Surgical Procedure

When the approach is via a transverse infrapubic incision about 3 cm long (▶Fig. 5.1a), it is possible that when the suspensory ligament is divided and the penis slides forward, the penis skin may pull back. If this withdrawal is to be reduced, using a V-Y flap is recommended instead (▶Fig. 5.1b).

The subsequent dissection spares the bilateral superficial dorsal arteries of the penis. The superficial dorsal vein of the penis is ligated, and the Buck’s fascia is incised longitudinally. Along the corpora cavernosa, the suspensory ligament of the penis is th en exposed (▶Fig. 5.1).

Before it is divided, the bilateral vascular branches coursing through the surrounding fatty tissue must be coagulated. Then, the suspensory ligament can be exposed by blunt dissection and the spermatic cords on either side can be held back with a Roux retractor. The ligament is divided with sturdy blunt-tipped scissors close to the symphysis down to the deep fascia where the two crura of the corpora cavernosa diverge (▶Fig. 5.2a, b).

The penis has now been shifted anteriorly. To prevent it from gliding back, the tunica albuginea of the root of the penis is fixed to the skin with simple interrupted sutures (▶Fig. 5.3a, b). The proximal penis can be further emphasized by moving back the junction of the scrotum on the ventral penis. This is done by anchoring the scrotal raphe to the tunica albuginea of the penis with a simple suture (e.g., with 2–3 Vicryl) placed through a small skin incision. The suture should be placed at the lowest point of the penoscrotal fold. Alternatively, a crescentic excision of the skin fold is performed, after which the wound edges are sutured to the tunica albuginea. In selected cases, a scrotum lift is performed (see Chapter 5.3, Scrotum Lift (▶Fig. 5.3c).

Aftercare

First the body of the penis is wrapped in compresses. These are fixed in placed with hypoallergenic adhesive tape. Then a bandage under tension toward the thigh is applied with another piece of adhesive tape to prevent strangulation of the penis. This tension should be maintained for 7 to 10 days as otherwise adhesions in the region of the penis root could develop and later impair erectile function. At the same time, this prevents the penis from gliding back into its original position and negating the desired lengthening.

Complications

The medically relevant complications include:

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  Severe bleeding, especially due to injury of the prostatic venous plexus of Santorini or the corpora cavernosa.

  
  
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  Postoperative bleeding.

  
  
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  Severe swelling (▶Fig. 5.3d).

  
  
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  Hematoma (▶Fig. 5.3f).

  
  
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  Impaired wound healing.

  
  
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  Local infections.

Bleeding, postoperative bleeding, and hematoma can be avoided if careful hemostasis is achieved during the procedure and the patient observes the rules for proper postoperative behavior. Postoperative hematoma or edema will not usually require further surgical therapy and will resolve under conservative treatment. Impaired wound healing and wound dehiscence are usually superficial. They are treated conservatively. A scar contracture can occur as a secondary complication.

Surgical Procedure

Patients of light to medium weight without massive suprapubic fat deposits are generally good candidates for penis augmentation. Obese patients and patients with a buried penis are not suitable for penis augmentation.

The procedure usually begins with the patient in a prone or lateral position to facilitate harvesting a free adipocutaneous graft from the gluteal fold. The size of the graft depends on the respective findings. As a general rule, three strips, each 1 cm wide, can later be obtained from a single graft. First, the skin is incised superficially and then the epidermis is removed from it by sharp dissection (deepithelialization) while maintaining constant tension. Fine petechial bleeding occurring in the dermis is a sign of proper dissection depth. Then the dermis is completely divided and the fatty tissue deep to it is mobilized down to a depth of 25 mm without injuring the muscle fascia. Then the tissue is removed en bloc, the donor site is closed, and the patient is positioned supine.

The graft is now adapted to the specific requirements. It is thinned accordingly, and its edges are beveled slightly so it will fit more easily into the recipient site. Then the graft is divided into three equal strips. A circular incision is made about 1 cm proximal to the corona of the glans. Then the tunica albuginea is exposed by dissecting the skin and the deep fascia of the penis (Buck’s fascia). The grafts are then each arranged dorsally and laterally and are anchored to the tunica albuginea with two to three simple interrupted sutures (e.g., with 2–0 Vicryl). The graft is then sized and placed under tension so that it fits distally into the coronary groove and ends proximally in the infrapubic region not far from the suspensory ligament of the penis. Then the Buck’s fascia and skin are drawn forward, and the edges of the wound are approximated and sutured in layers (▶Fig. 5.4a, b, ▶Fig. 5.5a, b).

Aftercare

Where present, the foreskin is fixed to the body of the penis with a strip of hypoallergenic tape to prevent movement or strangulation due to edema. The body of the penis is then wrapped in compresses, and the compresses are fixed. Then a bandage under tension toward the thigh is applied with another piece of adhesive tape to prevent strangulation of the penis. This tension is maintained for 7 to 10 days as otherwise the adipocutaneous grafts would be compressed, leading to adhesions that could later impair erectile function.

Complications

Irregularities in the surface or in the circumference of the body remaining after the healing phase can be managed by revision surgery or lipofilling (see Chapter 2.1.3, Fillers and Lipofilling in Genital Surgery), depending on their size. Necrosis of the skin of the penis is rare because of the good perfusion of the tissue. However, in some cases necrosectomy is necessary (▶Fig. 5.5c). In such cases, the resulting skin defect can usually be easily closed because of the good mobility of the surrounding skin. This means that using a split-thickness skin graft to cover a defect will only rarely be necessary.

Surgical Procedure

The size of the glans varies greatly and can become more apparent after phalloplasty. Augmentations with hyaluronic acid or other preparations are relatively easy to perform. However, they usually have only a temporary effect. In contrast, surgical augmentations produce a permanent effect, yet because of the compact size of the glans they are relatively elaborate.

The most common indication for glans augmentation is status post penis augmentation, and for this reason glans augmentation should be included in the planning of a phalloplasty as a matter of course.

The principle of glans augmentation is the same as that of penis augmentation. An appropriately large adipocutaneous graft is harvested from the gluteal fold and processed accordingly (▶Fig. 5.6). Alternatively, it can be taken from the suprapubic region if repositioning the patient intraoperatively should be avoided.

Again, a circular incision is made about 1 cm proximal to the corona of the glans. Then the tunica albuginea is exposed by dissecting the skin and the deep fascia of the penis (Buck’s fascia).

The skin is undermined with blunt-tipped scissors distally as far as the margin of the corona. The dissected mantle of skin is then folded on the glans and slightly elongated, and the dissection is continued in the cleft between the glans and the corpora cavernosa. It is important to spare the navicular fossa of the urethra just proximal to the urethral meatus. Then a graft of the appropriate size is placed in the dissected cleft and sutured (▶Fig. 5.7a–d).

The wound is closed in layers, i.e., by approximating the wound edges of the cleft between the glans and corpora cavernosa, the Buck’s fascia (4–0 Vicryl), and the skin (4–0 Vicryl Rapide). Acellular dermal matrices are increasingly being discussed as an alternative to an adipocutaneous graft, and therefore this option must be discussed with affected patients (▶Fig. 5.8a, b).