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Reconstruction of Penile Wounds following Complications of AlloDerm-Based Augmentation Phalloplasty
Abstract
In this case report, two patients developed extensive penile skin necrosis following augmentation phalloplasty with AlloDerm. The reconstruction of these penile wounds was accomplished through conservative wound management combining preservation of the remaining penile soft tissue with debridement of avascular tissue and foreign material until a healthy recipient site was suitable for skin grafting. Despite the current shortage of evidence regarding the safety and efficacy of cosmetic penile augmentation, the demand for this procedure will likely continue to rise. Until the appropriate studies are undertaken to establish indications for usage and the preferred procedure chosen, it is imperative that we carefully and honestly monitor outcomes to limit untoward results of all penile enlargement operations, including AlloDerm-based phalloplasties.
... In contrast to autologous grafts such as buccal mucosa, ADMs are associated with some, but not a robust, creation of blood supply. 34 If the penile reconstruction in question requires such graft take as in urethroplasty, ADMs such as Alloderm may not be an appropriate option. ...
... Bruno et al reported on 2 case reports of complications involving penile girth augmentation with Alloderm. 34 In both cases, the patient underwent a suspensory ligament release for penile elongation, a V-Y advancement flap, and dorsal placement of Alloderm for girth enhancement. The dorsal penile skin overlying the Alloderm graft necrosed in both cases. ...
... This occurrence was demonstrated in the cases by Bruno et al by necrosis of the STSGs placed overlying the ADM and, further, the V-Y advancement flap, which has its own blood supply, still appeared to have had poor take in this situation. 34 However, the Alloderm implant positioned between the native dartos tissue and second tunica vaginalis flap in the aforementioned congenital aphallia case by Chaudhry et al appeared to have performed well. 60 Great caution should be taken when using ADMs not only as free grafts but also with the intent of supporting flaps to become incorporated into the underlying tissue. ...
Introduction:
There have been major advancements in the field of urologic reconstruction and gender-affirming surgeries over the past 10 years. These operations have become increasingly complex involving multiple revisions, with limited healthy native tissue availability. Grafts are frequently needed when a patient's own tissue is expected to have poor wound-healing properties. To reduce the morbidity associated with autologous grafts and complications associated with synthetic grafts, acellular dermal matrices (ADMs) can be used as substitutes in genitourinary surgery as they demonstrate decreased immunogenicity and retaine structural integrity.
Objectives:
The purpose of this review is to describe the importance and potential uses of ADMs by reviewing the literature and highlighting key examples of our institution's expanded application of ADM grafts in genitourinary reconstruction.
Methods:
We performed a literature review for the use of ADMs in genitourinary surgery including the search terms acellular dermal matrix, alloderm, extracellular matrix, penis, penile reconstruction, intrapenile prosthesis, phalloplasty, neophallus, urethroplasty, artificial urinary sphincters, Peyronie's disease, and urology. We highlight 5 representative genitourinary reconstructive cases performed at this institution where ADMs contributed to surgical success. Genitourinary reconstructive surgeries that have used ADMs in the literature included neophallus construction for gender affirmation, phalloplasty for trauma, penile augmentation, and plaque excision and grafting for Peyronie's disease.
Results:
Biomechanical studies across different graft types are limited in genitourinary applications. Initial studies using ADMs indicate benefits of limited inflammatory response, finite elasticity, and substantial tensile strength, acceptably mimicking properties of the native tissue.
Conclusion:
Our experience and the current literature suggest that human ADM is a valuable option for tunica albuginea replacement, but its use to support free grafts should be cautioned secondary to graft take. Haney NM, Huang MM, Liu JL, et al. Acellular Dermal Matrix Tissues in Genitourinary Reconstructive Surgery: A Review of the Literature and Case Discussions. Sex Med Rev 2020;XX;XXX-XXX.
... dermal fat grafts, and Spyropoulos et al. [8] achieved a greater enhancement of girth with this method than when injecting fat. Allografts in the form of an acellular inert dermal matrix derived from donated human skin tissue have also been used for penile girth procedures [17], but with a higher local complication rate [18]. Tissueengineered porcine dermal acellular grafts were tried by Alei et al. [2], with promising long-term results in 69 patients. ...
... Augmentation phalloplasty is usually used in cases of micropenis associated with true hypoplasia or, more commonly, in cases of penile dysmorphophobia. Whether aesthetic or functional, such surgery has a strong psychological effect on patients [2,3,5,18]. Especially in Arab countries, men requesting penile augmentation have unrealistic expectations of such surgery, and this was very evident during the present psychosexual assessment, and emphasises the role of a proper assessment and counselling. ...
Objectives
To assess the use of an acellular collagen matrix (Pelvicol, Bard Medical, Covington, GA, USA), a successful agent for reconstructive surgery, for enhancing penile girth.
Patients and methods
Between June and December 2011, 18 patients (mean age 24 years, range 19–38) had their penis augmented with Pelvicol; the mean (range) penile circumference was 9.2 (7–13) cm before treatment. They were divided into two groups; the first (10 patients) had a Pelvicol sheet of 8 × 12 cm inserted through a V–Y suprapubic incision and wrapped around the shaft in a bilayer under the dartos fascia, but not covering the urethra, with division of the suspensory ligament. The second group of eight patients had the Pelvicol inserted through a subcoronal degloving incision and placed in one layer. The penile circumference was measured at 6 and 12 months after surgery. Patient satisfaction at 1 year after surgery was assessed as ‘poor’, ‘unsatisfied’, ‘moderately satisfied’, ‘highly satisfied’, or ‘excellent’.
Results
The mean (range) increase in girth (circumference) was 2.8 (2–3.2) cm in group 1 and 1.7 (1.2–2) cm in group 2. In group 1, two patients were highly satisfied, four moderately satisfied and four unsatisfied; in group 2, three were moderately satisfied and five unsatisfied. Complications were common in both groups, with five patients in group 1 and three in group 2 developing severe penile oedema and ischaemic shaft ulcers. Removal of the graft was required in two patients in each group.
Conclusion
This pilot study shows that Pelvicol is not an ideal option for enhancing penile girth, and the method of placement did not apparently influence the result.
... The main limitations of current PGE procedures such as dermofat graft, autologous fat injection, and scaffold insertion, are invasiveness, long operation time, poor implant survival from movababilty and reabsorption, and uncommon devastating necrosis from poor blood supply with inflammatory reactions [2,[10][11][12]. ...
... Recently, allograft dermal scaffold (AlloDerm; LifeCell Corp, Branchburg, NJ, USA) has been used for the advantages of no donor-site scarring [2], no complex harvesting with resultant short operation time, good graft survival, low complication rate [14], cosmetic benefit of symmetry, and durability. Although AlloDerm easily provides an increase in penile girth, it can induce penile skin necrosis by prohibiting blood supply to the overlying penile skin [12]. Other complications associated with the use of AlloDerm include erosion, fibrosis, infection, reabsorption, and skin loss [2]. ...
Despites the debates on penile girth enhancement (PGE), demands for enhancement are increasing. Recently, various fillers have been widely used for soft tissue augmentation with proven efficacy and safety.
To identify the feasibility and efficacy of PGE by injection of filler.
Fifty patients with subjective small penis who visited Korea University Guro outpatient clinic were enrolled and prospectively followed. Restylane Sub-Q (Q-med, Upssala, Sweden) was injected into the fascial layer of penile body via 21G cannula with "Back & Forth Technique" and homogenized with a roller.
From April 2006 to February 2008, 50 patients were enrolled and 41 patients were followed until 18 months after PGE. Changes in penile girth at midshaft were measured by tapeline at 1 and 18 months. Patient's visual estimation of residual volume (Gr 0-4), patient's satisfaction (Gr 0-4), and any adverse reactions were also evaluated.
Mean injected volume was 20.56 cc (18-22). Compared with basal girth of 7.48 ± 0.35 cm, maximal circumference was significantly increased to 11.41 ± 0.34 cm at 1 month (P < 0.0001) and maintained as 11.26 ± 0.33 cm until 18 months. In patient's visual estimation, two patients complained the decrease as Gr 3 with focal depression at 1 month. At 18 months, all patients answered as Gr 4 without asymmetry. Patient's and partner's satisfaction score was 3.71 ± 0.46 and 3.65 ± 0.48 at 1 month and 3.34 ± 0.53 and 3.38 ± 0.49 at 18 months. There were no inflammatory signs or serious adverse reactions in all cases.
Considering the property of material, methods, and follow-up results of 18 months, PGE using filler is a very effective and safe technique for penile augmentation.
... Compared to penopubic junction incision, our coronary sulcus approach avoids hair bearing and more importantly avascular necrosis of the dorsal penile skin. 14 The arterial blood supply to penile skin and prepuce is provided by the superficial penile arteries branching from the inferior external pudendal arteries. 15 Pubic incisions tend to disrupt the blood supply to the subdermal plexus. ...
Introduction and Objective
Many men often have the need to enlarge their penises for psychological gain and to satisfy or to impress their partners. Many surgical techniques have been reported. However, none is the gold standard.
Aim
To evaluate the efficacy and safety of human acellular dermal matrix allograft in augmentation phalloplasty technique.
Methods
From March 2015 to September 2017, a total of 182 patients were prospectively recruited into our cohort after complete physical and psychological evaluation that deemed suitable for penile enhancement. Penis circumference was measured at the mid-length of the penis. Mean was 7.03 cm (6.93 ± 1.00 cm) and 12.1 cm (10.59 ± 1.15 cm) during flaccid and erection, respectively. All patients received human acellular dermal matrix graft under spinal or local anesthesia. The allograft was preconditioned in normal saline for 20 minutes, and mesh incisions were made to optimize blood flow. The width was equal to the circumference of both corpus cavernosa but without corpus spongiosum. The length of the graft was determined by measuring the length between the tip of the coronary sulcus and the root of penis. A complete incision below the coronary sulcus to the depth of the Buck’s fascia was made. Then separate the dartos fascia from the Buck’s fascia. The prepared graft was then placed on top of the Buck’s fascia, with the blood-remained side facing the Buck’s fascia. The graft was sutured using 4-0 absorbable polyglycolic acid suture to the Buck’s fascia. Extra caution needed to be taken when fixing ventrally to avoid injuring the urethra. Once completed, the dartos fascia was restored, the dartos fascia and subcutaneous tissue were sutured with 4-0 absorbable suture, and skin closure is achieved subsequently.
Results
The post-operative course was without complications. At the follow-up after 1 year, the mean flaccid girth increased to 8.07 ± 1.06 cm ( P < .05), while the mean erect girth increased to 12.79 ± 1.23 cm ( P < .05). Sexual activity was allowed after 8 weeks of surgery. The majority reported that sexual self-esteem and functioning significantly improved. In addition, 59 patients reported alleviation of premature ejaculation.
Conclusions
Compared to autologous dermis-fat graft and xenograft, augmentation phalloplasty using human acellular dermal matrix has several advantages: (1) it avoids harm harvesting site of the autograft; (2) the effects of dermis allograft can last at least 1 year; and (3) acellular dermal matrix is more likely to be accepted by people.
... QUALITY AND SAFETY are important indeed. Nevertheless, the use of human allograft products in augmentation phalloplasty is not without risk (Bruno et al., 2007;Park et al., 2011). In 2009, a leading US tissue establishment introduced BellaDerm TM , the first dermal tissue graft (derived from donated human skin) offered specifically for facial and body contouring procedures. ...
The transplantation of human tissue grafts, such as heart valve replacements and skin for severely burnt patients, has saved many lives over the last decades and the late eighties saw the emergence of tissue engineering with the focus on the development of biological substitutes that restore or improve tissue function. There is a distinct difference between tissue and organ donation, although it is usually not well perceived by the public. Solid organs (e.g. kidney, liver and heart) can be taken only from donors who are brain-dead and on life support or immediately after irreversible cardio-respiratory arrest. Organs have to be transported quickly from donor to recipient and are not, or only slightly, processed. Their procurement is generally controlled by surgeons in transplant hospitals and allocation is usually coordinated by national or regional organizations. In contrast, human cells and tissues (e.g. bone, skin and heart valves) may come from live organ donors but more usually come from deceased donors in hospitals, morgues or even funeral homes. These cells and tissues are often transformed and stored, sometimes for years, in “tissue establishments” from which they can be distributed across the world. Tissue brokers, processors and distributors steer the allocation of the resulting human cells, tissues, cellular and tissue-based products (HCT/Ps). Successful lobbying on key areas of regulatory and policy processes by industry, in congruence with policymaker’s risk aversion (focusing on quality and safety issues) and urge to promote growth and jobs, has led to business oriented human cell and tissue legislation. Today, almost anywhere in the world HCT/Ps are considered to be tradable goods. This raises some relevant ethical issues such as the legal or illegal (trafficking) import/export for profit and without regard for self-sufficiency, the commodification and the irresponsible allocation (e.g. human skin products for vanity procedures) of human cells and tissues, which were procured without consent or were altruistically donated for use in meaningful therapies or research. Up till now, policymakers have disregarded ethical issues. EU policymakers, for instance, adopted the principle of subsidiarity as a way of evading them. This may not be appropriate as one may assume that health is a universal ethical good. Could the processing of human bodily material lead to a product that is no longer subject to ethical principles? One could consider HCT/Ps to be ‘‘dual products,’’ consisting of human bodily material and an added value in the form of a technological process. Both parts clearly have a different moral status, which leads to an ethical dilemma; the human bodily material is not a tradable good, while the added technological process (knowhow) clearly is. The problem is that one cannot be sold without the other.
... Under Anglo-American law, corporate managers even have a strict fiduciary duty to act in the interest of share-holders (Norman 2000). Examples of profit-maximizing activities are the systematic processing of human donor skin, the golden standard in the management of severe burns (Hermans 2011), into more lucrative products that can be used in plastic surgery or in vanity procedures such as penis-widening or lip enhancement in people with normal penis and lip sizes (Terino 1998;Bruno et al. 2007). More problematic is the possibility that some less lucrative, but life-saving, HCT/Ps will no longer be available. ...
With this analysis we would like to raise some issues that emerge as a result of recent evolutions in the burgeoning field of human cells, tissues, and cellular and tissue-based product (HCT/P) transplantation, and this in the light of the current EU regulatory framework. This paper is intended as an open letter addressed to the EU policy makers, who will be charged with the review and revision of the current legislation. We propose some urgent corrections or additions to cope with the rapid advances in biomedical science, an extensive commercialization of HCT/Ps, and the growing expectation of the general public regarding the ethical use of altruistically donated cells and tissues. Without a sound wake-up call, the diverging interests of this newly established 'healthcare' industry and the wellbeing of humanity will likely lead to totally unacceptable situations, like some of which we are reporting here.
... High blood sugar levels can damage nerves and contribute to blood vessel narrowing, thereby disrupting the nerve and blood supply to the penis. In addition to poorly controlled diabetes, the BellaGen TM , though theoretically providing increased cosmetic girth, was an avascular component introduced into the tissues and may have inhibited the onset of inosculation, ultimately hindering skin viability 10 . The location of the injection is also important to note. ...
BellaGen™ is an injectable acellular dermal matrix granule derived from donated human skin tissue that was recently developed for soft tissue augmentation. Its use has been sporadically reported in penile girth enhancement procedures. Many cases of complications have been reported after injecting acellular dermal matrices like AlloDerm or SureDerm™ but few reports on complications associated with BellaGen™ injection. We report here on penile skin inflammation and necrosis following augmentation phalloplasty with BellaGen™, which developed 3 days after the injection and persisted for more than 2 weeks. The patient had a 15 year history of type 2 diabetes mellitus, and he was treated with oral antibiotics and wet dressings with KMNO4 solution to combine preservation of the remaining penile soft tissue with debridement of avascular tissue. The lesion improved with this treatment, but the patient experienced pain for about 2 weeks. All patients should be informed of the potential complications with the use of injectable acellular dermal matrices before treatment. Patient selection for augmentation is also important to have the most desirable results.
Introduction:
Correction of chordee remains a prerequisite prior to urethroplasty in children with severe hypospadias. The use of an interposition graft is indicated when significant chordee (>300) persists after division of the urethral plate. The use of free dermis or tunica vaginalis are most often used, but the use of a pre-packaged graft material is attractive with regards to efficiency. The success with small intestine submucosa (SIS) has been variable and experience with Alloderm® has not been published.
Objective:
To determine if Alloderm®, an acellular dermal matrix with regenerative properties, can effectively, safely, and efficiently be used for corporal grafting in cases of severe chordee in children associated with hypospadias or intersex STUDY DESIGN: All boys underwent planned staged repair of severe hypospadias (penoscrotal or more proximal). If artificial erection (AE) demonstrated chordee >450 after penile degloving and removal of fibrotic tissue, and again after urethral plate division, the ventral tunica albuginea was incised 1800 transversely and the oval defect measured in both axes. Alloderm® was trimmed to size and sewn into the defect. AE confirmed chordee correction. At the second stage repair (>6 months later), AE was performed to confirm continued absence of chordee.
Conclusion:
Alloderm®is safe, effective and simple to use graft material for correcting severe chordee. The benefits include performance efficiency without need for separate harvesting and donor site closure, and redundancy of material, if needed. Additional series and longer follow up must confirm these results and better assess durability.
Results:
Humans have been preoccupied with penile augmentation from time immemorial. In modern times, a wide variety of approaches have sought to increase penile length, girth, or, in some cases, both. While there is no consensus regarding appropriate indications, penile augmentation has been used in the setting of microphallus, fibrosis, trauma, and penile dysmorphia. Techniques for girth enhancement include injectable therapies, grafting, and implants. Penile lengthening procedures include traction therapy, suspensory ligament division, flap and liposuction procedures. This chapter aims to provide a brief review of historical and current approaches to penile augmentation, as well as a critical review of evidence regarding efficacy and complications.
Introduction:
Acellular dermal matrix (ADM) is a common filler used widely in clinical practice to increase penile girth for cosmetic reasons, but there are few studies on its complications.
Aim:
The aim of this study was to investigate and analyze the complications of penile girth enhancement (PGE) with ADM.
Methods:
The medical records of 78 patients who underwent PGE with ADM between June 2016 and January 2019 were retrospectively reviewed.
Main outcome measure:
Related complications and their subsequent management were summarized and analyzed.
Results:
78 patients (mean age 31.14 years [21-66 years]) received PGE with ADM. At the 3-month follow-up, the penile circumference was increased by 1.1 (0.5-2.1) cm on average. There were 47 patients with erectile discomfort, 12 with delayed healing, 10 with unobvious augmentation effect, 8 with wound hematoma, 7 with prepuce edema, 4 with wound infection, and 3 patients with skin necrosis of the dorsal side. 7 patients eventually underwent ADM removal.
Clinical implications:
These adverse complications indicate that ADM should be used with caution for PGE.
Strength & limitations:
This study adds important data, as there are few published reports on the complications of PGE with ADM. However, this study did not compare postoperative complications with ADM to those seen with other filler material.
Conclusion:
Even with standardized surgical methods and rigorous postoperative care, complications of PGE using ADM are severe, which indicates that it is not an ideal or safe method for PGE. Xu T, Zhang G, Bai W, et al. Complications and Management of Penile Girth Enhancement with Acellular Dermal Matrix. J Sex Med 2019;XX:XXX-XXX.
Die Größe des Penis ist für viele Männer ein Symbol der Männlichkeit und der sexuellen Leistungsfähigkeit. Gleichzeitig sind viele Männer überzeugt davon, dass ihr Selbstwertgefühl und die Anerkennung in der Partnerschaft maßgeblich durch die Penisgröße bestimmt sind und in der Regel „größer“ als besser empfunden wird. Aus diesem Grunde ist die Nachfrage nach ästhetischen, den Penis vergrößernde Operationen rasant angestiegen. Inhalt dieses Kapitels ist es, zunächst eine Landmarke zu setzen mit Hinblick auf Penismaße und Hintergründe für den Wunsch nach einer Vergrößerung. Im Anschluss wird die äußerst komplexe Anatomie und nervale Verschaltung des männlichen Genitales dargestellt mit Überleitung zu operativen Techniken sowohl für die Vergrößerung des Umfangs als auch die Verlängerung des Penis.
This chapter describes the augmentation procedures for the penis. While micropenis represents the only real indication for penile augmentation, patients will still seek augmentation surgery despite having a normal-sized and functioning penis. Abdominal and pelvic liposuction, and lipectomy are usually carried out in combination with other augmentation procedures such as suspensory ligament division and penile girth enhancement. In cases where significant truncal obesity results in a buried penis, an abdominoplasty is performed. In the absence of extensive lichen sclerosus on the foreskin, this procedure is normally enough to allow the penis to be unburied. Penile augmentation using skin flaps is indicated when the penopubic skin “traps” the penis preventing its normal physiologic elongation during erection. The most common technique used is an inverted V-Y advancement flap, also known as a V-Y plasty, which can be combined with a suspensory ligament division.
Allograft is an acellular dermal matrix (ADM), which is available in sheets. ADM is acquired from donated skin using proprietary processing techniques that are reported to preserve the biochemical and structural components of the extracellular matrix (ECM). This promotes tissue regeneration. Human ADM is extremely useful in burn care [1] and reconstructive surgery, such as breast reconstruction [2], abdominal hernia repair [3, 4], and cleft palate repair [5]. In addition, ADM graft can be combined with autologous thin split-thickness skin graft for safe and effective reconstructive procedures [6].
To describe the indications and results of techniques to change the appearance of the penis for aesthetic reasons. Provide recommendations concerning cosmetic surgery of the male genitalia.
We have selected from Medline Database, articles published between 1990 and 2011. Forty articles have been selected excluding papers reporting populations less than five cases per type of procedure.
There is no consensus on the size below which it is justifiable to accept or attempt to modify the size of the penis. Length of the penis in maximal tension less than 9.5cm or 10cm in erection can be considered as an acceptable limit, in a patient who suffers from it. The assessment of men asking for penile enlargement must include a psychosexological or psychiatric evaluation, looking for a dysmorphophobia or another psychiatric condition. Penile extenders under medical control must be the first-line treatment option for patient seeking penile lenghtening procedure when justified. In case of failure, three techniques can be used alone or in combination: penile lengthening by section of the suspensory ligaments and suprapubic skin advancement, lipectomy of Mons pubis and scrotal webbing section. The results are modest, the rate of complications significant and satisfaction low. Girth enlargement techniques by injection of autologous fat give inconsistent aesthetic results and satisfaction rates are low. All other techniques remain experimental.
Cosmetic surgery of the penis is associated with a high risk of forensic exposure and surgery should be only proposed after a multidisciplinary consensus, followed by a time of reflection given to the patient after full disclosure. Applications for the purpose of reconstruction surgery after trauma or consequences of cancer treatment are justified.
Micropenis in adults is defined as a stretched length of <7.5 cm. Many aetiologies exist, including congenital and endocrinological causes as well as pathological conditions, such as penile lichen sclerosus, trauma and genital cancer. The resulting reduction in functional penile length can lead to considerable psychosexual morbidity. Furthermore, the subset of patients with micropenis who also suffer from penile dysmorphic disorder require careful and intensive psychological counselling. Corrective surgery for micropenis can be performed in patients with realistic expectations. Total phalloplasty using radial-artery-based forearm skin flaps can offer restoration of normal penile length in selected patients. More-conservative surgical techniques to improve length or girth are limited by minimal enhancement but associated with a significantly lower rate of complications and comorbidity compared to total phalloplasty. Emerging tissue engineering techniques might represent a suitable alternative to penile replacement surgery in the future.
Penile augmentation is an ongoing debate. Emerging evidence proves a relationship between dissatisfaction with penile size and sexual dysfunction. Despite a widespread belief of the value of penile size, and the prevalent complaint of a "small penis," penile augmentation still stands short of addressing the demand. This report highlights the studies added to medical literature on penile augmentation in 2011-2012, including data on normal penile dimensions and the expected dimensions for a normal person, determination of the prevalence of the dissatisfaction with penile size, its effect on erectile function, female partner's opinion of the value of penile size, as well as further experience with augmentation techniques.
Penile trauma is common with standard management options. Gender reassignment techniques are rapidly changing and penile augmentation remains a controversial topic. Consequently, there is need for a state-of-the-art information in this area.
This study aims to develop an evidence-based state-of-the-art consensus report on the management of penile trauma, gender, reassignment and penile augmentation.
The study provides state-of-the-art knowledge regarding the prevalence, etiology, medical and surgical management of penile trauma, gender reassignment and penile augmentation, representing the opinion of leading experts developed in a consensus process over a 2-year period.
Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.
Penile fracture should be managed surgically. Information should be readily available to patients to help them decide the surgical technique desired for gender reassignment and to justify any form of penile augmentation.
As male genital corrective surgery is becoming increasingly requested by patients, the need to reach a general consensus on indications and techniques is now imperative. This review of published data provides an overview concerning patient selection modalities, benefits/risks and expected outcomes of surgery. Finally, the article focuses on ethical issues caused by the growing aesthetic nature of this surgery.
Interest has been sparked by animal studies, the description of innovative techniques for lengthening and girth enhancement techniques, reconstructive phalloplasty and penile implant surgery. Data suggest that better objective surgical outcomes are possible, though in many cases long-term data and patient-rated satisfaction details are lacking. Most importantly, studies show the importance of having a multidisciplinary team in charge of patient selection.
Although more long-term data are required before a general consensus can be reached, recent findings point to the absolute need for a thorough psychological assessment of men requesting penile enhancement surgery. Urologists should work in very close collaboration with psychologists or psychosexologists both during the preoperative phase (to verify eligibility for surgery) and afterwards (to provide counselling).
Most men who request surgical penile enhancement have a normal-sized and fully functional penis but visualize their penises as small (psychological dysmorphism).
The aim of this review is to describe the various reported techniques and to provide the available scientific data on the success and complication rates of penile enhancement procedures.
We performed an extensive systematic review based on a search of the MEDLINE database for articles published between 1965 and 2008. The following key words were used: penis, enhancement, enlargement, phalloplasty, reconstruction, girth, lengthening, and augmentation. Only English-language articles that were related to penile surgery and dysmorphobia were sought. We excluded articles in which fewer than five cases were described and articles in which the type of surgical treatment and the outcome were not clear. Of the 176 papers found, 34 were selected and critically analyzed.
We found only a small number of well-designed and comprehensive studies, and most of the published articles reported data that were obtained from small cohorts of patients. The more recently published studies presented better methodologies and descriptions of the surgical techniques than did the older publications. In general, penile enhancement surgery can cause a 1-2-cm increase in penile length and a 2.5-cm augmentation of penile girth. Unwanted outcomes and complications, namely penile deformity, paradoxical penile shortening, disagreeable scarring, granuloma formation, migration of injected material, and sexual dysfunction were reported frequently in these studies. Disappointing short- and long-term patient satisfaction rates following these procedures were also reported in most studies.
To date, the use of cosmetic surgery to enlarge the penis remains highly controversial. There is a lack of any standardization of all described procedures. Indications and outcome measures are poorly defined, and the reported complications are unacceptably high. In our opinion, until new, reliable, and more objective and reproducible data are available, these procedures should be regarded as investigational and patients should be discouraged from undergoing these invasive treatments.
The prepuce is formed by a combination of folding and epithelial proliferation, and separates from the glans after it has developed a blood supply. The arterial input, through 4 branches from the external pudendal arteries, is terminal and after birth supplies the outer and inner preputial surfaces in succession. Similarly, the venous return arises from small veins running transversely in the prepuce that connect to larger subcutaneous veins along the dorsal aspect of the shaft. Because the 2 preputial surfaces have a single blood supply they must be treated as 1 unit. Unfolding the prepuce leaves the former inner segment with only a terminal blood supply. The pedicle containing the superficial blood supply must remain attached to the skin flap or it will be devascularized. However, since this circulation goes exclusively to the flap, the more proximal portion of the prepuce that was raised to form the pedicle becomes ischemic when used as ventral cover. A double-faced flap avoids this complication.
Complications of the recent cosmetic technique of penile lengthening and girth enhancement are reviewed.
During a 16-month period 12 men presented with complications of penile augmentation performed elsewhere. All 12 patients had undergone release of the suspensory ligament and 10 had received autologous fat injection.
The chief complaint was poor cosmetic appearance (irregular residual fat nodules in 7 men, skin deformity and scarring in 4 and scrotalization in 4). Reoperation was necessary in 6 patients, wound complications occurred in 6 and sexual dysfunction was reported by 4. Only 1 patient reported a subjective increase in penile length.
Although a verifiable complication rate may never be available, the morbidity of elective penile lengthening and girth enhancement is noteworthy. These cosmetic techniques should be regarded as experimental.
More than 30 patients presented for reconstruction of penile deformities secondary to penile enlargement surgery performed by other physicians. Lengthening was performed by releasing the suspensory ligament of the penis and advancing pubic skin with a V-Y advancement flap. Girth was increased by injecting autologous fat. Specific complaints relating to the lengthening procedure involve hypertrophic and/or wide scars, a proximal penile hump from a thick, hair-bearing V-Y flap, and a low hanging penis. Complications relating to autologous fat injections include disappearance of fat, penile lumps and nodules, and shaft deformities. The repair of these deformities is described.
From 1994 through October 1996, 19 men underwent 24 various combinations of reconstructive operations, such as scar revisions, V-Y advancement flap reversal, and removal of fat nodules and asymmetrical fat deposits.
Penile appearance and function were improved. Complications include 1 hematoma requiring drainage, minor wound complications and 1 inadequately reversed V-Y flap.
The methods of various repairs are discussed, including reconstructive limitations, timing and staging. Significant improvement can be achieved with proper reconstruction of penile deformities.
- Alter