Gary J. Alter

A NEW TECHNIQUE FOR CORRECTION OF THE HIDDEN PENIS IN CHILDREN AND ADULTS

PURPOSE A phenomenon known as hidden penis has numerous origins, including congenital buried penis and obesity with descent of the escutcheon. No previous report to our knowledge mentions abnormal hypermobility of ventral skin and dartos fascia, which is a major cause of surgical treatment failures. Because the skin and dartos fascia are inadequately attached to Bucks fascia, the corporeal bodies telescope proximally inside the scrotum and pubis. Therefore, the subdermis of the penoscrotal junction must also be tacked to the tunica albuginea ventrally to stabilize the proximal penile skin and prevent the penis from retracting into the scrotum. The surgical technique for correction of the hidden penis in adult and pediatric patients with adequate penile shaft skin is described. MATERIALS AND METHODS Surgery for hidden penis from multiple causes was performed in 6 adults and 7 children. Tacking sutures were taken from the subdermis of the ventral penoscrotal junction to the tunica albuginea in all cases. A combination procedure with either suprapubic dermatolipectomy, tacking of the penopubic subdermis to the rectus fascia, penoscrotal Z plasty, circumcision revision or lateral penile shaft Z plasty also was performed in some patients. RESULTS Improvement was noted in all cases. One child requires suprapubic lipectomy for optimal improvement and 3 minor wound problems occurred. CONCLUSIONS Surgery for hidden penis achieves marked aesthetic and often functional improvement. Surgical failure can be diminished by placing ventral tacking sutures from the tunica albuginea to the subdermis of the penoscrotal junction.

RECONSTRUCTION OF DEFORMITIES RESULTING FROM PENILE ENLARGEMENT SURGERY

PURPOSE More than 30 patients presented for reconstruction of penile deformities secondary to penile enlargement surgery performed by other physicians. Lengthening was performed by releasing the suspensory ligament of the penis and advancing pubic skin with a V-Y advancement flap. Girth was increased by injecting autologous fat. Specific complaints relating to the lengthening procedure involve hypertrophic and/or wide scars, a proximal penile hump from a thick, hair-bearing V-Y flap, and a low hanging penis. Complications relating to autologous fat injections include disappearance of fat, penile lumps and nodules, and shaft deformities. The repair of these deformities is described. MATERIALS AND METHODS From 1994 through October 1996, 19 men underwent 24 various combinations of reconstructive operations, such as scar revisions, V-Y advancement flap reversal, and removal of fat nodules and asymmetrical fat deposits. RESULTS Penile appearance and function were improved. Complications include 1 hematoma requiring drainage, minor wound complications and 1 inadequately reversed V-Y flap. CONCLUSIONS The methods of various repairs are discussed, including reconstructive limitations, timing and staging. Significant improvement can be achieved with proper reconstruction of penile deformities.

Split-thickness skin graft urethroplasty and tunica vaginalis flaps for failed hypospadias repairs.

PURPOSE Via a 2-stage procedure, 10 patients with failed hypospadias repairs were treated by a varied combination of split-thickness mesh graft urethroplasty and tunica vaginalis flap. MATERIALS AND METHODS A bed for the mesh graft in 3 patients was provided by a tunica vaginalis flap. Tunica vaginalis flaps were also used as an intermediate layer during stage 2 of the repair. RESULTS No strictures or fistulas occurred in 8 patients. Two patients await stage 2 repair after successful stage 1 placement of the mesh graft. CONCLUSIONS The combination of split-thickness mesh graft urethroplasty and a tunica vaginalis flap appears to achieve success in the difficult patient with complex hypospadias subsequent to multiple failed repairs.

USE OF A PREFABRICATED TUNICA VAGINALIS FASCIA FLAP TO RECONSTRUCT THE TUNICA ALBUGINEA AFTER RECURRENT PENILE PROSTHESIS EXTRUSION

PURPOSE Although a penile prosthesis usually perforates into the urethra, it can extrude through the glans or corporeal shaft. Various materials have been used to reconstruct tunica albuginea but no method of repair has been satisfactory in such difficult cases. Repair of the weakened tunica albuginea should ideally be performed with autogenous tissues. Inasmuch as the scarred tissue bed is inadequate to ensure graft survival and no local flaps are available for this purpose, prefabrication of a local flap has been designed. MATERIALS AND METHODS We present 2 cases in which the distal corpus was reconstructed with a prefabricated tunica vaginalis fascia flap. The first stage involves grafting rectus fascia onto the external tunica vaginalis of the testicle. At the second stage the prefabricated tunica vaginalis fascia flap is transposed to the distal corpus, placing it as a buttress between the cylinder and urethra medially or between the cylinder and thin lateral and distal tunica albuginea. The flap also replaces part of the tunica albuginea. RESULTS In both patients repair of the tunica albuginea was successful and each has a functioning inflatable penile prosthesis at 2 1/2 1 1/2 years postoperatively, respectively. CONCLUSIONS Reconstruction of the weak tunica albuginea with a prefabricated tunica vaginalis fascia flap is an excellent procedure in these difficult cases.

Surgical techniques: surgery to correct hidden penis.

A hidden or buried penis is essentially synonymous. The hidden penis with adequate penile shaft skin is buried in the pubic fat and scrotum. The penile corporal bodies telescope proximally inside the pubis and scrotum, in part because the penile skin and dartos fascia are inadequately attached to Bucks fascia and corporal bodies. Therefore, the corporal bodies go in and the penile skin stays out. The hidden penis, in adult and pediatric patients with adequate penile shaft skin, has numerous pathophysiological causes. These include the congenital buried penis with restraining bands of Scarpas fascia, obesity with a large suprapubic fat pad, aging or weight loss with excess pubic skin and descent of the escutcheon, an improper circumcision, and abnormal hypermobility of ventral skin and dartos fascia. The typical patient has a large fat pad in the suprapubic region. A hidden penis can occur in uncircumcised men or boys. A circumcision that removes too much normal shaft skin and leaves preputial skin does not have the normal attachments and can bury the penis. A circumcision that removes too much skin altogether is even worse, as the penis is trapped in the pubis and scrotum. To prevent the penis from “hiding” in the pubic region or retracting into the scrotum, appropriate repair involves strategic placement of tacking sutures, both dorsally and ventrally. The surgery techniques below only apply to correction of patients with adequate penile skin. Glans

Management of the Mons Pubis and Labia Majora in the Massive Weight Loss Patient

The high incidence of female obesity and weight loss has resulted in common complaints of a large, protuberant mons pubis and labia majora (outer labial lips) related to unsightly fat deposits and skin ptosis. The author presents a technique to correct the protuberant mons and pubic descent by performing a pubic lift, fat excision, and liposuction, and then tacking the superficial fibrofatty tissue to the rectus fascia. The labia majora enlargement is treated by fat excision and/or liposuction and skin excision. These techniques eliminate difficulties with sexual intercourse, poor hygiene, and discomfort, while also improving self-esteem.

Aesthetic Surgery of the Male Genitalia

Appearance of the male genitalia is linked with self-esteem and sexual identity. Aesthetic surgery of the male genitalia serves to correct perceived deficiencies as well as physical deformities, which may cause psychological distress. Attention to patient motivation for surgery and to surgical technique is key to achieving optimal results. In this review, the authors describe aesthetic surgical techniques for treatment of penile and scrotal deficiencies. They also discuss techniques for revision in patients with previous surgery.

The Nomenclature of “Vaginal Rejuvenation” and Elective Vulvovaginal Plastic Surgery

Vulvovaginal plastic surgery is an umbrella term encompassing multiple procedures that are quite distinct from one another. Since many of these terms have evolved from marketing rather than scientific literature, ambiguity and inconsistency exist. This is readily apparent in the yearly Cosmetic Surgery National Databank statistics compiled by the American Society for Aesthetic Plastic Surgery for “vaginal rejuvenation.”1 Regarding the term vaginal rejuvenation , a recent publication in a major obstetrics and gynecology journal stated, “Unfortunately, neither patients nor medical professionals know exactly what is meant by this term.”2 In fact, there is probably a …

Commentary on: The Safety of Aesthetic Labiaplasty: A Plastic Surgery Experience

This is another study showing the relative safety of aesthetic labia minora reduction (labiaplasty). The authors perform an edge or trim technique to reduce the labia and then close the wounds with a running vertical mattress suture.1 It is reassuring that the authors had such seemingly good results. However, there are many questions that are unanswered by this paper. The results must be evaluated more closely to put their conclusions in perspective. After seeing many labiaplasty complications referred to me, many issues come to light. Success rate is determined by many factors, including the technique chosen and the precision of the surgeon. Other surgeons perform trimming labiaplasties using a variety of techniques, including excising the labia with a scalpel, scissors, laser, or radiofrequency. The authors rightly make the markings with patient approval to determine the amount of residual labia remaining. I am glad that they emphasize the necessity of conservative reduction, especially since many women present to me with partial or total amputation of the labia minora from an edge or trimming technique.2 In these women, the labia may have been pulled out and cut on tension. When released, …

Editorial Comment on “Penile Girth Enhancement With PMMA-Based Soft Tissue Fillers”

The number of respondents to the questionnaire was only approximately 28%. The satisfaction rate of the responders was 83%, which leaves 17% who were not satisfied or were not happy. That is a considerable dissatisfaction rate for a cosmetic procedure. The investigators state that they “could not find any obvious dissatisfaction in their notes of the remaining nonresponders.” That statement does not ease my concerns that more patients were not happy.