31 Aesthetic genital surgery

Synopsis

Male and female aesthetic genital surgery can greatly enhance confidence if a real or perceived deformity exists.

Many new genital surgeries have been developed.

In the male, penile enlargement surgery can result in severe deformities, which can often be reconstructed.

Hidden penis, penoscrotal web, and scrotum reduction surgeries are very successful with a low complication rate.

Labia minora and clitoral hood reduction performed by the “extended central wedge” excision gives a natural appearance with very high patient satisfaction.

Mons pubic lifting and labia majora reduction, with or without fat excision, increase self-esteem.

As with all aesthetic surgeries, genital surgery requires the same meticulous attention to detail.

Introduction

Identity and self-esteem are intimately related to a person’s image of his or her genitalia. Self-esteem can be impaired if a person feels inadequate compared with a perceived ideal. A normal man may consider his penis to be too small or a woman may judge her genital appearance as unsightly. These feelings develop from self-comparisons with pornographic photos or videos, media attention, or comments from a sexual partner or friend.

Patient awareness has led to significant demand for aesthetic genital surgery. Recently, new techniques to enhance the appearance of male and female genitalia have been developed, based partially on improved reconstructive pediatric and adult surgical procedures. Considerable aesthetic improvement in the genital appearance is now possible. The surgery is challenging and requires strict attention to detail and meticulous technique.

Male genital aesthetic surgery

Introduction

Several procedures are now available to enhance or improve the aesthetic appearance of the penis or scrotum. Penile lengthening is performed by releasing the suspensory ligament of the penis followed by the use of penile weights or stretching devices. Penile girth is increased by either injecting fat or by inserting dermal fat grafts or allografts such as AlloDerm into the dartos fascia. Penoscrotal webbing may be corrected with one or several Z-plasties, often combined with excision of the web skin. An enlarged, low-hanging scrotum can be reduced and lifted. The hidden or buried penis is corrected with a suprapubic lipectomy, possible upper pubic skin resection, and stabilization of pubic and penoscrotal skin.

Men are very resistant to psychiatric evaluation prior to penile enlargement surgery. Many of the men presenting for penile enlargement have significant generalized self-esteem issues, so refusal to perform the surgery may be justified. The psychological motivations of a man with a hidden penis, penoscrotal webbing, scrotal enlargement, or true congenital deformities are different from those of a man with a normal sized penis who desires only enlargement, so his care is usually more rewarding for both the patient and the surgeon.

Schonfeld and Beebe ¹ determined that the length of the fully stretched flaccid penis correlated closely with the erect penis. The dorsal length from the junction of the penopubic skin to the tip of the glans in the fully stretched flaccid penis correlated closely to the erect penis. Erect girth or circumference correlated with girth measurements of the flaccid penis according to a more complicated ratio.

Da Ros and Teloken et al.² performed artificial erections on 150 Caucasian men, measuring penis length from the center of the pubic bone to the tip of the glans and penis circumference at the corona and base. Average penis length was 5.7 inches; 18 were shorter than 4.7 inches and 18 longer than 6.3 inches. Circumference at the base of the penis ranged from 3.5 to 5.9 inches (average 4.7) and at the coronal groove from 3.2–5.5 inches (average 4.4).

Wessells et al.³ compared the relationship between penile length in the flaccid stretched and in erect states and also concluded that there was a positive relationship. The average flaccid stretched penile length was 11 cm, while the average erect penile length was 12.5 cm. The correlation between stretched length and erect length was r² = 0.769. Average flaccid circumference was 10 cm with an average erect circumference of 12.5 cm, and, therefore, correlation was not favorable for circumference. They also state that a thick pubic fat pad decreases visible flaccid penile length but not functional penile length during intercourse.

Patient selection/examination

The patient is evaluated both standing and supine to determine variations that change with gravity. While standing, the penis is checked for concealment owing to descent of the pubic fat pad and escutcheon from gravity, since supine positioning often eliminates this abnormality. A protuberant abdomen with excess skin and fat may overhang the penis and functionally interfere with sexual intercourse, so he may need an abdominoplasty in addition to a suprapubic lipectomy and skin excision. The amount of suprapubic fat between the pubic symphysis and the skin should be evaluated to determine potential length improvement from suprapubic lipectomy or liposuction. Penis position must be checked to see if it is partially encircled by the scrotum. The underside of the penis should be examined for penoscrotal webbing that causes an aesthetically or functionally shorter penis. Supine measurements are taken from the pubic bone and from the skin over the pubis to the tip of the glans on full stretch while the penis is at 90° to the abdomen. Circumference is measured at the base and corona with the penis on full stretch. The penis should be palpated for Peyronie’s plaques, which are firm scars on the tunica albuginea.

It is important to question and evaluate function prior to penile surgery. Urinary and orgasmic function should be normal but are not affected by these procedures.

The patient is asked if he has any erectile difficulties or penile curvature. Most men have some minor curvatures, but these are not bothersome and are not an issue. However, if girth surgery is considered, any known or suspected curvature should be documented. The patient is asked to present photographs showing his erect penis from various angles. If the patient is unwilling to present photographs, an erection can be obtained, and then photographed, by patient self-stimulation or by intracavernosal injection of prostaglandin E1. This pharmacologic agent is injected with a 30-gauge needle transversely into the cavernosal bodies at the base of the penis. The injected dosage usually is 10 µg in the normal male. The patient should be cautioned about the possibility of priapism and the necessity for mandatory reversal of the erection if it persists longer than 4 hours. The erection can be immediately reversed with a low-dose intracavernosal injection of phenylephrine, which is routinely performed to reverse a pharmacologic erection at the end of surgery.

Once the diagnosis is made, the possible procedures are discussed with the patient, as well as risks and benefits. Penoscrotal webbing and extensive suprapubic fat and pubic descent may not be presenting complaints, but the physician must describe these abnormalities and possible corrective surgery. Each individual is evaluated to determine the best method to achieve his goals, since several procedures are available depending on the patient’s anatomy. He must have a realistic understanding of the design and limitations of the surgery in order to prevent misconceptions and dissatisfaction. Exaggerated promises lead to patient disappointment, depression, and hostility; therefore, honesty, clear communication, and compassion are mandatory for both patient and physician. Because not all malpractice carriers will cover physicians for penile enlargement procedures, verification of coverage is recommended.

Anatomy

The suspensory ligament of the penis is a thick, triangular band extending from the linea alba and the upper portion of the symphysis pubis and arcuate ligament to the dorsal midline of the penis.⁴ It derives from the outer investing fascia of the abdomen and divides into a sling at the junction of the fixed and mobile portions of the penis. In addition, thickened bands of Scarpa’s fascia, called the fundiform ligaments, firmly attach to the rectus fascia above the pubic symphysis and extend onto the dorsal and lateral penis, possibly restricting penile excursion.⁵

The skin of the penis is thin, hairless (more distal), and has loose connections with the deeper structures of the penis. No adipose tissue is present under the skin. The superficial or subcutaneous fascia of the penis (dartos fascia) is continuous with the Scarpa’s and Camper’s fascias of the lower abdomen and extends to the corona of the penis. The dartos fascia contains scattered smooth muscle cells. Branches of the superficial external pudendal vessels provide the blood supply to the dartos fascia and skin. The internal pudendal system, which includes the deep dorsal arteries and veins and the cavernosal and urethral vessels, usually communicates with the external pudendal system only at the glans and corona.⁶ Because the dartos fascia is highly vascular, it provides an excellent tissue bed for grafts. Buck’s fascia invests the shaft of the penis deep to the dartos fascia. The dorsal nerves of the penis supply erogenous sensation to the glans penis. The deep dorsal vessels and the dorsal nerve travel in the pudendal canal along the ischial ramus and then pass ventrally along the margin of the inferior ramus of the pubis in the deep perineal pouch. The neurovascular bundles pierce the perineal membrane inch from the symphysis pubis and continue within Buck’s fascia of the penis. Each of the two deep dorsal arteries lies between the deep dorsal vein in the midline and the dorsal nerves of the penis laterally.

Penile enlargement

Penile lengthening

Penile lengthening is achieved by releasing the suspensory ligament of the penis and the postoperative use of penile weights or stretching devices (Fig. 31.1A).⁷^–¹⁰ The ligament is released only one fingerbreadth by cutting directly on the periosteum throughout the length of the midline pubic symphysis. The release is usually performed through a 3–4 cm lower transverse incision just above the penopubic junction, but many surgeons advance infrapubic skin onto the penis using a VY advancement flap (Fig. 31.1B,C).^11,¹² This VY flap theoretically increases penile length or gives the penis the appearance of increased flaccid length, which may occur if the patient has a shortage of penile skin. Penile length gain is disputed in most cases, and the VY flap can actually cause the penis to appear either longer or shorter in the flaccid state. The VY flap is based distally at the penopubic junction varying from a small (2–3 cm) to a large base. The larger flap encompasses the entire dorsal base of the penis and part of the scrotum, which causes interruption of a significant portion of the proximal penile dartos fascia and skin. The blood supply and lymphatic drainage of the penis is thus partially interrupted which can cause healing complications such as flap tip loss, poor wound healing with wound dehiscence, and postoperative swelling. Healing problems predispose to hypertrophic or wide scars, which create hairless pubic scars and depressions (Figs 31.2A, 31.3A). The large VY flap also advances thick, hair-bearing tissue onto the penis, which frequently creates an unnatural hump at the penile base and the appearance of a low-hanging penis.¹³^–¹⁶ The penis can appear surrounded by the scrotum (scrotalization) with an overhanging large pubic fat pad, which makes the penis look shorter and hidden. A VY flap can also create ‘dog-ears’ at the distal scrotal flap incision. Smaller VY advancement flaps cause less frequent problems, but wound and aesthetic complications also occur.

Fig. 31.1 Method commonly used for penile lengthening that often causes penile deformities. (A) The suspensory ligament is released. (B) A large VY advancement flap is designed. (C) The flap is advanced, resulting in hair on the proximal penile shaft, bilateral dog-ears, and a lower-hanging penis.

Fig. 31.2 Complete reversal of VY advancement flap. (A) The scar is marked for excision. The marking at the base of the VY flap on the left is the estimated location for the reapproximation of the flap to the pubic hairline. (B) Complete reversal of the VY flap resulting in a semicircular incision line. Hair on the VY flap is aligned with the pubic hair.

Fig. 31.3 Patient who had release of the suspensory ligament, a large VY advancement flap, and fat injections. (A) The deformity shows a low-lying penis, hair on the proximal shaft, bilateral dog-ears at the penoscrotal junction, a short-appearing penis, wide pubic scars, and fat in the shaft. (B) Reconstruction after partial reversal of the VY advancement flap, correction of the VY dog-ears, scar revisions, and selective removal of fat. Complete reversal of the VY flap was not possible due to previous partial loss of a portion of the VY flap.

Dermal and dermal fat grafts

Girth enlargement is also performed by inserting either dermal or dermal fat strips into the dartos fascia or by wrapping dermal fat sheets circumferentially between the dartos and Buck’s fascias.⁷^–¹⁰ The strips can be placed through either a partial circumcision incision or a transverse pubic incision. The sheet graft, which is not commonly performed, is usually placed through a hemi-circumcision incision and wrapped about 80% of the circumference of the penis with the urethra left uncovered. The grafts are sutured proximally and distally to prevent migration. Usually, the dermal fat grafts ‘take’ well and provide circumference girth increase from 2–4 cm. However, difficulties with penile immobilization and the thickness of the grafts increase the risk of poor ‘take’ and subsequent severe complications such as restriction of erection with penile shortening or penile curvature. The procedure is far more invasive than fat injections and requires several hours of surgery. Donor site scars from the buttock crease, suprapubic region, or flanks can be very unsightly. Nodules and fat reabsorption are less common with dermal fat grafts than fat injections. Significant penile edema and induration exist for 6 weeks postoperation, and relatively normal texture returns in 4–6 months. Wrapping a sheet of dermal-fat grafts, rather than inserting strips, provides smooth texture with less risk of ridges and displacement. Penile skin loss has been seen with dermal fat grafts.

Allograft dermal matrix grafts

Alloderm use for girth expansion was motivated by the unpredictability of dermal fat graft ‘take’ with its cosmetically unappealing donor site scars. Layers of Alloderm are inserted in a plane above the Buck’s fascia and stabilized proximally and distally. Theoretically, the Alloderm is a matrix for the ingrowth of tissue and becomes integrated into the area. However, this does not always occur, so the Alloderm can be isolated within a capsule. Since Alloderm does not stretch, the patient may complain of loss of length or curvature. Patients may also complain of an unnatural feel of the penis, displacement of the Alloderm, asymmetry, and visual and palpable deformities. Many cases of infected Alloderm have occurred resulting in chronic infections and chronic skin sinuses with or without skin loss.

True corporal girth increase can be obtained by making lengthwise incisions through the tunica albuginea at the 3 and 9 o’clock locations and then patching these defects with Alloderm or long saphenous vein grafts.¹⁷ This procedure was derived from penile straightening operations for Peyronie’s disease. However, most of the results are anecdotal with no large series. The risk of erectile dysfunction is theoretically possible if infection or poor healing occurs, since the erectile chamber is violated.

Other techniques are being tried to increase girth by using tissue engineering with biodegradable scaffolds.¹⁸

Reconstruction of penile enlargements

Patients present with a diverse array of deformities and reconstructive issues.^15,¹⁶ They may have a combination of penile lengthening with VY flaps and/or fat injections, or penile lengthening with Alloderm, etc. The patient must prioritize his reconstructive goals, because complete correction of all the deformities may not be possible at one operation, if at all. He may want only limited fat or Alloderm removal, partial or no VY flap reversal, or minimal scar revisions. Realistic expectations must be emphasized.

Reversal of VY advancement flap

The most common repair is partial or complete reversal of the VY advancement flap with excision of the wide scars (Figs 31.2, 31.3).¹⁴^–¹⁶ Reversal and scar revision eradicates the unsightly dorsal penile hump and proximal penile hair-bearing tissue by re-draping the penis with the normal shaft skin. The penile skin is elevated to its normal position by aligning the hair on the ‘V’ flap with the pubic hair. The suprapubic concavity and unsightly scars are usually also corrected by partially or completely reversing the VY flap, excising scar tissue, mobilizing Scarpa’s fascia and skin from both sides of the vertical scar, and approximating the wound. Complete VY reversal resulting in a semicircular incision is ideal, but it is often impossible or undesirable. Part of the flap tip may have necrosed after the first procedure or must be excised on this revision to prevent tip flap loss. The patient may have had multiple circumcisions after fat injections stretched the penile skin. Therefore, the adequacy of shaft skin needs to be determined intraoperatively to insure that complete reversal of the flap does not shorten the penis (either real or illusory) and restrict an erection. A pharmacologic erection achieved by intracavernosal injection of Prostaglandin E1 helps to determine skin adequacy. No restriction of erection should occur by pulling on the erect penis. If there is inadequate penile skin for complete reversal, partial reversal is performed which results in an inverted Y-shaped scar with a shorter vertical limb (Figs 31.3B, 31.6). The resulting ‘Y’ scar is more noticeable than the scar from complete reversal.

Fig. 31.6 Partial reversal of VY advancement flap. (A) The VY flap is reversed as much as possible while preserving penile length. (B) Dog-ears are removed by making lateral darts. The can also be removed by extending the incision along the lateral scrotum.

Reversing the VY flap can cause scrotal ‘dog-ears’, which are usually followed along the lateral scrotum. The method of closure and ‘dog-ear’ excision is determined by judging the tightness of the penile skin, taking care not to restrict an erection. Do not eliminate skin discrepancy or ‘dog-ears’ by making a circular incision through the skin and dartos fascia at the penile base, since prolonged lymphedema or skin loss can occur. Alternatively, the ‘dog-ear’ is excised from the mid-portion on the lateral side of the incision, creating a lateral dart instead of following the ‘dog-ear’ medially around the penile base (Fig. 31.6).

Excision and scar revision require meticulous skin closure without tension, thus reducing the potential for re-developing a hypertrophic scar. A suction drain is used. Despite careful wound closure, minor healing problems often occur at the common junction of the flaps of the ‘Y’ with the partial reversal. In addition, some spreading of the scar is common.

Re-release of the suspensory ligament is performed only if the patient complains of penile shortening, since the risk of injury to the dorsal neurovascular structures is increased. In order to prevent reattachment of the corpora bodies to the symphysis in a shortened position, a fat flap or flaps transposed from spermatic cord lipomatous tissue should be placed between the corpora and the pubic symphysis (Fig. 31.4).

Fat removal

Most patients with fat injections do not want complete removal of the fat. They usually complain of nodules or penile asymmetry with various concavities or convexities. Removal of fat nodules and/or penile contouring is performed through a limited or complete circumcision incision, a medial raphe incision, or part of a previous VY incision (Fig. 31.5). Shaft incisions are cosmetically unacceptable and unnecessary. Deforming or firm fat deposits are removed first followed by contouring of the residual fat. Over-resection of fat creates unsightly concavities, so perform contouring by removing small increments of the deforming fat.

Complete removal of most of the fat can lead to significant complications, so attempts to dissuade the patient from this should be made. If performed, complete fat removal or excision of large diffuse areas of injected fat is usually performed through a circumcision or hemi-circumcision incision. The fat deposits are removed, preserving as much dartos fascia as possible, even if some fat remains. Despite all attempts to leave dartos fascia, a high complication rate occurs; lymphedema may persist for up to 6 months, skin attachment to the Buck’s fascia may occur, and fibrous attachments from the dorsal corpora to the pubic subcutaneous tissue and skin can shorten the penis. These skin and fibrous attachments may necessitate Kenalog injections. However, another difficult operation may be required to release this scar tissue and transpose unilateral or bilateral fat flaps to fill the dead space or the area of the skin attachment.

If VY flap reversal is performed, simultaneous removal of fat nodules or deforming fat deposits is limited. Fat is removed through a several centimeter tunnel on one or both sides of the most distal aspect of the VY incisions without undermining the V flap, and/or through a limited circumcision incision. One side of the penis must be kept relatively inviolate to assure adequate lymphatic and blood drainage. However, a proximal medial raphe incision in a patient with a large VY flap reversal may injure the remaining nontraumatized proximal dartos fascia. Removal of large diffuse fat deposits should rarely be done at the same time as the VY reversal, since further flap disruption and dartos fascia injury decrease vascularity of the flap and possibly prolong edema. This large fat removal should not be done earlier than 6 months after VY flap reversal, allowing time for revascularization of the scarred areas.

Dermal fat graft and Alloderm removal

Dermis, dermal fat grafts, and Alloderm present with a variety of different problems, including penile shortening, curvature, and areas of induration.³ Removal of the grafts are performed though one or a combination of circumcision, median raphe, or low pubic incisions. An indurated, scarred graft that is not adhered to the Buck’s fascia can be removed without much difficulty, thereby correcting the deformity (Fig. 31.7

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