Aesthetic Augmentation Phalloplasty: A Systematic Review of Techniques and Outcomes

Techniques for Penile Augmentation Surgery: A Systematic Review of Surgical Outcomes, Complications, and Quality of Life

The increase in practices related to enhancing penile size can be attributed to the belief that an improved genital appearance contributes to a man's virility, coupled with an altered self-perception of his body. It is crucial to tailor interventions to meet the genuine needs of patients by thoroughly assessing their history, psychological state, and potential surgical benefits, all while considering the associated risks of complications. This systematic review aims to summarize the available evidence on outcomes, complications, and quality of life after penile augmentation surgery, examining both minimally invasive and more radical techniques. A search of the PubMed and Scopus databases, focusing on English-language papers published in the last 15 years, was performed in December 2023. Papers discussing surgery in animal models and case reports were excluded from the present study unless further evaluated in a follow-up case series. The primary outcomes were changes in penile dimensions, specifically in terms of length and girth, as well as the incidence of surgical complications and the impact on quality of life. A total of 1670 articles were retrieved from the search and 46 were included for analysis. Procedures for penile length perceived enhancements include lipoplasty, skin reconstruction plasty, V-Y and Z plasty, flap reconstruction, scrotoplasty, ventral phalloplasty, and suspensory ligament release; techniques for increasing corporal penile length include penile disassembly, total phalloplasty, and sliding elongation. Finally, penile girth enhancement may be performed using soft tissue fillers, grafting procedures, biodegradable scaffolds, and Penuma®. In conclusion, while penile augmentation surgeries offer potential solutions for individuals concerned about genital size, the risks and complexities need to be accounted for.

Suspension of the penis - dissection, anatomical description and highlighting of anatomical risks in sectioning the suspensory ligaments

BACKGROUND

The suspension of the penis is provided by two ligaments: fundiform and suspensory. These ligaments are sectioned during some augmentative surgical procedures. The structure, the relations and the variability of these ligaments have been demonstrated. The penile neurovascular bundle and its relationships have also been emphasized. A clear knowledge of these details should ensure a reduction of the risk of surgical injury during augmentation procedures.

RESULTS

We dissected the ligaments providing the suspension of the penis in 7 formalized corpses. We identified, for each of the ligaments, the origin, the insertion and the relations. The dissection pieces were photographed and the images obtained were discussed upon. We described the variability of the anatomical distribution and highlighted the relations with the vascular and nervous structures for each of these ligaments. The anatomical variability of the fascia and the relations with the base of the penis were also emphasized. For the suspensory ligament, we identified three groups of fibers through which it is attached to the penile body.

CONCLUSIONS

The dissections were conducted in layers, corresponding to the operative steps for the penile augmentation procedures. We believe that our study highlights the anatomical basis necessary to safely perform these surgeries. The study contributes to the description of the anatomical variability of the ligaments and logically presents details that contribute to preventing most surgical incidents.

Lengthening Phalloplasty with Division of the Suspensory Ligament and Distally Based Fat Flaps in Penis Enlargement Operations

SUMMARY

Small penile size is worrying for most men and leads to poor self-esteem, anxiety, and depression. A penis can be enlarged in two ways: by increasing the length and by increasing the circumference. The purpose of this article is to present a new procedure of augmentation phalloplasty thst combines these two parts in the same operation with a new technique to fill in the dead space created by the suspensory ligament division. The lengthening of the penis is achieved with an inverted V-Y plasty followed by a division of the suspensory ligament of the penis all the way down the pubic symphysis. Two distally based fat flaps are advanced into this area to fill in the dead space. The widening of the circumference is performed with fat injections. The penile length gain postoperatively is 2 to 4 cm in the flaccid state, and the widening component with the fat grafting technique gives an approximate circumference increase of 1 cm with excellent natural results. Sexual self-esteem and functioning improvement was reported by the patients, 75 in total. Three patients returned after the operation for revision of fat injections 6 to 12 months after the operation. The literature regarding the long-term results after augmentation phalloplasty is poor, and it is difficult to compare results with other techniques. Penile enlargement, when performed for the appropriate reasons, can have a positive effect on the lives of many men. After 15 years of experience, this procedure gives very pleasing results with minimal complications.

Genital Self-Image and Aesthetic Genital Surgeries: Novel Perspectives Across the Cisgender and Transgender Spectrum

Genital-focused body image concerns or negative genital self-image are a common experience across the gender spectrum, including among cisgender and transgender populations. Such concerns can result in lower psychological and sexual well-being. In this article, it is proposed that the development of genital self-image concerns may be partly explained by the theoretical framework of cisgenderism. This theory proposes that there are only 2 genders-men and women-and these are dictated solely by the appearance of the genitals. Any deviation from these 2 categories can result in discrimination, which particularly impacts transgender individuals. An increasing number of cisgender and transgender people are seeking out aesthetic genital procedures to alleviate genital self-image concerns (and gender dysphoria in transgender populations). The growing body of research suggests that cisgender and transgender men and women are relatively satisfied with the results of their genital procedures. However, this research is limited by a lack of standardized and validated patient-reported measures to evaluate surgical outcomes. Furthermore, despite negative genital self-image being a key motivator for surgery, it is often not included as an outcome measure. In this article, recommendations are proposed for conducting higher-quality evaluation studies of aesthetic genital procedures in cisgender and transgender populations. Moreover, future research and clinical directions are suggested to assist transgender men and women who choose not to undergo genital gender-confirming surgery. The vast majority of transgender individuals do not have this surgery and so are in great need of support in managing their gender dysphoria and negative genital self-image.

Clinical use of hyaluronic acid in andrology: A review

Background

Hyaluronic acid is a glycosaminoglycan widely used in the fields of orthopedics, ophthalmology, and aesthetic medicine due to its significant ability to reduce the synthesis of pro‐inflammatory proteins and its activity against oxidative stress, a feature of many degenerative illnesses.

Objectives

The objective of the present review is to provide a comprehensive narrative review of the most recent literature on the use of hyaluronic acid in andrology in order to facilitate the use of this therapeutic device in the common clinical practice of many physicians. Specific conditions covered in the review are Peyronie's disease, premature ejaculation, and penile enlargement.

Materials and methods

A broad and comprehensive literature search included Medline, EMBASE, and the Cochrane Libraries, with no time restriction up to December 2020 and restricted to English language publications. Unpublished studies were not included. The study was registered as “The role of hyaluronic acid in andrology: A systematic review and meta‐analysis” in PROSPERO with the ID CRD42021223416.

Discussion and conclusion

Hyaluronic acid is a valid choice for the treatment of Peyronie's disease in terms of the resolution of the acute phase of the disease and of contributing to stabilizing the disease as a bridge to potential surgery. Data, furthermore, suggest that hyaluronic acid is frequently associated with an overall clinical improvement, allowing the patient to resume normal sexual activity.

With regard to premature ejaculation, data suggests hyaluronic acid‐based treatments were effective in prolonging intra‐vaginal ejaculation time. Furthermore, hyaluronic acid was found to be safe and well‐tolerated, with main adverse events limited to local discomfort, ecchymosis, papule formation, and glans numbness, all of which were reported to resolve spontaneously.

Last, with regard to penile enlargement, the overall perception of experts is that hyaluronic acid may be an extremely well‐tolerated compound with potential for application in specific areas of male sexual health that are often neglected as compared to more common, and relatively simpler to treat, conditions.

Penile girth enhancement procedures for aesthetic purposes

The present study aimed to describe and critically discuss the current evidence regarding the penile girth enhancement procedures for aesthetic purposes. We designed a narrative review of the literature. A comprehensive search in the MEDLINE database was performed. Original articles in English-language, published until March 2021, were selected. A total of 29 studies were included (3 reporting non-invasive approaches, 11 injection therapies, and 15 surgical procedures). The vast majority of articles (26, 89.7%) were not randomized controlled trials, with overall low quality and limited level of evidence. Only 1 (33.3%) paper regarding non-invasive approaches reported a minimal (+0.03 cm) but a significant increase of penile girth (p = 0.034). A low rate (11.2-14.4%) of mild, temporary adverse events and poor-to-moderate patient satisfaction were found. Eight (72.7%) articles concerning injection therapies showed a significant increase in penile girth (p < 0.05). A low rate of mild complications, generally at the injection site, and a high patient satisfaction rate (75-100%) were highlighted. Nine (60%) papers on surgical treatments found a significant increase in penile girth (p < 0.05), while the other 6 (40%) studies reported a generic improvement in penile circumference. Skin necrosis or ulcers, wound infections, or need for reoperation were reported in 8 (53.3%) studies. A high patient satisfaction rate (60-100%) was reported. Our review highlighted the overall positive results of injection procedures, the poor outcomes associated with non-invasive techniques, and the good efficacy and satisfaction with a non-negligible risk of complications in patients undergoing surgical treatments. However, the adverse events are probably largely under-reported and these procedures should still be considered under investigation due to the limited evidence available and the lack of guidelines.