European Urology

1. Introduction

Male self esteem can be affected by external genitalia image and if a man perceives his penis as inadequate, whether real or imagined, then such feelings invade his interaction with his sexual partners and social associates [1], [2], and [3]. The perception a male has of the adequacy of his penis, does not necessarily coincide with the true dimensions of the organ. Thus, men with penile hypoplasia may declare themselves satisfied with their sexual life while others, who are considered normal may request augmentation as a result of an altered perception of the size of the organ, a condition called “penile dysmorphophobia”. Dysmorphophobia may be an aesthetic issue: a patient whose penis is normal but who is dissatisfied with its dimensions in the flaccid state, or a functional issue: a patient with a normal penis who is dissatisfied with its size during erection [1].

Currently, as the media expose normal male figures and create interest in phallic enlargement, the demand for genital corrective surgery is increasing. However, augmentation phalloplasty procedures for penile dysmorphophobia, are still evolving and are considered a highly controversial issue, since none of the proposed methods has been unanimously approved and significant questions regarding their methodology and effectiveness exist [1], [2], [3], and [4].

In this article, we report our four year experience on performing such procedures (patient selection, surgical techniques, outcome evaluation), introduce a novel questionnaire devised by us, which aims at facilitating selection of the most suitable candidates for these operations and, present and propose a technical modification.

2. Subjects and methods

From February 2000 to November 2003, we performed augmentation phalloplasty procedures in eleven (11) men aged 25 to 35 years (median 28). They were part (39%) of a group of twenty-eight (28) patients who consulted us complaining of sexual inadequacy attributed to functional or aesthetic penile dysmorphophobia (perception of “small penis”) and seeking surgical correction. In order to select those who qualified for surgery, all were subjected to a screening protocol including: (a) medical history, physical examination and biochemical/sex hormone serum profiles, (b) psychiatric/psychosexual assessment and (c) a novel questionnaire designed by our department aiming at objectively quantifying the impact of the problem upon patients’ sexual self esteem and the level of their desire to be subjected to penile augmentation, as well as at measuring the outcome of surgery (Table 1). This questionnaire, termed “Augmentation Phalloplasty Patient Selection and Satisfaction Inventory” (APPSSI), consists of four questions each having five possible answers graded from 0 to 4. Questions 1,2,3 were asked preoperatively while 1,2,4 postoperatively and the grades of answers of both question sets were summated to yield a total pre and postoperative score (APPSSI-score), that escalated from 0 to 12.

Invasive diagnostic workup (ICI-test) was optional as none complained of erectile dysfunction. Penile measurements were made of the length from the pubo-penile junction to the tip of the glans in the dorsal surface and of the circumference at the base and coronal groove, with the penis flaccid - stretched (maximal extension) [4], [5], and [6]. The mean penile length (±SD) was 9.12 ± 1.17 cm [range: 7–11.3 cm], the mean circumference at base 6.4 ± 0.5 cm [6–7 cm] and subcoronally 6 ± 0.4 cm [5.5–6.5 cm]. In four (36.4%) patients, dysmorphophobia was of the functional type and in seven (63.6%) it was considered as aesthetic-cosmetic. The study was approved by the Hospital's Scientific-Ethical Committee and all patients signed a consent form which thoroughly informed them on the possible complications and the likely surgery outcome. Five (45.4%) patients underwent penile elongation, four (36.4%) penile lengthening and shaft enlargement and in two (18.2%) obese patients (BMI > 35), celioplasty, suprapubic lipectomy and penile elongation were performed.

Penile lengthening (Fig. 1) consisted of a suprapubic Z-plasty skin incision, mobilization of the triangular flaps, dissection of the subcutaneous tissue down to the pubis, suprapubic lipectomy and incision of the fundiform and suspensory ligaments of the penis preserving the dorsal penile nerves and vessels. The subpubic space was filled with free fatty tissue and the wound was closed by moving and suturing the triangular flaps downwards and upwards [2], [3], [6], and [7].

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Fig. 1 Penile lengthening procedure: Through a suprapubic Z-plasty incision, bands of the fundiform ligament (white arrow) are dissected and transversely incised with electrocautery (a); dissection and release of the suspensory ligament (black arrow) then follows (b); the subpubic dorsal penile surface has been released and mobilized and the resulting dead space is filled with free fatty tissue (c); Closure of the wound by moving and suturing the triangular flaps downwards (the one on the right side) and upwards (that on the left side) advancing thus, lower abdominal skin onto the penis (d).

Penile lengthening and shaft enlargement (Fig. 2) consisted of an elliptical groin skin incision (8–12 cm length and 4–6 cm width) followed by de-epithelialization and progressive freeing of the dermis and subcutaneous fat off underlying Scarpa's fascia, leaving a free dermal-fat graft of approximately 1–1.5 cm in thickness. Under a Z-plasty-incision, suspensory ligamentolysis was performed as previously and through either this or a circumcision incision, the penile shaft was totally degloved and the dermal-fat graft was patched–sutured on its dorsal surface with the dermal side superficial, avoiding the spongiosal body [2], [3], [6], and [7]. Before patching it, we performed four concentric, approximately 45° angled -1 cm length incisions at 2–5–7 and 10 o’clock positions of the graft, to increase its total surface area (Fig. 3)

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Fig. 2 Penile lengthening and shaft enlargement: Sites of elliptical groin and suprapubic Z-plasty incisions (a); de-epithelialization of the skin using small fine scissors (b); dermis and underlying subcutaneous fat beeing progressively freed off underlying Scarpa's fascia and tailored to a thickness of approximately 1–1.5 cm (c); Following total shaft skin degloving (through either the suprapubic or a circumcision incision) the free dermal-fat graft is patched with the dermal side superficial, on the dorsal surface of the penis. Distal end is sutured subcoronally, lateral wings are attached to the junction of the corpus spongiosum with corpora cavernosa taking care not to incorporate the urethra (risk of restricting an erection) while, the proximal end is sutured to the base of the shaft penis (d).

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Fig. 3 Free dermal-fat graft modification: four concentric, approximately 45° angled 1 cm length incisions at 2–5–7 and 10 o’clock positions of the graft are performed, to increase its total surface area and to deteriorate graft shrinkage, in case fibro-elastic tissue involution would appear.

Panniculectomy-celioplasty, suprapubic lipectomy and penile elongation: In cooperation with the Plastic Surgery Department, panicculectomy-celioplasty was performed followed by suspensory ligamentolysis-suprapubic lipectomy as previously described.

Postoperatively, penile weights were not routinely used but, instead, patients were instructed to manually stretch the penis several times a day. Clinical follow up was carried out at 3,6 and 10 months after surgery and during visits the patients were subjected to physical examination, penile measurements and questions 1–2–4 were completed.

For the statistical analysis, the two-sided paired Student's t-test was used, at 95% level of significance (p < 0.05).

3. Results

All patients tolerated the operations well and no major complications (severe bleeding or infection, injuries to the neurovascular bundle or urethra) occurred. Skin ecchymoses (n = 3) [27.3], prepuce edema and/or paraphimosis (n = 3) [27.3%], sustained wound drainage (n = 1) [9.1%], temporary ( months) dermal-fat graft sclerosis resulting in curvature and pain on erection (n = 1 out of 4 [25%]), transient (<2 months) pain on erection (n = 3) [27.3%] and hypetrophic scar formation (n = 1) [9.1%], were the most significant complications. Mean operative time was 102′(90′–115′) for celioplasty-penile lengthening, 115′(105′–130′) for penile lengthening and enlargement and 65′(55′–70′) for penile elongation while, median follow-up time was 14 months (6 to 24). Penile length and girth changes postoperatively are shown in Table 2. Length gain ranged between 1 to 1.4 cm in three (27.3%) patients, from 1.5–1.9 cm in six (54.5%) and was ≥2 cm in 2 (18.2%) obese patients who underwent celioplasty-penile lengthening. Measurements at 3, 6, 10 and 24 months, demonstrated sustained clinical benefit over time.

The psychosexual impact of the operations was favorable in the majority of cases. Sexual self-esteem and patient satisfaction were significantly improved as shown by the marked increase in mean APPSSI-score. Preoperatively it ranged between 0 to 3 in five (45.45%) patients, in other 5 (45.45%) from 4 to 5 and in one (9,1%) it was 6, yielding thus a mean preoperative score of 4.36 (±2.06 SD) which shifted to a mean of 7.54 (±1.4 SD) postoperatively (p < 0.0001). Specifically, in one patient (9%) no change occurred, in 9 (82%) the improvement rate varied between 20% to 40% (2: 20%, 3: 27%, 2: 33%, 2: 40%) and in one patient (9%) the score increased by 53%. These figures remained essentially unchanged at 3, 6, 10 and 24 months. Sexual activities were initiated at 1(1/2) to 3 months and all patients resumed full, uneventful sexual functioning 4–5 months after surgery.

4. Discussion

Excluding cases of congenital penile hypoplasia or acquired deformity, augmentation phalloplasty is currently performed in patients who express penile dysmorphophobia, either of the aesthetic or the functional type and, therefore, the definition of this type of surgery has changed from “reconstructive urological surgery” to “aesthetic plastic surgery” [2], [3], [7], and [8]. As such, the basic principles of aesthetic surgery should be followed and penile dysmorphophobia surgery should quarantee a higher degree of safety concerning both functional and cosmetic results [1], [3], [7], and [8]. Men desiring genital enhancement typically suffer from feelings of penile inadequacy, in which case surgical treatment is not objectively necessary but becomes a more subjective therapy to satisfy the patient and, hence, whether or not such operation is ethical and whether or not it should be performed, is a major challenge [1], [2], [3], [7], and [8]. Like other authors, we believe that a standardised preoperative protocol and strict patient selection criteria should be established for this type of surgery. Evaluation of the patient's motivations and expectations is imperative and psychologic/psychiatric consultation is recommended especially in questionable cases (severely depressed, psychotic or unrealistic) [2], [3], and [7]. To our knowledge, parameters for selecting the appropriate patients, have not yet been well defined and in order to address this issue, we devised a questionnaire aiming at objectively estimating and grading justification for this type of operation. The three first of its four questions aim at quantifying the impact of dysmorphophobia on patient's sexual self esteem and his desire and determination to proceed with corrective surgery while, the fourth evaluates the outcome of the operation in terms of patient satisfaction–condition improvement. In the APPSSI-scaling system, score-0 characterizes a patient of extremely low sexual self esteem who desperately seeks surgical correction while, score-12 implies that the small penis perception does not adversely affect his sexual behavior and surgical treatment appears remote. Based on the questionnaire, we considered as qualifying for surgery those with a score of ≤6. Postoperatively, the score varied between 0 (dissapointed) to 12 (excited with the result).

Since all patients claimed normal erectile function and most of them had aesthetic type dysmorphophobia, they were appreciably reluctant to accept ICI-test in order to estimate erect penis size. Therefore, we decided to perform all penile measurements in the flaccid-stretched state considering as low normal limit of penile length that of 9 cm and of shaft circumference that of 6 cm [2], [3], [5], and [6]. Although the lack of data on penile size during erection can be considered limitation of our study, we believe that the above decision was appropriate, as it was based on numerous studies showing a close correlation between flaccid-stretched and erect lengths as well as circumference, rendering measurement of stretched length and girth suitable estimate of erect dimensions [2], [3], [5], [6], and [9]. Austoni et al performed penile elongation in men with erect lengths from 6 to 11.2 cm, while other authors in patients with flaccid stretched length ranging between 7.5 to 10 cm [1], [4], and [8].

Penopubic ligamentolysis and advancement of lower abdominal skin onto the penis, constitute the most popular method for penile lengthening that we applied in all our cases [2], [7], and [10]. This technique achieves an apparent and not real lengthening since penile structures remain unchanged. Thus, any increase in penile length is noticeable when flaccid but is minimal when erect [7], [8], and [10]. Genuine penile elongation can be obtained by the penile disassembly technique as well as by various other methods (dermo-fat free graft taken from the cruro-gluteal area, multiple incisions in the tunica albuginea combined with placement of penile prostheses and placement of intracavernous cutaneous expanders) [7], [8], [11], [12], and [13]. All these techniques are feasible but rather aggressive and potentially hazardous and achieve moderate erect length gain since the low elasticity of the neurovascular bundle is a limiting factor. Therefore, their benefits should outweigh their risks and they should be offered primarily to select patients with penile hypoplasia or deformities [8], [10], [12], and [13].

The volume of the penis can be increased either by pericavernosa (subcutaneous placement of autologous fat, dermis-fat, veins, mucous membranes, synthetic materials) or tunica albuginea enlargement phalloplasty [1], [2], [3], [7], and [8]. Dermal-fat grafts, either free or vascularized, taken from the lateral groin or from the gluteal creases and sutured over the corpora cavernosa, provide excellent penile girth with virtually low complication rate [1], [2], [3], and [14]. This technique increases penile volume mainly in the flaccid state while, during erection the grafts are compressed by the superficial dartos fascia and the increase tends to be cancelled out [1]. Tunica albuginea enlargement phalloplasty (longitudinal albugineal incisions and incorporation of autologous dermis grafts, saphena vein grafts, synthetic materials) increases the volume of the corpora cavernosa but, it is considered experimental and the theoretical possibility of adversely affecting the erectile mechanism, should make as very sceptical when counseling young patients with cosmetic penile concerns [1]. Since our four patients seeked volume increase of the flaccid penis, we proceeded with pericavernosal incorporation of free dermal-fat graft taken from the groin area. In addition, we introduced a modification of graft handling which consists of transforming the ellipsoid graft to a cruciform shaped form by making incisions sited at the 2–5–7 and 10 o’clock positions. This modification aims at expanding the graft surface area as well as at deteriorating graft shrinkage, in case fibro-elastic tissue involution appears.

Claims of 3-inch length gain after ligamentolysis and pubic skin advancement are greatly exaggerated and a 1-inch (2.5 cm) gain in the flaccid stretched state represents a success while, minimal or no gain is possible [1], [2], and [3]. In our series, the mean total penile length gain of 1.6 cm was statistically significant but, in only two patients with marked obesity, the result was impressive (>2 cm increase). Austoni et al reported a mean erect penis length increase of 1.6 cm (1.5–2.5 cm) [1], Perovic-Djordjevic using the penile disassembly technique achieved a mean penile length gain of 3.068 (2.4–4.1) cm and 2.95 (2.3–3.6) cm in the erect and flaccid penis respectively while, Randone et al claim length gain from 2.5 to 3 cm in the erect state by using the dermo-fat free graft method [10], [11], [15], and [16].

Dermal-fat grafts achieve an average penile girth increase of 1 to 2 inches which is usually symmetric and satisfactory in appearance and texture [2], [3], and [4]. In our cases, the average perimeter increase was 2.3 cm at the base of the penis and 2.6 cm at the coronal groove, achieving an aesthetically appreciable penile shaft volume increase in the flaccid state. Austoni et al., reported increases in the average penile diameter ranging from 2.64 cm (flaccid) to 4.82 cm (erect) by incorporating saphena vein grafts to longitudinal openings of the tunica albuginea [1], and [7].

Complications were of low rate and of minor severity. In general, the adverse effects of ligamentolysis are insignificant consisting mainly of inflammatory, healing problems usually conservatively treated while, dermal-fat grafting may be complicated by infection, poor graft “take” (lysis, fibrotic thickening), skin loss and penile hypoesthesia [1], [2], [7], [10], [14], and [17].

To our knowledge, reports on phalloplasty outcomes regarding patient satisfaction and psychosexual impact, have been limited and in most cases gross estimates are presented [1], [2], [3], [7], [10], and [12]. Kim et al. reported satisfaction varying between 69% and 77% after injecting hyaluronic acid for glans penis augmentation [18]. Based on our questionnaire, we were able to objectively estimate the psychological effects of the operation. In all but one, surgery significantly satisfied the patients and improved their sexual self esteem and function by 20% to 53%. The one patient with no improvement had a high score preoperatively while, the highest improvement rates (40–53%) occured in patients with marked obesity. In contrast, Austoni et al. reported that a high percentage of patients who underwent dermal-fat graft penile girth enhancement, were dissatisfied [1], and [7]. This difference may be attributed to different patient selection criteria, as our patients were concerned on penile size in the flaccid state mainly. Regarding clinical applicability of the APPSSI-questionnaire, we realize that limitation of our study is the fact that we did not use established psychometric or quality of life tests in order to cross-match the results and measure its validity. Furthermore, due to the small number of patients, we decided not to determine its reliability and internal consistency at the present time but, instead, to address these and the above limitations of this “pilot” study, in a larger scale, multi-center study in the near future. Consequently, the introduced questionnaire is not validated yet and in order to consider this a clinically valid and widely acceptable instrument, we propose that it should be applied to a significantly larger number of patients and tested by other researchers interested in the field.

5. Conclusion

Although penile lengthening (ligamentolysis–skin advancement) and enlargement (dermal fat grafts) procedures cannot achieve spectacular phallic image alterations, they are characterized by substantially uneventful clinical course with low morbidity and a significantly positive impact on sexual self-esteem and function in the majority of patients. Therefore, this type of surgery can be considered a reasonable treatment modality for strictly selected and fully informed patients who suffer from penile dysmorphophobia and only when, conservative measures of alleviating sexual performance anxiety and feelings of sexual inadequacy, have been exhausted. Technical refinements and establishment of validated instruments facilitating proper patient selection, would further advance safety and efficacy of this type of surgery.