienced surgeons.
Patient satisfaction is much more difficult to measure in this type of surgery because the expectations are high and the surgery is performed on a normal organ. Many surgeons have seen « penis cripples » who are emotionally, psychologically, socially and sexually impaired due to a deformed penis after this type of surgery. In addition, the surgery is not covered by insurance, and many men become greatly distressed and demand monetary compensation if the results are not perfect. Some patients even turn violent. Many lawsuits have been filed, and two surgeons have had their licences suspended in the last 2 years.

Conclusion

At present, penile augmentation surgery is still in its infancy. Many controversial issues remain unresolved (Table 1). Due to the unpredictable nature and potentially disastrous consequences thawwt may result from even minor complications, extensive consultation with the surgeon and a psychologist before surgery is mandatory.
Surgical approaches for augmentation phalloplasty
Procedure Advantages Disadvantages
Skin incision
VY-plasty Single procedure Length increase unpredictable
More wound complications
Transverse or scrotal Fewer complications Does not lower penis itself
Needs penile weights
Cutting suspensory ligament
Superficial ligament Simple No gain in length unless combined with VY-plasty or penile weight application
Deep ligament Gains more length Same as above
May damage neurovascular bundle
Penile weights
Alone Non-invasive Time consuming
Length not sustainable
With surgery More reliable More costly
Girth enhancement
Fat injection Simpler procedure 50-70% reabsorbed
Require repeat injections
May develop deformity
Dermal fat graft Predictable result Large skin incision
Time-consuming
Ahmed I. EL-SAKKA and Tom F. LUE

REFERENCES

  • Johnston JH. Lengthening of the congenital or acquired short penis. Br J Urol 1974; 46: 685-688.
  • Rigaud G, Berger RE. Corrective procedures for penile shortening due to Peyronie’s disease. J Urol 1995; 153: 368-370.
  • Long DC. Elongation of the penis. Chin J Plast Surg Burns 1990; 6: 17-19.
  • Wessells H, Lue TF, McAninch JW. Complications of penile lengthening and augmentation seen at 1 referral center. J Urol 1996; 155: 1617-1620.
  • Kelley JH, Eraklis AJ. A procedure for lengthening the phallus in boys with exstrophy of the bladder. J Pediatr Surg 1971; 6: 645-649.
  • Horton CE, Vorstman B, Teasley D, Winslow B. Hidden penis release: adjunctive suprapubic lipectomy. Ann Plast Surg 1987; 19: 131-134.
  • Roos H, Lissoos I. Penis lengthening. Int J Aesth Restorative Surg 1994; 2: 89-94.
  • Alter GJ. Augmentation phalloplasty. Urol Clin North Am 1995; 22: 887-902.