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Male Genital Rejuvenation (Aesthetic Surgery of the Male Genitalia)

A man's perception of his genitalia has a significant effect on self-esteem and sexual identity. Many cultures associate penile length with virility and sexual prowess. With increased exposure to popular media and pornographic material, men and women may develop a misconception of male genital norms. Hence, male patients present for aesthetic genital surgery with the aim of altering the external appearance of the penis or scrotum despite the fact that they are often normal in size and shape.

Advances in surgical techniques have made possible aesthetic improvement in the male genitalia. However, it is always crucial to examine the patient's underlying motivation for the surgery, as well as to rule out psychiatric problems. Aesthetic surgery of the male genitalia serves to correct perceived deficiencies as well as physical deformities, which may cause psychological distress.

Frenuloplasty of prepuce of penis

A Frenuloplasty of prepuce of penis is also known as a Release of Frenulum. An abnormally short or sensitive frenulum of the penis can make some types of sexual activity uncomfortable or even painful. This may be a complication of circumcision or a naturally occurring event. When it is a naturally occurring event, a short frenulum can restrict normal retraction of the foreskin during erection (a condition known as frenulum breve).

The goal of treatment is to allow normal retraction of the foreskin. Circumcision may relieve this condition but is not indicated solely for treating frenulum breve. However, circumcision can also lead to an abnormally sensitive frenulum.

Procedure

The Frenuloplasty can be conducted under general or local anesthesia.

The procedure usually involves the removal of the frenulum or the creation of an incision in the frenulum that is then stretched to lengthen it and stitched closed. The incision can be z-shaped, y-shaped or a single horizontal cut. Once healed, the procedure effectively elongates the frenulum, allowing normal function. Under normal circumstances the incision heals completely in around four weeks, after which time normal sexual activity can resume.

A retained frenulum after circumcision. Note the notch on the frenulum where it was horizontally divided to release it from the glans
A removed frenulum preputii penis

Peno-scrotal Webbing Correction

"Peno-scrotal webbing" refers to excessive skin that spans between the under surface of the penis and the scrotum. Penoscrotal webbing can occur as a result of bad circumcision by quacks, whereby the underside of the penis is adhered to the scrotum. As a result a web forms, and the scrotal tissue becomes attached to the underside of the penis like a turkey neck. Some men find this unsightly and want the web removed. For others, the skin can be so excessive it can interfere with intercourse or even the ability to roll a condom onto the penis. A peno scrotal web can be improved by a procedure that actually lengthens the midline of the web, allowing it to settle back towards the scrotum. In some cases excess skin will be removed.

This procedure can be performed under local anesthesia if it is a small web, but larger webs requiring skin removal are best dealt with under a general anesthesia (with you asleep). Marking for skin excision is performed with a pharmacologic erection. Mild webbing may be treated with a single or double Z-plasty, with the vertical limb aligned along the median raphe at the penoscrotal junction. For more severe webbing, excess skin can be resected along the median raphe, with a Z-plasty at the penoscrotal junction to prevent recurrent scar contracture. You will be asked to keep the area dry for 5 days following surgery and the sutures will dissolve on their own within 3 weeks. You will need to avoid strenuous activity such as sports or vigorous exercise for 4 to 6 weeks following surgery.

Testicular Implants

Testicular implants are available at our Revive Clinic, Lucknow for men who have had an absence since birth or who have had one or both testicles removed/ lost for various reasons. Men that have very small and/or deformed non-functional testes may also choose to have a testicular implant. The implants come in several sizes and can be matched to the other side. Adolescents are eligible for this surgery once they have reached maturity so that the appropriately sized implant can be chosen to match the other side. But always remember, these implants are artificial testes made up of silicone, and can never produce sperm or hormones & are non-functional. They are used for aesthetic reason.

The surgery is performed under general anesthesia and takes between a half and one hour. The incision is made at the top of the scrotum just beside the base of the penis and the scar will be very inconspicuous. You will be able to shower on the 3rd day following surgery and you will be asked to refrain from any vigorous activities for 2 weeks.

Circumcision / Repair

Circumcision is a personal decision which many men make later in life for various reasons such as, tight foreskin that are uncomfortable or even painful, having too much foreskin. For others, they simply prefer the appearance of a circumcised penis. It is important to understand that the sensation of the glans (head) of the penis may be irreversibly altered (reduced) and therefore one should be certain that circumcision is right for them before proceeding.

Many men are bothered by a poorly performed circumcision. Common problems include uneven or wide scars, suture "track marks," and uneven, excessive or tethered skin. In some cases, usually following a circumcision performed as an adult, too much skin has been removed leading to uncomfortable or painful erections and intercourse. Fortunately, there are solutions to repair circumcisions and many of our patients express satisfaction and great relief after finally having had these issues dealt with. In most cases, the procedure may be performed using local anesthesia and it will take under an hour to complete. You will be asked to keep the area dry for 3 days. The sutures will dissolve on their own within about 3 weeks. You will need to refrain from sexual intercourse for 4 to 6 weeks following your procedure.

Scrotal Reduction

Aging, stretching due to a hydrocele or varicocele, or congenital laxity may lead to an enlarged and/ or low-hanging scrotum by patients, leading to concerns with self-image or discomfort from skin irritation.

A horizontal excision of the mid to upper scrotum allows removal of excess scrotal skin. Asymmetrical excision of the lower scrotal skin may be performed if there is unilateral scrotal enlargement. Skin with underlying dartos fascia is excised. The dartos is reapproximated with resorbable sutures, and the skin is closed with subcuticular resorbable sutures. Care should be taken to preserve the posterior scrotum due to its superior lymphatic drainage. Hemostasis is important as hematoma is the most common complication.

Hidden or Buried Penis

A hidden, buried, or concealed penis refers to a penis in which its appearance is obscured partially or completely within the pubic skin and fat and/or scrotum. Most patients have normal corporal length but function and aesthetic appearance are hindered. There are many causes, such as penile skin deficiency from over resection of shaft skin during circumcision or from chronic inflammation, obesity, weight loss with skin excess, aging with skin descent, or congenital buried penis. If the patient has adequate skin, the underlying deformity is characterized by a lack of firm attachments between the Buck's fascia and the dartos fascia and skin. This causes the corporal bodies to remain inside the body, while the skin telescopes on the outside.

Procedure

Surgery to correct hidden or buried penis is usually done under general anesthesia.

A moderate pubic fat pad can be reduced with liposuction if no significant buried penis is present. Usually, excess pubic skin is excised; the suprapubic fat pad is removed with liposuction and/or lipectomy; and the pubic escutcheon is elevated. The pubic skin and subcutaneous tissue need to be stabilized to the rectus fascia with

tacking sutures. The ventral penile skin usually needs to be tacked to the tunica albuginea at the penoscrotal junction to prevent burying into the scrotum.

If the patient does not have a significant pubic fat pad and skin descent, pubic liposuction with tacking from the skin at the penopubic junction to the corpora cavernosa can be performed in association with the penoscrotal tacking.

The surgery for hidden penis is very successful and results in improved penile visual and functional length, and often improves the chronic skin inflammation associated with a severe hidden penis.

Penile Girth Enhancement (Augmentation Phalloplasty)

Autologous fat injections into the dartos fascia are used commonly to increase penile girth. Advantages include lack of rejection and availability of material. Complications include unsightly nodules and irregularities from uneven fat injections and re-sorption, as well as asymmetry of the penis and loss of penile rigidity due to excess fat or rarely fat embolism may occur.

Dermal or dermal fat grafts may also be used to increase penile girth. These are usually placed as strips within the dartos fascia. Alternatively, a sheet graft is inset around the majority of the circumference of the penis, which has the advantage of a smooth texture. A partial circumcision or transverse pubic incision is used. The grafts are secured proximally and distally with sutures to prevent migration. Typically, an increase of girth ranging from 2 to 4 cm is achieved. Complication can occur if the grafts do not survive completely. The resulting scar formation can cause penile shortening or curvature; donor site scars can also be very long and unsightly.

Penile Lengthening or Enhancement or Enlargement Surgery

(Augmentation Phalloplasty)

Approximately one-third to one-half of the penis is inside the body, and is integrally attached to the undersurface of the pubic bone. Penis lengthening involves the release of the fundiform ligament and the suspensory ligament that attaches the two erectile bodies to the pubic bone (ligamentolysis). The ligament is released for a width of one fingerbreadth along the length of the pubic symphysis by incising directly on the periosteum in the midline. This is usually achieved through a pubic transverse incision just above the penopubic junction. A V-Y advancement flap based distally at the penopubic junction may give the appearance of increased flaccid penile length.

Complication of penile lengthening procedure include; V-Y flap complications as the blood supply of the penis may be disrupted, leading to healing problems such as partial flap loss and wound dehiscence. Reattachment of the penis to the pubis may paradoxically result in shortening of the penis, while a change in the angle of erection may also result. A rare complication of suspensory ligament release is penile instability, which is invariably caused by an overly aggressive release of the ligament.

The amount of penile length gained with suspensory ligament release is controversial, and may vary. The use of penile weights or stretching devices postoperatively potentially allows increase of length gain. The patient commences use of these devices approximately one week after surgery and continues daily for a period of months to years.

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