Aesthetic Genital Surgery (Masculine)

Why and for who?

The harmony and proportion between the different parts of the body is also important in the most noble organs.  The application of techniques to reform the external genitals by a plastic surgeon, who has precise knowledge of anatomy, gives healthy people undeniable benefits in self esteem and sometimes, the direct recuperation of the relationships in their personal life.

Wide variations exist in the shape and size of the penis.  However, the relevance of these dimensions is a question that has long been debated in many cultures, becoming a focus of interest nowadays due to the wide availability of photos.  It is now causing frequent insecurities and changes in self-esteem, especially when it is inevitable to see and be seen by others, in dressing rooms for example, which is a problem that many men deal without throughout their lives.

This interest doesn’t go away with age. However, it doesn’t necessarily mean an abandonment of all care for the noble parts.  Furthermore, many patients who look for help do it secretly, which can lead to remedies with doubtful scientific relevance.

In other men, our procedure is aimed at repairing undesired consequences, results of birth defects, problems which shorten or curve the penis.  This includes mutilation from accidents, illnesses, tumors, and previous interventions.

Recommendations before genital aesthetic surgery treatment

It is useful to make a list of questions so you don’t forget any, as it is important to clear all your doubts about the procedure you plan to undergo with your doctor to help with any fear you may have before the operation, instead of remaining uninformed.

Prepare yourself before the surgery.  Get all the medicines and products the doctor prescribes for you and be sure to have the correct clothes ready for after the operation.  Trousers must have enough space to accommodate your genitals comfortably, without rubbing.  You will also need to keep in mind the dressings or bandages that we will apply after the surgery.

Who could be a candidate for these treatments?

The best decision is a result of real and balanced deliberation, checking different alternatives, weighing the benefits and inconveniences, understanding the proposed techniques, and respecting the necessary convalescence period.

To obtain an objective and efficient advice, an experienced psychologist can also participate.  Furthermore, for a multidiscipline approach, the opinion of an Urologist may be considered when necessary.  This could be beneficial, for example, in patients with cases of impotence.  For patients with glandular disorders, an endocrinological consult is necessary.

Treatments done with genital aesthetic surgery

1. Elongation Phalloplasty (penile lengthening)

This procedure is done by partially liberating the ligaments which connect the corpus cavernosum to the pubis.  It is sometimes complimented by rearranging the skin of the scrotum and pubic liposuction in some cases.  The increase in length obtained varies, depending on individual characteristics, between 1.5 and 4 cm, but we can sometimes obtain more length by maintaining the penis in the correct shape for 6 months, starting 2 weeks after the operation.

Differences exist in the previously mentioned procedure.  For this reason, some patients operated by others, get deformities like lumps at the base of the penis, undesired irregularities, hair on the back of the penis, as well as a delay in the healing process.  These are circumstances that we correct in patients who have them and we prevent them in new patients by not using techniques which favor these complications.

Patients must anticipate that the angle of the erection when standing, from a more vertical position before the operation to a less elevated position after the operation, but this does not interfere with capacity for relations.

2. Phalloplasty to thicken a flaccid penis:

Appropriate techniques exist for each case in particular.  For example, fat grafts previously taken from the abdomen or thighs, skin and fat grafts, or even skin collagen grafts.  The first can degenerate and cause distortions, irregular nodules, and alterations in consistency.  The others are more widely used, although they can result in shortening and curvature.  However, the techniques which cause hanging parts in the pubic tissue don’t bring about these inconveniences.

Furthermore, we have applied vein grafts over the corpus cavernosum, improving the results from penile thickening procedures in an erect penis by 1.5 to 2 cm.

Depending on the type of procedure recommended, and in patients who are considered ideal, we combine lengthening and thickening of the penis when flaccid or when erect.

Some techniques require a 6 month delay.  Other thickening methods which use grafts of strange materials can change the level of sensitivity of the penis.

The majority of these treatments can be done with local anesthesia with sedation as a day clinic procedure.  This means it is not necessary to stay the night in the hospital, only a short stay in the morning.  Some other techniques require that you stay in the hospital for one night.  The convalescence period depends on the procedure being done, although it could be between 3 and 5 days, enough time for the most immediate revisions.  The sutures tend to reabsorb spontaneously.  4 weeks after the operation patients can begin to re-establish sexual relationships.

The question of size:  We must establish a maximum for the dimensions of the penis, this is the “constant” variability.  The following measurements have been taken from scientific literature (not counting any studies of race, or of doubtful rigor or method):

Flaccid, the average length from the dorsal base to the end of the penis is 10-11 cm, and the circumference around the middle portion is 8-9 cm.

Erect, length 15-16 cm, and circumference 10-12 cm.

3. Hidden penis correction:

The consequences of excess skin or adipose tissue in the pubis and abdomen are becoming more and more common.  They are aggravated by radical circumcisions in childhood which makes the penis difficult to find and even requires the patient to sit down to urinate.

Congenital forms exist, which are associated with tissue which retracts inward.

This condition can be improved using liposuction, with or without the extraction of excess tissue, and fixation of residual tissues to the root of the corpus erectile.

4. Phimosis, primary or secondary treatment, and lengthening of the frenulum of the prepuce:

In some cases, the narrowness of the prepuce, normally from birth, blocks the exit of the glans penis.  In other cases this can be due to scars.  They trigger complications such as paraphimosis (constriction of the glans penis by the ring of the retracted prepuce), infection, and cancer of the glans penis (50% have phimosis).

We liberate the prepuce in the most conservative manner possible.  We can also help with cases which re-appear due to insufficient prior treatments and even with cases where the penis is hidden due to aggressive circumcision.

5. Correcting congenital curvature of the penis:

This problem appears in 1 of every 300 males births.

When erect, it is possible to curve to either side.  If this interferes with sexual relations then correction could be a consideration.  We can straighten the penis by applying sutures to the convex side.

6. Treatments for Peyronie’s disease or the growth of fibrous plaques in the soft tissue of the penis:

The most common induration in men between 40 and 60 years old can provoke the formation of plaques which cause curvature and shortening of the penis.  More than 30% of cases get worse over time, making treatment necessary when sexual relations become difficult.

We obtain the best results by eliminating the plaque and filling the spaces with skin grafts, veined and others of muscle.  In cases where a well-formed erection is not possible, implants could be an option.

7. Congenital testicular absence, or due to posterior loss:

This is corrected using prosthetic implants made of silicone gel or saline serum.  Silicone gel being more consistent.

8. Scrotal rejuvenation:

Over time, some men develop a pendulum appearance in the scrotum and possible softening in the creases of the skin.  Correction requires a reduction of the excess, re-establishing the previous relation with the penis.

9. Re-adaptation of ambiguous genitals:

Genital re-modeling allows intersexual patients, whose external genitals are insufficient for their personal orientation, to have a sex life.

10. Other reparative treatments:

Correction of conditions resulting from earlier operations and anomalies in the positioning of the urethral opening, be it on the ventral side or dorsal.  Liberation of scar tissue or penis-scrotum adhesions, which require new, healthy tissues.

11. Gynecomastia treatment:

Breast development in males can be corrected with minimal scars, usually under brief general anesthesia and with a stay of one morning in the clinic.

Frequently Asked Questions:

With penile operations, is the function or sensitivity of the penis altered?

The urinary capacity is always respected in these procedures.  With sexual relations, the angle of the erection of the penis will be modified, from a more vertical position to a less elevated position after surgery, but this will not interfere in the capacity of sexual relations.  Temporary changes in sensitivity are common, due to inflammation. 

Other, more permanent changes are not common.

When can I begin to have sexual relations again?

In procedures for lengthening, thickening, and hidden penis, you must wait at least 4 weeks after the operation.

In procedures for correcting phimosis and the frenulum, the inflammation recedes more quickly and the patient need only wait 2 weeks.

What other inconveniences can I expect?

The inflammation of the penis and/or testicles can last as long as 2 or 3 weeks.  The discomforts are not normally intense, and are usually covered during the first few days by oral painkillers.  The post-op period may require some special protection of the sutures temporarily.

Do the operations take a long time?

Most of them don’t, but it varies according to each particular case, for example, penis lengthening, correction of phimosis, frenulum, and placement of prosthetic testicular implants are particularly fast techniques.

When can I go back to work?

It depends on the techniques being used, but at least 1 week off from work is recommended.  In cases involving strenuous activity especially with intense physical effort, another week is recommended.

Can I have more than one procedure done at the same time?

It depends on the problems being treated and the techniques being used to treat them in each case.  For example, interventions for lengthening and thickening are often done together, without the complications posed by fat grafting or the requirement of waiting 6 months before having the second surgery performed, as is the case with skin and fat grafts.

Hidden penis operations and corrections of phimosis can not be associated with other operations because it could aggravate these conditions.

What are the instructions for post-operative care?

Most of these procedures are performed on an outpatient basis, as a day surgery, in which post-operative care requires the abstention from sporting activities and sexual relations during the first month.

You will have your first review the day after the surgery.  In the next visit, after 2 or 3 days, we will remove any drains to allow the patient to begin to wash and dry the area.

The sutures will be examined after 8 or 10 days.  Meanwhile, we recommend using bandages to reduce inflammation.

Do you do sex change operations for the redevelopment of sexual identity?

Comprehensive and adequate treatment for gender dysphoria is subject to international protocols (www.symposion.com/ijt/soc-01/index.htm), and requires a period of both hormonal therapy and psychiatric therapy for a period of about 2 years prior to any genital surgery with irreversible results.  Although the aesthetic results are generally acceptable, they can sometimes be controversial.

What types of anesthesia may be necessary?

LMost treatments like lengthening, thickening of the penis (by fat or skin grafting), correction of curvatures from birth or acquired in adulthood (Peyronie’s disease), testicular implants, scrotal resurfacing, and also correction of phimosis and lengthening of the frenulum, normally require intravenous sedation and local anesthesia for adult patients.  It is done as an ambulatory procedure.

Thickening of the erect penis with vein grafts, correction of hidden penis, ambiguous genitalia, and more complex reconstructive surgeries are done under general anesthesia with hospitalization required for at least the first 24 hours due to the fact that they are longer operations.

The final decision on what type of anesthesia is for the medical team to decide, but always considering how it will harmonize with the procedure being done, and adjusting it for each patient according to their individual needs.

What might the risks be in operations like these?

Every intervention carries some risks that are generally considered common, others which depend on the type of anesthesia used, and finally the specific risks derived from the procedure and the area being treated.

• General risks:

Immediately after the procedure (first 24 to 48 hours), bleeding, with or without hematoma (often prevented by drainage), edema or swelling (prevented by cold); some don’t appear until up to three weeks after the procedure, like: seroma or an accumulation of clear liquid, local infection, opening of the wound (dehiscence), loss of skin.

Reactions due to intolerance to the suture material or bandages such are adhesives or antiseptics.  Finally the scar, which in most cases is short, can be visible or thickened, evolving during the first 11 months.

• Anesthesia risks:

These range from the effects of local anesthesia (like pain at the puncture site), to the effects from a more invasive epidural or general anesthesia with possible nausea and/or vomiting for the first 12-24 hours.  Having the adequate tools in the operating room can reverse more serious complications, such as intolerance to a medication.

• Specific risks:

Changes in the sensitivity of the skin and of the penis, which are usually temporary and due to inflammation.  In some cases another intervention may be necessary, depending on the complexity of the problem being treated.  This may be the case with early or late complications such as scar contractures or dissatisfaction with the result.  Occasionally during the convalescence period, patients may experience a period of disillusionment, which is resolved when the results are obtained.

External genitalia: adult male anatomical diagram 

Penis: Located just below the pubic symphysis, cylindrical morphology, and comprising a rear inside or perineal position, and another anterior or free

Variable dimensions, accepting information from Testut, flaccid, measured from symphysis to tip of the glans penis: 10-11 cm, and circumference around the middle: 8-9 cm.  Erect 15-16 cm long and 10-12 cm in circumference.

Made up of three erectile bodies wrapped in white or albuginea fibrous sheets, two dorsals and laterals or corpus cavernosum , 15-16 cm in length and 20-21 cm when erect, interconnected in the middle, except in their origen; with one ventral, middle or urethral, situated amongst the above: corpus spongiosum, with dilations in its source or bulb of the penis, at its beginning which the urethra passes through, and distal conoid expansion called glans, covered by a crease of skin – mucous or prepuce, whose frenulum generally originates 8-10mm behind the urinary meatus.  It houses the portion called spongy urethra.

The extreme posterior or root, which is fixed to the pelvic wall on one hand by inserting corpus cavernosum in the ischium-pubic rods, and on the other, by fibroelastic ligaments: fundiform ligament, which originates below the linea alba or the middle of the abdomen and is separated in two halves on both sides of the member, and the suspensory ligament which originates on the anterior surface of the pubic symphysis, from which a fan reaches the back of the penis in its fixed to mobile transition through middle fibers which bind to albuginea in corpus cavernosum, and lateral fibers that outline it, forming a cinch.  Behind this, there are very thick and short conjunctive fibers or the fibrous Luschka ligament.

Among the muscles of the perineum (the set of soft tissue that closes the pelvis, traversed by rectum, urethra, and genitals) anterior or genital with erectile function, ischiocavernosus stands out, from the belly extending and flattening to the root of the corpus cavernosum by a fibrous sheet, which ends before the insertion of the bulbocavernosus.  Both act during erection and ejaculation by compressing corpus cavernosum, expelling arterial blood into the anterior portion of the penis.

Sack: cutaneous and fibromuscular sack, inferior and posterior to the penis, with a prominent line in the middle portion as a result of the fusion from its original duplication.

Formed by 6 successive layers:

Wrinkled skin (scrotum); smooth muscle (dartos) which when contracted, especially from cold, gathers and fits with the superficial fascia or Cooper, the septum between the two testicles, incomplete in humans, but it continues in its most anterior part with the superficial fascia of the anterior abdominal wall or Scarpa fascia, and behind with the superficial perineal fascia or Colles.  Muscular or cremaster with reflexive, fibrous, and finally vaginal function:  serous membrane with two sheets, parietal and visceral which line the inferior edge of the testicles.

Testicle: Paired organ, generator of sperm and an internal secretion gland, continues up the first segment of the epididymis , and vans deferens.  They are located under the penis, between the thighs, generally the left is more declined, consistent with right-handed people (the opposite in left-handed people), with the ability to move towards the inguinal ring due to the contraction of the dartos and cremaster.  In the case of a lack of unilateral development it is called monorquidia, and anorquidia is bilateral.  Differences in position or ectopia condition their function, the absence of which is called cryptorchidism, and is usually unilateral.  Average dimensions: length 45mm, height 70mm, and weight 20 gr., with age they can atrophy 20% - 40% of their volume.  At the extreme posterior scrotal ligament is inserted, a fibromuscular sheet which fixes to the cover.