This paper will review the anatomy and embryology of congenital micropenis and discuss both conservative and surgical management options for men seeking penile elongation therapy. To fully understand limitations of small penis size and the surgical correction possibilities, we must review the relevant basic penile anatomy. The penis is composed of three large cylinders—two corpora cavernosa dorsally, which contain the erectile tissue, and the corpus spongiosum which constitutes the urethra.
The main components of the penis are surrounded by areolar tissue and peripherally encased with skin. Each layer of the penis plays a significant role in the function and dynamics of the penis during sexual activity and voiding 1. Skin plays an important role in protecting the penile tissues from trauma during intercourse and as a barrier from bacterial infection.
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If infection or trauma do occur, the skin can impair intracavernosal functioning and result in a contained abscess or hematoma formation, respectively. The skin is firmly attached to the glans and only loosely attached to the shaft, allowing for mobility during intercourse. At the base of the penis, the dartos fascia combines with smooth muscle fibres and creates a well-defined penoscrotal angle between the scrotal wall and the skin. The deep fascia adheres to the tunica albuginea 1. The base of the penis is firmly attached to the pubic rami by penile ligaments composed of connective tissue.
The ligaments arise from the external oblique aponeurosis and are fixed to the symphysis pubis. The suspensory ligament arises from the linea alba and provides dorsal support and stabilization of an erection by attaching midline to the penile root 2. This ligament also helps cover the neurovascular bundle of the penis and protects it during repetitive sexual trauma. The fungiform ligament attaches to the pubis and fans laterally and ventrally to the encircle the entire penile root, acting like a sling for support 1.
During embryologic development, gender remains indifferent until approximately seventh week of gestation. From the eighth week onward, male and female developmental pathways diverge. In males, maternal chorionic gonadotropins from the placenta stimulate growth and development of the testicular Leydig cells, which eventually produce their own testosterone for further development 3.
The development of the external genitalia in males is dependent on the conversion of testosterone to the active component dihydrotestosterone DHT. The genital tubercle enlarges to form both the shaft and glans of the penis. The urogenital folds fuse along the midline to become the penile urethra and the glans invaginates to create the glandular urethra. The labioscrotal folds fuse to create the scrotum. Complete penile differentiation should be complete by the end of the first trimester. Penile length and size increase during development in proportion to other fetal development 5.
The average penile length increases by a mean of approximately 2 cm between 14 weeks and term. Penile elongation in utero is complete by androgens produced by the fetus. After the first trimester, the fetus depends on his own hypothalamic-pituitary axis for gonadotropin production. After normal development, there is an LH surge at birth which stimulates an increase in testosterone production and penile growth. This surge only lasts about 12 h and subsequently hormone levels drop quite low. Slowly, gonadotropin and androgen levels begin to rise and peak again.
This rise in levels lasts for approximately 6 months and allows for continued penile growth 7. Ongoing penile growth occurs throughout development, without the need for surges, but rather as a result of normal growth. At puberty, the HPG axis gets activated and stimulates testicular testosterone production, which subsequently leads to further penile growth into adulthood 7 , 8. Accurate measurement of penile length is important for both clinical and academic purposes.
For this reason, a standard practice for measurement has been defined to maintain consistency. Rather than measuring a flaccid penis, which offers limited clinical significance, stretched penile length SPL measurement is considered best practice for adult men as it most closely replicates normal erect penile length 9.
For accurate clinical assessment, SPL needs to be measured by a clinician. Studies have demonstrated that men who are satisfied with their penile length overestimate their size, whereas men who are dissatisfied consistently underestimate Wiygul outlined the mean SPL in children as well as the diagnostic length for micropenis at each age Normal values for preterm infants born between the 24th and 36th week of gestation can be calculated using the formula: As mentioned, micropenis develops as a result of a central or local hormonal imbalance during fetal development.
True micropenis is a congenital anomaly and is different from acquired penile length abnormalities such as buried penis or trapped penis. Based on the etiology of the hormonal dysfunction, micropenis can be divided into three broad categories: Other, less common causes of micropenis have been documented and are listed in Table 1.
Disorders of sexual differentiation may present with micropenis, although hypospadias is more common The majority of men seeking penile elongation treatment have a normal penile size, which is functionally adequate for sexual activity and micturition 14 , Men complaining of small penis, despite adequate length, typically suffer from either penile dysmorphophobia disorder PDD or small penis anxiety SPA. In both of these disorders, men consistently underestimate the size of their own penis and overestimate the mean size for other men Men are so preoccupied with their penis size and length, they may develop depressive episodes associated with social, occupational, and sexual dysfunction.
There is a high prevalence of psychogenic erectile dysfunction and lack of sexual satisfaction in men with BDD, despite their normal libido Patient anxiety persists despite evidence from a clinical examination to negate their concern SPA may be an obsessive rumination or an aspect of psychosis which results in significant emotional distress and behavioral impairment Multiple scales and nomograms have been created by researchers to reassure patients that their length is normal.
Unfortunately, due to the nature of their anxieties, results of these studies are only minimally helpful to this patient population 9 , The idea of treating actual and perceived penile shortening with intervention is controversial.
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Most academic urologists have moved away from treatments such as penile elongation and therefore this has become strictly a market in the private sector Wessells created guidelines for penile elongation in , and not much has changed since. At that time, it was felt that only men with a flaccid length of less than 4 cm or a SPL of less than 7. An ethical review on penile elongation procedures did report that after clearly hearing and understanding the risks and complications associated with each procedure, most men with a normal penis size will decline.
All men undergoing penile elongation surgery with an SPL within normal limits, should undergo psychiatric evaluation In cases of true micropenis, the goal of treatment should be restoration of a functional penis size in order to improve body image and self-esteem, allow normal standing micturition and enable satisfying sexual intercourse. In children with true micropenis, the first step in management is always the least invasive, which includes the application of exogenous testosterone.
If insufficient penile growth is not achieved with replacement, multiple courses of replacement can be considered without significant reduction in stature 22 - In , the beneficial effects of hormonal therapy on penile growth in children with micropenis was confirmed. In this study, prepubertal children were treated with 25 mg of exogenous parenteral testosterone enanthate once a month for 3 months, and pubertal or postpubertal children were treated with intramuscular hCG once a week for 6 weeks.
Exogenous administration of hormone replacement in these boys resulted in a significant increase in SPL and suggests that these treatments could be the primary form of therapy for micropenis in paediatric patients In addition to exogenous testosterone, topical applications have been studied in the micropenis population.
The administration of exogenous testosterone in childhood does not compromise ultimate penile length increase in adulthood, however, the long-term effects of testosterone administration in childhood are still not fully understood and long-term data are needed Although men on androgen deprivation therapy for prostate cancer have been observed to have a significant decline in penile length, there does not appear to be any beneficial effect in length with the use of testosterone in men without hypogonadal dysfunction Further studies could be done to look at this potential application for local benefits in the aging population.
Penile traction devices PTD have been explored both as an independent strategy to help with penile elongation and as an augment to surgery. These devices cradle the penis and gently apply tension in attempt to stretch tissue and increase length. Multiple brands of these devices have been created and studied including: Prospective studies have looked at men complaining of a subjectively small penis. The duration of application of these devices has not been concluded, but usually ranges from 4—6 h per day 29 , In one study, after 2 months, men were asked to leave the traction device on for 9 h per day Compliance and patient selection is a significant issue given the time requirements for this minimally invasive treatment.
Outcomes have been encouraging as patient satisfaction has unanimously improved after use for 3—6 months and flaccid or SPL has increased 1—3 cm in different studies 29 - Oderda and Gontero conducted a review which aimed to explore whether nonsurgical methods of penile lengthening may have some scientific background. They concluded that penile extender devices seem to be non-inferior to surgery Limitations of these studies included non-validated patient satisfaction questionnaires, small patient populations, and selection bias More recently traction devices are being studied for their pre-operative and post-operative use to augment outcomes from surgical procedures.
Similarly, in early trials, pre-operative use of PTD has been shown to increase penile length prior to implantation of penile prosthesis and therefore allowing insertion of a larger caliber of cylinder Although limited data exists, there appears to be a role for use of PTD both independently in men not interested in surgery, as well as an augment to other surgical procedures.
Different types of injectable materials have been used for penile augmentation including liquid silicone, polyacrylamide, hyaluronic acid and mineral-oil 35 - However, there is a significant risk of foreign body reaction, swelling, penile distortion, granulomas and need for removal This is a much less invasive procedure compared to flap reconstruction or V-Y advancements. To obtain a fat graft, fat is liposuctioned from areas of excess, placed in 10 mL syringes and then centrifuged for 3 min at g.
The superior oil layer and lower aqueous layers are removed and the middle adipose layer is collected as the purified fat graft. The fat is transferred into smaller syringes for injected in multiple layers to improve fat graft survival. This technique has been refined by Sydney Coleman in recent years 38 , Panfilov described his technique for penile augmentation with fat grafting in 88 patients.
Incisions are made radially through the frenulum preputial and approximately 40—68 cc of fat is injected between the superficial penile fascia and the profunda, down to the root of the penis. The average length and circumference increase was 2. In one patient, the penis gained 3 cm in length at 6 months, but due to fat graft resorption, the stable length was 2 cm at 7 years. This technique can be combined with suspensory ligament release to further increase length. Unfortunately, it was not specified which patients had just the autologous fat grafting versus both procedures and the resulting gain in length.
Penile augmentation with fat grafts also increase the weight of the penis, which can itself increase the length by 2—3 cm Dermal fat grafting has also been described to increase girth and length of the penis, which may have better fat retention and decreased contour irregularities at the expense of a larger donor-site scar 37 , As discussed, the suspensory ligament anchors the penis to the pubic symphysis and while providing support, acts as the mobile point for the penis during erection.
This attachment prevents the penis from moving further outward and creates an arched angle to the penile base The suspensory ligament is composed of the suspensory ligament proper and the arcuate subpubic ligament that attaches the tunica albuginea to the midline of the pubic symphysis.
Surgical release of this ligament changes the acute angle of the penis to the pubic symphysis to an obtuse angle which allows the penis to lie in a more dependant position and therefore gives the perception of lengthening Division of the suspensory ligament, with or without bulking agent, fat pad excision or V-Y plasty is the most widely accepted surgical technique for penile elongation The suspensory ligament can be accessed through a V-Y incision or a subcoronary circumcision technique Complete release of the corpora from the pubic ramus has been described to further increase length, but is associated with significant risk to the neurovascular bundles of the penis, causing denervation and devascularisation of the penis Outcomes from suspensory ligament release have not consistently been favourable.
On average, the surgery increases flaccid penile length by 1—3 cm, especially with post-operative use of a PTD 45 , Many patients in early studies had a recurrence following surgery, which resulted in penile shortening. Therefore, optimal surgical technique now involves placing a buffer in place of the ligament. Buffer options have included a vascularized flap from the lipomatous tissue of the spermatic cord or a small testicular prosthesis 45 , Srinivas et al.
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After the inverted V-Y incision and suspensory ligament release, a silicone sheath from a penile prosthesis was inserted in the soft tissue defect created between the base of the penis and the symphysis pubis. They achieved a lengthening of 2. Dermal fat grafts have also been described to fill this space Paradoxically, the main side effects of this procedure are recurrence, penile shortening, and the lack of penile support during erection, resulting difficulty with sexual intercourse and penetration Poor satisfaction rates make this surgical technique not favourable for many patients.
Penile elongation using a dorsal V-Y incision in the congenital or acquired short penis was first described over 40 years ago. A dorsal V-shaped incision was made, combined with partial detachment of the crura from the pubic ramis, which were then re-approximated in the midline and the dorsal incision was closed as a V-Y advancement flap. The V-Y incision and subsequent V-Y advancement is commonly used in conjunction with a suspensory ligament release. The incision is typically an upside down V, which is closed in an upside-down Y-shape, which lengthens the dorsal skin by bringing lateral tissue to the midline Figure 1.
The flap is distally based, and poor wound healing, flap dehiscence and distal flap loss can occur if the flaps blood supply is compromised during dissection Bulging of the penoscrotal transition can also occur, which can be treated using bilateral Z-plasties It is difficult to determine the average length achieved by V-Y advancement as it is typically combined with other procedures.
An additional suspensory ligament release and partial release of the corpora cavernosa is depicted. Suprapubic lipectomy has been performed to increase perceived penis length, particularly for patients with a buried penis. In these patients, weight loss does not always reduce the problem of a large overhanging fold, or mons pannus. These folds can cause problems with hygiene, directing the urine stream and sexual function Removal of the skin and fat concealing the penis can be performed as a suprapubic lipectomy or limited panniculectomy.
The skin is removed as a trapezoid incision. The inferior portion of the incision is marked 2 cm above the penis to allow closure of the base of the penis to the pubic symphysis periosteum, and the superior portion should not interfere with the waistline sulcus This technique increases the exposed penile length. This can be combined with removal of diseased shaft skin, which may be inflammatory due to the buried condition and chronic infections.
The shaft skin can be closed with a skin graft taken from the lateral thigh, or from the removed mons pubis skin to avoid a donor site If there is need for further length, release of the suspensory ligament can be performed along with the suprapubic lipectomy If the buried penis is secondary to cicatrix post circumcision, which is more common in children but can present in adults, either Z-plasties or removal of the entire penile skin with skin grafting and vacuum assisted closure with a negative pressure wound dressing can be performed.
Suction lipectomy, or liposuction, is considered inadequate to treat a buried penis unless it is used in conjunction with suprapubic lipectomy If no significant buried penis is present, but there is a moderate pubic fat pad, then liposuction may help to increase perceived penis length Rolle et al. The penis is degloved and the neurovascular bundle is mobilized.
After subtunical dissection, traction is applied to slide the distal penis away from the proximal shaft to perform the lengthening, the limit of which is the length of the urethra and neurovascular bundles 55 Figure 2. A prosthesis is then inserted into the tunical defects that are created by this technique. The authors report an average penile lengthening of 3.
The same group previously described this method of lengthening the penis with similar tunica incisions and subsequent pericardial grafting of the resulting tunical defect after lengthening, but felt that the grafting was time consuming and unnecessary A prosthesis is inserted into the tunical defects that are created by this technique. Perovic and Djordjevic describe a technique similar to sliding elongation, which they have used to treat short penises and congenital penile anomalies. Their procedure involves separating the penis into the glans cap with neurovascular bundle dorsally, the corpora cavernosa, and the urethra ventrally.
Thus, the corpora are separated completely from the surrounding structures. A space is created between the glans cap and the tip of the corpora cavernosa, on which an autologous rib cartilage graft is placed, and then the penis is reassembled 58 Figure 3. The cartilage is covered with the glans cap and the urethra and neurovascular bundles are sutured to the tunica. This technique was performed on 19 patients with a short penis with an average increased length of 2—3 cm and 3—4 cm in 13 and 6 patients, respectively There was no evidence of cartilage extrusion, erectile dysfunction or urethral damage at a mean follow-up of 3.
A The penis is degloved and the neurovascular bundle and corpus spongiosum are separated from the corpora cavernosa; B the glans cap is separated from the tip of the corpora cavernosa, and a space is created between these structures; C an autologous rib cartilage graft is placed, between the tip of the corpora cavernosa and the glans cap and the penis is reassembled. Local, regional and free flap options exist to lengthen the penis.
These have typically been described for penile lengthening if the penis is shortened due to epispadias and exstrophy, where a lack of soft tissue and dorsal skin or tethering of the penis to the pubic bone from fibrous bands Kramer and Jackson describe the use of local rhomboid flaps, based laterally, for dorsal skin coverage combined with partial release of the corpora cavernosa from the pubic ramus in 10 patients. These local flaps are necessary due to the lack of dorsal coverage once the corpora are released from the penis and advanced through an inverted V-shaped incision Figure 4.
This technique is described for both congenital and acquired short penis. They state that most patients obtained a doubling in their penile length. Other local flap options are lateral superiorly based scrotal flaps that are rotated onto the dorsal penis Dorsal Z and W-plasties may also be performed as local skin flaps, but may bring hair bearing skin onto the penis Penile elongation using laterally based local rhomboid flaps to obtain length of the dorsal skin, as described by Kramer and Jackson, This technique is used if there is a need for further dorsal tissue after an inverted V-shaped incision is performed.
Men complaining of short penis need to be clinically assessed for evidence of true micropenis and screened for PDD. Patients should first be treated conservatively with testosterone therapy, PTD, and a psychiatric assessment if applicable.
There are no current guidelines on the best surgical management for men requesting penile elongation. Multiple surgical techniques have been developed each with their own limitations and have been reviewed above. Further work in this field is required to devise the optimal surgical procedure with the smallest complication profile and the highest patient satisfaction.
The authors would like to thank Alison Wong, MD for preparing the diagrams to supplement the surgical descriptions within this manuscript. The authors would also like to thank Dr. Gerald Brock, MD for his support in preparing this manuscript. Conflicts of Interest: The authors have no conflicts of interest to declare. National Center for Biotechnology Information , U. While the procedure does not specifically add length to the penis, many patients comment that the added weight and size also give the penis length.
One of Dr. Shafer's patients commented, "The filler weight and positioning promotes a longer, fuller flaccid length. Since the patient is awake during the procedure, they can see the results instantly. The most common side effects are temporary swelling and possible bruising. Patient can return to normal activities after their treatment. Shafer commented, "After the procedure, patients return right back to work or out for the evening. Results can last two years or more.
Most patients have one session, but some return for a series of treatments for even larger enhancement. Individual results will vary depending on existing anatomy. Therefore, Dr. Shafer suggests scheduling a consultation to discuss your options. In many cases, the S.
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He notes a recent upturn in men seeking cosmetic surgery procedures for their bodies such as liposuction for chest and abdomen contouring and now, more than ever, non-surgical procedures such as Botox and penis enhancement. Shafer and his staff work closely with patients to develop a customized treatment plan. Treatments are performed in Dr. Shafer's midtown plastic surgery office. Patient privacy is highly valued and respected. To learn more about Dr.
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