Penis enlargement surgery - length and girth enhancement
Elongation of the penis has been contemplated since antiquity, but only since 1971 has it been carried out as a reconstructive surgical technique for congenital and acquired shortening of the penis. Cosmetic penis enlargement began with girth enhancements in Miami in the late 1980s, but it was the Chinese surgeon Long who in 1990 described division of the suspensory ligament and penile skin advancement as a cosmetic procedure to increase penile length. Since then, over 10,000 men have undergone penile lengthening and girth enhancement, although no peer-reviewed paper has reported a reliable description of the techniques or results.
In 1996, excellent descriptions of penis enlargement procedures were published by Alter, which allowed better understanding of the surgery and were intended to reduce the incidence of complications. Significant bleeding from the procedure is rare, although in 1992 a Miami lounge singer died after penis enlargement while on anticoagulation. Other potential risks of penile augmentation include infectious complications, downward deflection of the penis due to release of the suspensory ligament, resorption of fat grafts, and injury to the neurovascular bundle with resultant erectile dysfunction or penile numbness. Failure to increase penile length or girth is a notable possibility as well.
Penile lengthening procedures have traditionally been reserved for patients who suffer severe shortening of the penis as a result of epispadias, trauma, Peyronie's disease, or failed penile implant. The definition of micropenis in the neonate is established as greater than 2.5 standard deviations below normal, or 2.5 cm stretched length. In adults, controversy exists as to the definition of a penis small enough for lengthening. It is unclear whether the flaccid or erect length is an appropriate guideline, or whether normal men should be considered for the procedure, since even men with the smallest most deformed penises can have appropriate sexual relationships.
Early reports of penile lengthening describe division of the suspensory ligament and mobilization of the proximal crura off the inferior pubic rami. Because of the risk of injury to the neurovascular structures of the penis, cosmetic surgery for penile lengthening relies on division of the suspensory ligament and skin flap advancement to increase the pendulous penile length. The corpora cavernosa, fused along the distal three-quarters, are attached to the pubic symphysis by the suspensory ligament; this structure, a condensation of Buck's fascia, maintains penile position during coitus. Division of the ligament can be accomplished through a variety of infrapubic incisions, but the technique is straightforward.
Interpretation of results is difficult, since most practitioners of penis enlargement do not use standardized techniques to measure length before and after surgery. Ideally, flaccid length from penopubic skin to meatus, stretched length, and erect length would be measured by a single observer. Rosenstein reported a mean increase in length of 2.1 inches (5.3 cm), but he did not specify whether flaccid or erect and, most importantly, based measurements on photographs of the patients. Long reported a mean increase in length of 3.8 cm, but the measurements were taken in the operating room immediately after surgery, which makes their interpretation suspect. Bondil and Delmas preformed a study in cadavers and found that penile length after release of the suspensory ligament alone was increased by 0.5 cm, while addition of a skin advancement increased the gain in length to 1.6 cm.
Enlarging the girth of the penis may be esthetically desirable if penile length is also increased, thus maintaining the normal aspect ratio of the penis. Two methods have been proposed to enhance penile girth - injection of harvested autologous liposuction specimen and surgical placement of a dermal-fat composite free graft around the penis.
Injection of liposuctioned fat from the abdominal wall or inner thighs was popularized by Rosenstein, but has several potential pitfalls. Distribution of fat may be irregular, or the fat may migrate in the early postoperative period, leading to nodular deposits of fat with resultant penile deformity. Human fat grafts lose weight and volume over time, with as little as 10% remaining after 1 year. Thus re-absorption of fat is also likely, causing loss of girth and, if not uniform, penile distortion.
More recently, an alternative technique for girth enhancement has been undertaken by Austoni, described as corpo-plastic augmentation surgery. Increase in the diameter of the erect penis is achieved by enlarging the albuginea of the corpora cavernosa, by means of bilateral venous grafts. The albuginea are incised longitudinally from the glans to the pubis, along the lateral aspect of each corpus cavernosum, and a saphenous vein graft is placed. Nine months postoperatively the increase in penile diameter in the erect state was between 1.1 cm and 2.1 cm in the 39 patients reported. There was no significant increase in diameter of the flaccid penis.