Penile Lengthening

The procedure of lengthening the penis through the dorsal approach involves the advancement of the corpora cavernosa by disinsertion of the fundiform and suspensory ligaments. I recommend this technique when patients have a micropenia (small congenital penis), ie when the erect length is less than 10 cm and have torque problems.

Ideal candidates

There are patients who know or feel that they have problems with their couple due to their small size, less than 10 cm in length in erection and who do not have chronic decompensated diseases, who are not treated with medication such as anticoagulants, antiplatelets, antidepressants, oral antidiabetics or insulin, chemotherapy or other medication that may interfere with the healing process of the tissues or may cause unavoidable complications./p>

Before the operation of dorsal elongation of the penis

Once you have established that this procedure will be beneficial for your situation, a few steps are needed that will help and facilitate the healing process.

One of the most important aspects of any operation is the preoperative preparation

I recommend that you make sure that you know the recovery period because this way you will know how to plan your activity after the intervention, both at work and in the family, as well as in the social relations with friends.

It will be necessary to complete a document with your data (Patient Record) so that we know as much information as possible about your medical history, some chronic treatments administered in the past or present, other hospitalizations or other past operations.

I would recommend that you epilate with a blade, cream, hair clipper or clipper 2 days before the operation, but be careful not to cause skin lesions that can then increase the risk of postoperative infection.

I will recommend washing in the shower 3-5 days before the operation, with a solution of skin antiseptic (Betadine or chlorhexidine soap) on the areas where the perimeter of the operating fields will be delimited and after a few minutes of operation, rinse with water and shower gel so as not to impregnate your underwear in the situation where you will use dark products such as Betadine. In the morning of the intervention, I will recommend that after applying the antiseptic solution in the shower, you rinse only with water, without using shower gel. In this way we will prepare the areas that will be worked on and thus we will reduce the amount of bacteria that are normally on the skin and through this, we will reduce the risk of infection.

About 10 days before the operation you will have to perform the set of blood and urine tests that you will receive on time, so that 7 days before the operation I will receive the results and confirm if the parameters are within normal limits. and we can move on with the intervention.

One of the special requirements in this situation is related to the use of a traction device at least 1 month before the intervention, in order to facilitate this process in the postoperative period. It is based on the idea that in fact we will prepare both the local tissues for a postoperative mobilization process, and especially the patient will get used to the forces and intensity of traction. Therefore, after the operation of dorsal elongation of the penis, the patient will already be accustomed and will know how to control the traction so that the effect and efficiency are maximum.

Dorsal elongation technique

There are many pros and cons to this technique, but I would like to give you my opinion after more than 700 cases.

Anatomically, the base or root (radix) of corpora cavernosa is in the small pelvis, behind the pubic bone. They advance and climb sharply with the pubic bone, after which they make a downward curve, emphasizing the outside, with the portion that we see with the naked eye. In the portion through which the corpora cavernosa have an ascending disposition, they are attached to the pubic bone by the suspensory ligament. This is a fibrous, aponeurotic, hard and stable formation.

Stratigraphically, if we want to reach the level of the suspensory ligament, we will have to go through the skin, the fat and then the fundiform ligament. The latter is a fibrotic structure, hard but relatively elastic and represents the extension of the fascia of the abdominal right muscles, and more distally it will continue with the superficial penile fascia (Dartos). Therefore, the corpora cavernosa have an internal and an external portion, and in order to be able to control the internal one, it is necessary to interrupt the fundiform ligament in a way in which later the tissues can be mobilized according to a specific technique.

Once the pubic bone promontory has been reached, the suspensory ligament must be spotted, which begins to disintegrate step by step until it reaches depth, the terminal portion of the bone, and the lower limit of dissection is the interception of the deep dorsal vasculonervous bundle. . The disinsertion of the suspensory ligament must be performed completely both in depth and on the surface, in the lateral parts of the pubic bone and the limits of the dissection will be represented by the medial edges of the spermatic funnels. Both the deep dorsal vasculonervous bundle and the spermatic cord must be kept intact at all costs. After this dissection, the possibility of advancing the corpora cavernosa can be observed even intraoperatively, which will depend both on the thickness of the suspensory ligament and on its arrangement in depth and surface. This also depends on the length of the internal segment of the corpora cavernosa and their elasticity. This advancement can be done with 1-3 cm in the previous position, but let’s not forget that the penis at the moment of the intervention is in a relaxed state.

The suspensory ligament, as a personal opinion, is called inappropriate in this way, because it does not suspend the corpora cavernosa. That is, once it is interrupted, the penis will not fall into an erection. It is true that after this technique it is very possible that the angle between the erect corpora cavernosa and the suprapubic area will open more, ie the penis will not be as close to the abdomen as it was before, but that does not mean that it will be fell between his legs. This is because the highest percentage of the corpus callosum is due to its erectile capacity and much less due to the connection between the corpora cavernosa and the pubic bone. Therefore, I consider that a more correct name for it mentioned above, would be the stabilizing ligament, because it stabilizes the corpora cavernosa of the pubic bone, giving a stability that helps in erection to maintain a firmer axis of the corpora cavernosa.

If I take the example of a worker working on a tall pole, he will be secured with several straps, at different points, so that he can stand in a fixed position and use both hands. at the same time, performing the proposed work. If one of those straps loosened, it would not fall off the pole, but it would not be securely fastened so that it could use both hands, as it would have to be held in place by one of the straps.

It would be the same here. If the suspensory ligament stabilizes the penis from the pubic bone, its disinsertion from the bone can cause a loss of stability in certain positions of sexual intercourse.

If in a relaxed state you can advance the corpora cavernosa by 1-3 cm after the erection procedure of the penis, in an erect state, you can get about 50% of the gain in a relaxed state. This is due to the fact that in erection the penis grows due to the specific vascularization of the corpora cavernosa, and the ascending position that they adopt implicitly, makes part of the internal content curl inside, so that it is partially lost from that gain in a relaxed state. . If the penis remained in a descending and erect position, the gain obtained in a relaxed state would also be relieved in an erectile state.

At the end of the dorsal elongation procedure, the technique must be completed with the one that blocks the surface of the pubic bone from which the ligament was disinserted. If all this dissection were not completed by blocking the retraction of the suspensory ligament over the surface of the bone by a certain method, everything would be meaningless. The reason is that the internal disposition of the corpora cavernosa involves returning to the previous position, both due to their memory and their anatomy in an erect state. Therefore, it is necessary to block or cover the surface of the pubic bone from which the suspensory ligament was disinserted.

In the past, the solution we practiced was based on inserting a silicone implant between the corpora cavernosa and the pubic bone, so that they remain advanced. The variant in this case was by using a testicle implant that had a predetermined size and an oval shape, but the shortcomings of this technique were related to:

• much higher risk of infection due to the existence of a foreign body in a less vascularized area,
• the need to remove the implant after at least 3 months which means that the patient should return and have additional costs & nbsp;
• distorting the architecture of the initial scar with the formation of another and especially the possible & nbsp;
• Risk of compression of the corpora cavernosa at the level of the deep dorsal vasculonervous bundle, which in the long run may show a decrease in vascularity and hence a loss of erection quality of silicone) & nbsp;
• Pain and discomfort during sexual intercourse in the suprapubic area due to the compression of the implant on the base of the penis reported by most patients, which is why I tried to find other solutions that are much more effective and satisfying for patients. & nbsp; & nbsp; Thus, after a few months of using the silicone implant, we created a new technique, which is based on the use of our own tissues that will be able to cover the surface of the pubic bone from which the suspensory ligament was disinserted. This is based on the dissection of adipofascial tissue on the medial face of the spermatic funnels and which will be sutured like a bridge over the pubic bone periosteum, in the lowest possible position. That space which is created in a natural way by the disinsertion of the suspensory ligament and at the same time its advancement, must be filled so that the ligament does not reattach over the surface of the bone, and these tissues containing fascia and fat are very effective, thus eliminating all disadvantages. of the silicone implant. They are either sutured either by anchoring them like a bridge over the pubic bone periosteum (as if you were pulling 2 curtains towards each other from left to right and vice versa to cover a window), or by pre-preparing them in the form of flaps with own vascularization and then individually sutured over the surface of the bone (such as the movement with the hands made by footballers when they stand on the wall at a free kick and protect their intimate area).

The disinsertion of the suspensory ligament must be done completely, up to the lower edge of the pubic bone, until the transilluminal visualization of the deep dorsal vasculonervous bundle and thus, the sac fundus that will be created by default, cannot be completely filled with adipofascial tissues. because no matter how they are prepared, they cannot reach the steepest point of the bag. Therefore, in the deep area I will insert a thin drainage that has the role of removing any blood-lymph exudate that may accumulate in that space. This drainage should be removed after 1-2 days or when the amount of fluid does not exceed 30ml / 24h. At the end, the suture and also the scar will have the shape of the letter “Y” when it is inspected by the patient or “Y” returned when it is inspected from the front. The deep threads are absorbable, and the ones on the skin need to be removed after 7 days because they want to get an effective discharge of the wound lips that will ensure a much more efficient healing. At the same time, overflowing the edges of the skin with other sutures will prevent the sutures from penetrating deep, which can create skin infections or even deep ones.

Anesthesia

We always try to offer our patients maximum comfort, both during the phalloplasty operation and later, during the hospitalization period and then during the recovery period through specific controls and dressings. Therefore, when it comes to penis lengthening techniques, there are several options for anesthesia:

• Peridural (epidural) anesthesia or spinal anesthesia: involves removing the senses and movements of the lower limbs, from the umbilicus to the toes by a regional anesthesia that will address the space between the vertebrae that protects the spinal cord through which the anesthetic will be instilled. The duration of anesthesia can be several hours and can be extended as needed even after surgery for epidural (epidural) anesthesia due to the catheter which can be held in place to provide further control of any postoperative pain. During the operation under this type of anesthesia, the patient may be completely awake or may receive sedative medication to ensure a restful sleep. All this depends on the patient’s desire, which can be expressed even during the intervention. Sometimes we have patients who want to remain fully aware and we can discuss or collaborate with them throughout the intervention, about topics that may have nothing to do with the operation, relaxing the atmosphere in a very friendly way. Sometimes we recommend that patients watch a movie or listen to music on their headphones during the procedure. As an anecdote, I had a situation in which a patient during the penis lengthening operation, being awake and listening to music, was called by his wife, who did not know about his operation. He had to answer so as not to cause uncertainty or suspicion about his whereabouts and was instructed to buy certain items, which he purchased online over the phone, right during the intervention.
• Deep Sedation Anesthesia , general anesthesia by oro-tracheal intubation or laryngeal mask is the one we use whenever patients express a desire to be completely asleep, but it is not which I recommend routinely, because I consider that the regional one associated with superficial sedation is ideal when it can be performed in optimal conditions.

After dorsal elongation of the penis

Because we are talking about surgery in the true sense of the word, our clinic’s protocols imply the need to be able to control the operating area for a period of at least 10 days. This means that patients will need a 1-2 day hospitalization, and then they will be able to stay in Baia Mare or its surroundings (for those far away) and come for check-ups. For us, the safety of our patients is the most important, so we recommend that patients who want to opt or need this procedure, understand that any surgeon responsible for his patients, will want to ensure that the postoperative evolution is favorable or excellent and for However, remote controls using digital technology, no matter how advanced, cannot be done if there is a complication that requires the attention and intervention of the attending physician and the operating team.

During the recovery period, the patient will receive information about how the healing process is going and will be instructed to start the traction exercises with a special device that has the role of relaxing the scar that is to be formed in depth and to stabilize the result. This device involves attaching to the glans a suction cup that has an elastic strap at the end, which can be mounted at the thigh or just below the knee, with the ability to set the intensity of traction. The patient must have already purchased this device because I recommend using it 1 month before the operation, to get used to the sensation and the idea of ​​traction.

The traction device will ensure the relaxation of the deep scar and thus the stabilization of the result, but it cannot prevent the retraction of the ligament at the level of the pubic bone if the latter has not been covered or a tissue has not been interposed between it and the corpora cavernosa. this thing. By disinserting the suspensory ligament, the internal portion of the corpora cavernosa can be advanced and the space that is created by default we want to keep it as free as possible and the tissues to be relaxed, all these being obtained through the traction mechanism. The traction period is at least 6 months postoperatively. At first I recommend that patients use postoperative traction as much as their comfort allows, but later the vast majority of patients stay with the device for hours during the day, even when they are at work.

The deep sutures are absorbable and those from the skin are removed after 7-14 days and the resumption of intense physical activity will be after 3 weeks. The period of abstinence from sexual intercourse is at least 4 weeks.

Complications

As with any surgery, dorsal lengthening of the penis may involve some complications that should be addressed to patients before and after surgery.

Personally, I like to talk about them very seriously because one of the biggest situations I usually face with cosmetic surgery of any kind is the fact that it doesn’t hurt patients. They will often hear the phrase, “One of my problems as a doctor is that it won’t hurt!” The pain must be taken here in a positive sense, meaning that as a doctor I “want” the patient to feel a certain degree of pain, just to not make an effort after the intervention, in the case of inattentive patients. This postoperative state in which you do not feel any pain can make you believe that everything is fine and even when you make a certain type of effort nothing hurts. In these situations, there is a risk that lymphatic fluid will accumulate in deep spaces and form what we call SEROM, which is excess lymph that can cause infection or dehiscence of the suture (suture rupture because the fluid must drain somewhere). Another complication that can occur either due to insufficient intraoperative hemostasis or later due to extensive movements immediately postoperatively by the patient is the appearance of excessive bleeding, which can cause the appearance of HEMATOMA.

This requires reoperation and involves removing the blood clots, extensive lavage, coagulation or ligation of the involved blood vessel, and closing the suture.

INFECTION is another factor that must be considered even if the prevention and antibacterial therapy measures we offer you are the highest, because this region involves an interruption of blood vessels, lymphatic vessels, a disinsertion of the suspensory ligament and a suture to prevent the latter from reattaching to the pubic bone, all in a relatively avascular space, where a sack bottom will be created due to both the technique itself and the traction regime, where the risk of fluid accumulation may be quite high if the situation is not fully controlled. This requires a sufficient recovery period in which the physician can evaluate the healing process by repeated checks.

Phalloplasty procedures have nothing to do with penis function, meaning that any sexual performance (quality and duration of erection and period until climax) will neither be improved nor abolished. All with one condition: not to touch the erectile structures both directly and indirectly. In order for the dorsal elongation procedure to be performed correctly and completely, the disinsertion of the suspensory ligament must be performed until the lower part of the pubic bone where it ends and also in the surface long enough so that the advancement of the corpora cavernosa can be as good as possible. Immediately below the inferior insertion of the suspensory ligament on the pubic bone, the deep dorsal vasculonervous bundle can be seen by transillumination, made up of the deep dorsal artery with the 2 committing veins and the deep dorsal nerve. These structures must be kept intact because we want to keep the vascularity and innervation of the corpora cavernosa and glans intact.

During the interruption of the continuity of the fundiform ligament with the Dartos fascia and the deep descent on the bone poses for the disinsertion of the suspensory ligament, the lateral dissection must be made in such a way that the integrity of the spermatic funnels must be maintained. bottom and grease that we want to use to fill the deep spaces and to cover the disinsertion surface on the pubic bone. When either dissecting or anchoring them to the surface of the bone, spermatic fungi should be avoided.