Penile lengthening before and after erect

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Intraoperative penis length was measured before and after the dorsal phalloplasty. Overall patient satisfaction was measured on a 5-point rating scale and patients were requested to subjectively compare their postoperative penis length with memories of their penis length before the onset of ED.

Intraoperatively, the dorsal phalloplasty increased the visible length of the erect penis by an average of The average length before and after tacking was Postoperatively, seven patients The mean overall patient satisfaction score was 4. None of the patients developed postoperative complications.

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A dorsal phalloplasty during PPI is an effective method of increasing visible penis length, therefore minimising the impression of a shorter penis after implantation. Penile prosthesis implantation ppi results in high long-term patient satisfaction rates in comparison to non-surgical treatments. During this procedure, the penopubic junction PPJ is defined by tacking the pubic skin to the pubis , revealing the base of the penis and increasing the visible length of the penis from the pubic skin surface to the glans.

Before surgery, each patient was stood before a mirror and the PPJ was pressed down to mimic the effects of the dorsal phalloplasty. If the patient decided that the procedure would improve their visible penis length and agreed to undergo the combined surgery, they were included in the study. The combined PPI and dorsal phalloplasty procedure was performed under general anaesthesia via a penoscrotal incision. The dartos muscle was split open until the tunica albuginea of the corpora cavernosa. The penis was retracted to one side and the space lateral to the base of the penis was bluntly dissected down to the pubis.

Without pulling down or tethering the skin of the penis, the optimum location for the placement of the tacking suture on the undersurface of the pubic skin was determined by palpitating several potential points around the base of the stretched penis and choosing the point that revealed the penis the most. The tacking suture was subsequently tied, defining the PPJ and anchoring it to the pubis , revealing the base of the penis.

Intraoperatively, visible penis length from the pubic skin surface to the glans was measured with the prosthesis inflated both before and after tying the tacking suture [ Figure 2 ]. Following the completion of the procedure, the penoscrotal incision was closed in layers. Illustration of a dorsal phalloplasty to increase visible penis length after a penile prosthesis implantation showing the placement of the A pubic and B penopubic junction arms of the tacking suture. Photographs showing the surgical procedure of a dorsal phalloplasty to increase penis length during penile prosthesis implantation.

Initially, the A tacking suture was placed and the B pre-tacking visible penile length recorded. Following this, the C tacking suture was tied, the D penopubic junction defined and the E visible penis length measured again. Postoperatively, the patients were discharged on the same day and allowed to resume intercourse 45 days after the surgery. Each patient was followed-up for between 12—18 months mean: Patients were requested to rate their overall satisfaction with visible penile length on a 5-point scale, with a score of 1 indicating severe dissatisfaction and 5 indicating high satisfaction.

At their final follow-up appointment, they were also asked to subjectively assess their postoperative visible penile length in comparison to their memory of their erect penis length before the onset of ED. The development of any postoperative complications was documented. Statistical analysis was performed using an Excel spreadsheet, Version Microsoft Inc.

Results were expressed as means and standard deviations or frequencies and percentages, as appropriate. This study was approved by the ethics committee of the Department of Andrology at the Faculty of Medicine of Cairo University. Participants were assured of the confidentiality of their data. All patients provided informed written consent before their inclusion in the study. The mean age of the patients was Intraoperatively, the dorsal phalloplasty resulted in an average increase of Before tacking, the average length of the visible penis was The mean overall satisfaction score was 4.

None of the patients reported any infections, extrusions, prosthesis malfunctions or persistent penile pain lasting more than two months after the surgery. Moreover, none of the patients reported experiencing any pain at the tacking suture sites, instability of the erect penis during intercourse or a decrease in their perception of penis length over the duration of the follow-up period. Patient dissatisfaction with penis length following PPI can be addressed in various ways, including pre-and postoperative counselling, implantation of length-expanding prostheses and adjuvant pre-, intra- or postoperative augmentation techniques.

In the current study, a combined dorsal phalloplasty and PPI procedure was found to significantly increase intraoperative penis length and enhance postoperative patient satisfaction, without an increase in morbidity. A dorsal phalloplasty reveals the length of the penis hidden within the suprapubic fat pad; moreover, tacking the pubic skin at the PPJ is a relatively simple procedure, allowing both surgeries to be performed through the same incision and during the same session.

As such, other augmentation techniques requiring a secondary incision or a second surgical session are unnecessary. Furthermore, a dorsal phalloplasty circumvents the possible complications of other length enhancement procedures, such as wound dehiscence, infections, oedema or a downward erection angle.

This study is subject to certain limitations. There is a theoretical possibility that the tacking sutures may loosen over subsequent years and that patients may lose visible penis length accordingly. As a result, further studies with longer follow-up periods are required to determine the sustainability of length gain from a dorsal phalloplasty.

In addition, patients were asked to subjectively assess their impression of penis length gain by comparing their postoperative penis length with memories of their penis length before onset of ED, which may have resulted in inaccurate recollections of previous penis length. At that time, it was felt that only men with a flaccid length of less than 4 cm or a SPL of less than 7. An ethical review on penile elongation procedures did report that after clearly hearing and understanding the risks and complications associated with each procedure, most men with a normal penis size will decline.

All men undergoing penile elongation surgery with an SPL within normal limits, should undergo psychiatric evaluation In cases of true micropenis, the goal of treatment should be restoration of a functional penis size in order to improve body image and self-esteem, allow normal standing micturition and enable satisfying sexual intercourse. In children with true micropenis, the first step in management is always the least invasive, which includes the application of exogenous testosterone. If insufficient penile growth is not achieved with replacement, multiple courses of replacement can be considered without significant reduction in stature 22 - In , the beneficial effects of hormonal therapy on penile growth in children with micropenis was confirmed.

In this study, prepubertal children were treated with 25 mg of exogenous parenteral testosterone enanthate once a month for 3 months, and pubertal or postpubertal children were treated with intramuscular hCG once a week for 6 weeks. Exogenous administration of hormone replacement in these boys resulted in a significant increase in SPL and suggests that these treatments could be the primary form of therapy for micropenis in paediatric patients In addition to exogenous testosterone, topical applications have been studied in the micropenis population.

The administration of exogenous testosterone in childhood does not compromise ultimate penile length increase in adulthood, however, the long-term effects of testosterone administration in childhood are still not fully understood and long-term data are needed Although men on androgen deprivation therapy for prostate cancer have been observed to have a significant decline in penile length, there does not appear to be any beneficial effect in length with the use of testosterone in men without hypogonadal dysfunction Further studies could be done to look at this potential application for local benefits in the aging population.

A review of penile elongation surgery

Penile traction devices PTD have been explored both as an independent strategy to help with penile elongation and as an augment to surgery. These devices cradle the penis and gently apply tension in attempt to stretch tissue and increase length. Multiple brands of these devices have been created and studied including: Prospective studies have looked at men complaining of a subjectively small penis. The duration of application of these devices has not been concluded, but usually ranges from 4—6 h per day 29 , In one study, after 2 months, men were asked to leave the traction device on for 9 h per day Compliance and patient selection is a significant issue given the time requirements for this minimally invasive treatment.

Outcomes have been encouraging as patient satisfaction has unanimously improved after use for 3—6 months and flaccid or SPL has increased 1—3 cm in different studies 29 - Oderda and Gontero conducted a review which aimed to explore whether nonsurgical methods of penile lengthening may have some scientific background.

They concluded that penile extender devices seem to be non-inferior to surgery Limitations of these studies included non-validated patient satisfaction questionnaires, small patient populations, and selection bias More recently traction devices are being studied for their pre-operative and post-operative use to augment outcomes from surgical procedures. Similarly, in early trials, pre-operative use of PTD has been shown to increase penile length prior to implantation of penile prosthesis and therefore allowing insertion of a larger caliber of cylinder Although limited data exists, there appears to be a role for use of PTD both independently in men not interested in surgery, as well as an augment to other surgical procedures.

Different types of injectable materials have been used for penile augmentation including liquid silicone, polyacrylamide, hyaluronic acid and mineral-oil 35 - However, there is a significant risk of foreign body reaction, swelling, penile distortion, granulomas and need for removal This is a much less invasive procedure compared to flap reconstruction or V-Y advancements.

To obtain a fat graft, fat is liposuctioned from areas of excess, placed in 10 mL syringes and then centrifuged for 3 min at g. The superior oil layer and lower aqueous layers are removed and the middle adipose layer is collected as the purified fat graft. The fat is transferred into smaller syringes for injected in multiple layers to improve fat graft survival. This technique has been refined by Sydney Coleman in recent years 38 , Panfilov described his technique for penile augmentation with fat grafting in 88 patients.

Incisions are made radially through the frenulum preputial and approximately 40—68 cc of fat is injected between the superficial penile fascia and the profunda, down to the root of the penis. The average length and circumference increase was 2. In one patient, the penis gained 3 cm in length at 6 months, but due to fat graft resorption, the stable length was 2 cm at 7 years. This technique can be combined with suspensory ligament release to further increase length. Unfortunately, it was not specified which patients had just the autologous fat grafting versus both procedures and the resulting gain in length.

Penile augmentation with fat grafts also increase the weight of the penis, which can itself increase the length by 2—3 cm Dermal fat grafting has also been described to increase girth and length of the penis, which may have better fat retention and decreased contour irregularities at the expense of a larger donor-site scar 37 , As discussed, the suspensory ligament anchors the penis to the pubic symphysis and while providing support, acts as the mobile point for the penis during erection.

This attachment prevents the penis from moving further outward and creates an arched angle to the penile base The suspensory ligament is composed of the suspensory ligament proper and the arcuate subpubic ligament that attaches the tunica albuginea to the midline of the pubic symphysis. Surgical release of this ligament changes the acute angle of the penis to the pubic symphysis to an obtuse angle which allows the penis to lie in a more dependant position and therefore gives the perception of lengthening Division of the suspensory ligament, with or without bulking agent, fat pad excision or V-Y plasty is the most widely accepted surgical technique for penile elongation The suspensory ligament can be accessed through a V-Y incision or a subcoronary circumcision technique Complete release of the corpora from the pubic ramus has been described to further increase length, but is associated with significant risk to the neurovascular bundles of the penis, causing denervation and devascularisation of the penis Outcomes from suspensory ligament release have not consistently been favourable.

On average, the surgery increases flaccid penile length by 1—3 cm, especially with post-operative use of a PTD 45 , Many patients in early studies had a recurrence following surgery, which resulted in penile shortening. Therefore, optimal surgical technique now involves placing a buffer in place of the ligament.

Buffer options have included a vascularized flap from the lipomatous tissue of the spermatic cord or a small testicular prosthesis 45 , Srinivas et al. After the inverted V-Y incision and suspensory ligament release, a silicone sheath from a penile prosthesis was inserted in the soft tissue defect created between the base of the penis and the symphysis pubis. They achieved a lengthening of 2. Dermal fat grafts have also been described to fill this space Paradoxically, the main side effects of this procedure are recurrence, penile shortening, and the lack of penile support during erection, resulting difficulty with sexual intercourse and penetration Poor satisfaction rates make this surgical technique not favourable for many patients.

Penile elongation using a dorsal V-Y incision in the congenital or acquired short penis was first described over 40 years ago. A dorsal V-shaped incision was made, combined with partial detachment of the crura from the pubic ramis, which were then re-approximated in the midline and the dorsal incision was closed as a V-Y advancement flap. The V-Y incision and subsequent V-Y advancement is commonly used in conjunction with a suspensory ligament release. The incision is typically an upside down V, which is closed in an upside-down Y-shape, which lengthens the dorsal skin by bringing lateral tissue to the midline Figure 1.

The flap is distally based, and poor wound healing, flap dehiscence and distal flap loss can occur if the flaps blood supply is compromised during dissection Bulging of the penoscrotal transition can also occur, which can be treated using bilateral Z-plasties It is difficult to determine the average length achieved by V-Y advancement as it is typically combined with other procedures.


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An additional suspensory ligament release and partial release of the corpora cavernosa is depicted. Suprapubic lipectomy has been performed to increase perceived penis length, particularly for patients with a buried penis.

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In these patients, weight loss does not always reduce the problem of a large overhanging fold, or mons pannus. These folds can cause problems with hygiene, directing the urine stream and sexual function Removal of the skin and fat concealing the penis can be performed as a suprapubic lipectomy or limited panniculectomy.


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The skin is removed as a trapezoid incision. The inferior portion of the incision is marked 2 cm above the penis to allow closure of the base of the penis to the pubic symphysis periosteum, and the superior portion should not interfere with the waistline sulcus This technique increases the exposed penile length.

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This can be combined with removal of diseased shaft skin, which may be inflammatory due to the buried condition and chronic infections. The shaft skin can be closed with a skin graft taken from the lateral thigh, or from the removed mons pubis skin to avoid a donor site If there is need for further length, release of the suspensory ligament can be performed along with the suprapubic lipectomy If the buried penis is secondary to cicatrix post circumcision, which is more common in children but can present in adults, either Z-plasties or removal of the entire penile skin with skin grafting and vacuum assisted closure with a negative pressure wound dressing can be performed.

Suction lipectomy, or liposuction, is considered inadequate to treat a buried penis unless it is used in conjunction with suprapubic lipectomy If no significant buried penis is present, but there is a moderate pubic fat pad, then liposuction may help to increase perceived penis length Rolle et al. The penis is degloved and the neurovascular bundle is mobilized. After subtunical dissection, traction is applied to slide the distal penis away from the proximal shaft to perform the lengthening, the limit of which is the length of the urethra and neurovascular bundles 55 Figure 2.

A prosthesis is then inserted into the tunical defects that are created by this technique. The authors report an average penile lengthening of 3. The same group previously described this method of lengthening the penis with similar tunica incisions and subsequent pericardial grafting of the resulting tunical defect after lengthening, but felt that the grafting was time consuming and unnecessary A prosthesis is inserted into the tunical defects that are created by this technique.

Perovic and Djordjevic describe a technique similar to sliding elongation, which they have used to treat short penises and congenital penile anomalies. Their procedure involves separating the penis into the glans cap with neurovascular bundle dorsally, the corpora cavernosa, and the urethra ventrally. Thus, the corpora are separated completely from the surrounding structures. A space is created between the glans cap and the tip of the corpora cavernosa, on which an autologous rib cartilage graft is placed, and then the penis is reassembled 58 Figure 3. The cartilage is covered with the glans cap and the urethra and neurovascular bundles are sutured to the tunica.

This technique was performed on 19 patients with a short penis with an average increased length of 2—3 cm and 3—4 cm in 13 and 6 patients, respectively There was no evidence of cartilage extrusion, erectile dysfunction or urethral damage at a mean follow-up of 3. A The penis is degloved and the neurovascular bundle and corpus spongiosum are separated from the corpora cavernosa; B the glans cap is separated from the tip of the corpora cavernosa, and a space is created between these structures; C an autologous rib cartilage graft is placed, between the tip of the corpora cavernosa and the glans cap and the penis is reassembled.

Local, regional and free flap options exist to lengthen the penis. These have typically been described for penile lengthening if the penis is shortened due to epispadias and exstrophy, where a lack of soft tissue and dorsal skin or tethering of the penis to the pubic bone from fibrous bands Kramer and Jackson describe the use of local rhomboid flaps, based laterally, for dorsal skin coverage combined with partial release of the corpora cavernosa from the pubic ramus in 10 patients. These local flaps are necessary due to the lack of dorsal coverage once the corpora are released from the penis and advanced through an inverted V-shaped incision Figure 4.

This technique is described for both congenital and acquired short penis. They state that most patients obtained a doubling in their penile length.

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Other local flap options are lateral superiorly based scrotal flaps that are rotated onto the dorsal penis Dorsal Z and W-plasties may also be performed as local skin flaps, but may bring hair bearing skin onto the penis Penile elongation using laterally based local rhomboid flaps to obtain length of the dorsal skin, as described by Kramer and Jackson, This technique is used if there is a need for further dorsal tissue after an inverted V-shaped incision is performed.

Men complaining of short penis need to be clinically assessed for evidence of true micropenis and screened for PDD. Patients should first be treated conservatively with testosterone therapy, PTD, and a psychiatric assessment if applicable. There are no current guidelines on the best surgical management for men requesting penile elongation. Multiple surgical techniques have been developed each with their own limitations and have been reviewed above.

Further work in this field is required to devise the optimal surgical procedure with the smallest complication profile and the highest patient satisfaction. The authors would like to thank Alison Wong, MD for preparing the diagrams to supplement the surgical descriptions within this manuscript. The authors would also like to thank Dr. Gerald Brock, MD for his support in preparing this manuscript. Conflicts of Interest: The authors have no conflicts of interest to declare.

National Center for Biotechnology Information , U. Journal List Transl Androl Urol v. Transl Androl Urol. Jeffrey Campbell 1 and Joshua Gillis 2. Author information Article notes Copyright and License information Disclaimer. Corresponding author. I Conception and design: J Campbell; II Administrative support: None; III Provision of study materials or patients: None; IV Collection and assembly of data: All authors; V Data analysis and interpretation: All authors; VI Manuscript writing: All authors; VII Final approval of manuscript: All authors.

Correspondence to: Jeffrey Campbell. Received Sep 20; Accepted Sep Copyright Translational Andrology and Urology. All rights reserved. Abstract Penile elongation surgery is less commonly performed in the public sector, but involves a collaborative approach between urology and plastic surgery. Micropenis, elongation, dysmorphophobia, surgery. Penile anatomy To fully understand limitations of small penis size and the surgical correction possibilities, we must review the relevant basic penile anatomy. Penile length Normal penile length Accurate measurement of penile length is important for both clinical and academic purposes.

Table 1 Etiology of micropenis. Open in a separate window. Penile dysmorphophobia The majority of men seeking penile elongation treatment have a normal penile size, which is functionally adequate for sexual activity and micturition 14 , Non-surgical management The idea of treating actual and perceived penile shortening with intervention is controversial.

Testosterone In cases of true micropenis, the goal of treatment should be restoration of a functional penis size in order to improve body image and self-esteem, allow normal standing micturition and enable satisfying sexual intercourse. Traction devices Penile traction devices PTD have been explored both as an independent strategy to help with penile elongation and as an augment to surgery. Surgical management Penile augmentation Different types of injectable materials have been used for penile augmentation including liquid silicone, polyacrylamide, hyaluronic acid and mineral-oil 35 - Suspensory ligament release As discussed, the suspensory ligament anchors the penis to the pubic symphysis and while providing support, acts as the mobile point for the penis during erection.

V-Y advancement Penile elongation using a dorsal V-Y incision in the congenital or acquired short penis was first described over 40 years ago. Figure 1. Suprapubic lipectomy Suprapubic lipectomy has been performed to increase perceived penis length, particularly for patients with a buried penis. Figure 2. Penile disassembly Perovic and Djordjevic describe a technique similar to sliding elongation, which they have used to treat short penises and congenital penile anomalies.

Figure 3. Flap reconstruction Local, regional and free flap options exist to lengthen the penis. Figure 4. Conclusions Men complaining of short penis need to be clinically assessed for evidence of true micropenis and screened for PDD. Acknowledgements The authors would like to thank Alison Wong, MD for preparing the diagrams to supplement the surgical descriptions within this manuscript. Footnotes Conflicts of Interest: References 1. The inconspicuous penis in children.

Nat Rev Urol ; Surgical anatomy of the penis in hypospadias: Urology ; Johnson P, Maxwell D. Fetal penile length. Ultrasound Obstet Gynecol ; The development of the fetal penis--an in utero sonographic evaluation. Hughes IA. The testes: Sperling MA. Pediatric Endocrinology. Philadelphia, PA: Saunders; ; Sex determination and disorders of sex development according to the revised nomenclature and classification in 46,XX individuals.