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in the mid‑1980’s and continues to be used due of its limitations of the techniques. Patients with unrealistic
versatility. expectations that do not understand this information
must be discouraged from the procedure because the level
Traction treatments are the only ones able to achieve of disappointment will likely be very high. It is extremely
effective length improvements of the penis, producing important not to assure the patient that any type of result
an increase in actual tissue mass and at the same time will be an improvement; patients should understand that
“softening” the corpora cavernosa fascial and osseous it is possible to see no improvement, an event caused
attachments. The combined use of both types of usually by an inadequate scar contraction.
treatments (suspensory ligament release and extender
use) can produce the best outcome by extending the Composite augmentation phalloplasty techniques are safe
“hidden” part of the penis with generation of additional and reproducible and yield satisfactory results if properly
tissue. All penis lengthening techniques are based performed. Although apparently easy to perform, a
on the release of natural physiologic anchors that thorough knowledge of anatomy and grafting techniques
bind the corpora cavernosa to the pubic symphysis, is needed to get good results and avoid complications.
isquiopubic bone branches, and abdominal aponeurotic Volumetric enhancement by ligament release and
expansions. Although this lengthening can be performed cutaneous advancement together with an increase in
through a simple transverse incision or even using an girth with fat grafting is probably a safer option, with
endoscope (not published), a number of ancillary skin better results and lower morbidity. The future of penis
advancements can be performed to ease ligament release enlargement will be enhanced with techniques that
and to procure advancement and stabilization, and thus provide dynamic improvements in size, possibly through
prevent length loss due to scar contracture. In this the use of tissue engineering.
regard several techniques have been published such as
M‑plasty (popularized in China and reported by Reed ), REFERENCES
[15]
VY advancement (Roos and Lissoos ), Z‑plasty (Horton ),
[17]
[16]
double Z‑plasty (Alter [18,19] ) and personal techniques of 1. Mondaini N, Ponchietti R, Gontero P, Muir GH, Natali A, Caldarera E, Di
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Abecassis and Panfilov. Although the author supports Loro F, Biscioni S, Rizzo M. Penile length is normal in most men seeking penile
[21]
the use of local tissues to fill the advancement gap to 2. lengthening procedures. Int J Impot Res 2002;14:283‑6.
Monreal J. Fat tissue as a permanent implant: new instruments and refinements.
additionally maintain advancement, some authors have Aesthet Surg J 2003;23:213‑6.
published their experience inserting small testicular 3. Monreal J. Male and female genital aesthetic surgery: basic techniques and
prostheses as spacers with no better results. [22] concepts. AECEPJ 2006;1:8‑17.
4. Hinderer UT, Espinosa JF. New enlargement technique with volume
In our practice performing suspensory ligament release, enhancement in penis hypoplasia and hypospadias. Cir Plast Iberlatinamer
skin flap advancement together with simultaneous girth 1997;23:151‑60.
enlargement using fat grafts is the most satisfactory 5. Dillon BE, Chama NB, Honig SC. Penile size and penile enlargement surgery:
a review. Int J Impot Res 2008;20:519‑29.
approach to increase penis size. This composite technique 6. Ghanem H, Glina S, Assalian P, Buvat J. Position paper: management of men
generates real volume increase which results in a better complaining of a small penis despite an actually normal size. J Sex Med
perceptual outcome for the patient. Additionally, the 2013;10:294‑303.
increase in shaft convexity and downward position creates 7. Parodi PC, Dominici M, Moro U. Penis invalidating cicatricial outcomes in
an enlargement phalloplasty case with polyacrylamide gel (Formacryl). Int J
the illusion of a longer penis as well. The incidence of Impot Res 2006;18:318‑21.
complications or side effects is relatively low and easy to 8. Oderda M, Gontero P. Non‑invasive methods of penile lengthening: fact or
solve without affecting final results. A thorough knowledge fiction? BJU Int 2011;107:1278‑82.
of regional anatomy helps to prevent serious or minor 9. Colpi GM, Martini P, Scroppo FI, Macini M, Castiglioni F. Efficacy of daily
complications. There are two good safety rules: perform penis‑stretching technique to elongate the “small penis”. Int J Impot Res
2002;14:155.
the ligament release as close to the bone as possible and 10. Shaeer O, Shaeer K. Penile girth augmentation using flaps “Shaeer’s
do not perform any grafting that may exceed the capacity augmentation phalloplasty”: a case report. J Sex Med 2006;3:164‑9.
of the tissue. Although liponecrotic cyst occurrence can 11. Alei G, Letizia P, Ricottilli F, Simone P, Alei L, Massoni F, Ricci S. Original
be solved easily, damage to the deep penile neurovascular technique for penile girth augmentation through porcine dermal acellular
grafts: results in a 69‑patient series. J Sex Med 2012;9:1945‑53.
structures usually has disastrous consequences. Patient 12. Jin Z, Wu YG, Yuan YM, Peng J, Gong YQ, Li GY, Song WD, Cui WS, He XY, Xin ZC.
satisfaction after augmentation phalloplasty is lower Tissue engineering penoplasty with biodegradable scaffold Maxpol‑T cografted
when compared with other popular aesthetic surgical autologous fibroblasts for small penis syndrome. J Androl 2011;32:491‑5.
procedures. In our series, only 32% perceived the result 13. Perovic SV, Byun JS, Scheplev P, Djordjevic ML, Kim JH, Bubanj T. New
perspectives of penile enhancement surgery: tissue engineering with
as very good and an additional 43% as good, in spite biodegradable scaffolds. Eur Urol 2006;49:139‑47.
of being clearly informed about the limitations and 14. Austoni E, Guarneri A, Cazzaniga A. A new technique for augmentation
outcomes for other patients and follow‑up demonstration phalloplasty: albugineal surgery with bilateral saphenous grafts ‑three years
of experience. Eur Urol 2002;42:245‑53.
of improved average measurements. As with any other 15. Reed HM. Augmentation phalloplasty with girth enhancement employing
aesthetic surgery procedure, informing the patient is autologous fat transplantation: a preliminary report. Am J Cosmet Surg
extremely important in achieving an adequate degree of 1994;11:85‑9.
satisfaction. Two relatively distinct patient groups exists: 16. Roos H, Lissoos I. Penis lengthening. Int J Aesthetic Restorative Surg 1994;2:89‑96.
those who present with a real hypoplasia and those cases 17. Horton CE, Vorstman B, Teasley D, Winslow B. Hidden penis release:
adjunctive suprapubic lipectomy. Ann Plast Surg 1987;19:131‑4.
of body dismorphic disorder. The former tend to show 18. Alter GJ, Salgado CJ, Chim H. Aesthetic surgery of the male genitalia. Semin
higher degrees of satisfaction and understand easily the Plast Surg 2011;25:189‑95.
32 Plast Aesthet Res || Vol 2 || Issue 1 || Jan 15, 2015