Many patients have undergone penile enlargement operations by other physicians resulting in cosmetic and functional deformities. One particular surgeon operated on thousands of men with a large number of complications and cosmetic penile deformities. He performed penile lengthening by releasing the suspensory ligament of the penis and advancing pubic skin using a large VY advancement flap. (FIGURE 1) Large-volume fat injections were used to increase girth. Other problems seen from other physicians are complications relating to dermal or dermal-fat grafts.
Specific complaints related to the lengthening procedure using VY flaps include wide, thick scars; a hairless depression in the pubic area; decreased penile length; a hump deformity at the base of the penis from thick, hair-bearing VY flaps; a low-hanging penis with scrotal ‘dog-ears’; and loss of sensitivity on the shaft or head (glans) of the penis. (FIGURE 2A & 3A) The most severe deformity occurs when the soft penis is surrounded by the scrotum (scrotalization), and the penis retracts under a thick VY flap and pubic fat pad. Complications relating to fat or filler injections include disappearance of fat, penile lumps and nodules, shaft asymmetry and distortion, excess penile skin near the glans, and inadequate rigidity owing to excessive fat and an overly large base (usually when combined with the VY flap). Other complaints include impotence, urinary leakage, and persistent penile pain. Complaints relating to dermal or dermal-fat grafts include penile distortion and asymmetry, hard strips or nodules, restricted erections with penile shortening, and penile curvature.
The unhappy patient is usually depressed and often desperate. He distrusts physicians because the other surgeon may have inadequately informed him of possible complications or deceived him. This first surgeon or an ensuing surgeon may have performed one or more subsequent operations with no improvement or worsening of his situation. Therefore, I concentrate on regaining patient trust at his first appointment.
The patient is evaluated while he is standing and lying down. He must prioritize his reconstructive goals, because complete correction of all the deformities may not be possible at one operation, if at all. The goals and possible result are carefully explained and shown to the patient in front of a mirror.
During the past 20 years, I have reconstructed over 200 men with multiple deformities and problems.(FIGURE 2B & 3B) The low-hanging penis with an unsightly hairy, dorsal hump at its base is caused by a VY advancement flap and is reconstructed by reversing the flap and replacing it in its normal position. At the same time, the wide, unsightly scars are excised and revised using plastic surgical techniques. Lumps and fat nodules resulting from fat injections are removed through incisions in the lower pubic hair, in the natural line in the middle of the underside of the penis, in the scar from a previous circumcision, or in a previous surgical scar. No new scars are made on the shaft of the penis. If the penis has a large amount of fat, contouring or removal of the fat is performed through a circumcision incision or through a previous enlargement incision. Removal of a large amount of fat and reversal of the VY advancement flap are not done at the same time for fear of causing injury to the tip of the V-flap or prolonged swelling of the penis. Usually, the VY flap is reversed first along with the removal of a limited amount of fat. Six months later, more aggressive fat removal can be performed.
Dermal or dermal-fat grafts causing problems can be totally removed through a circumcision incision, a longitudinal incision on the underside of the penis, or a low pubic incision. Removal of the scarred dermal graft usually eliminates the deformity, curvature, or penile restriction. However, several operations for correction may be necessary if severe scarring is present.
Reconstructive surgery is usually not very painful. Most patients are required to stay nearby for about 3-4 postoperative days. All wound closures are performed with meticulous plastic surgical techniques.
Most patients are very pleased after penile reconstruction, since their appearance again becomes much more normal. They are able to resume a normal life again without the severe cosmetic and functional deformities. Self-esteem is restored.