Genital aesthetic and penile enlargement surgeries are relatively new. Most results are anecdotal, but some surgeons are trying to generate meaningful data. Follow-up data are often difficult to obtain because many patients travel long distances for the surgery.

Dermal-fat grafts have been successful, although some patients resist the operation primarily because of the large donor scar(s). Gluteal crease donor scars are less noticeable than groin scars. Physicians performing fat injections promise small scars and minimal morbidity but emphasize the frequent necessity for re-injections. Dermal-fat grafts do not need re-operations and appear to have good long-term results. A reasonable aesthetic proportion between the shaft and the glans should be maintained. Some men with massive fat injections, however, appreciate the greatly enlarged shaft despite the “grotesque” appearance resulting from the disproportion between the shaft and the glans. The limited size of the dermal-fat grafts does not allow for massive thickening of the shaft because circumference increase of 1 to 2 inches is reasonable even with a relatively small glans. No effective procedure for enlargement of the glans is known.

Penile lengthening operations in the normal patient remain a major question. There is no satisfactory incision for skin advancement onto the penis, but a Z-plasty or double Z-plasty may be acceptable. Z-plasty is preferable owing to the high incidence of hypertrophic scars, wound disruption, and dorsal humps with V-Y advancement flaps. Moreover, exaggerated length claims of many physicians are unrealistic; a gain of 1 inch is considered a success. The patient with the 3-inch gain may be deformed with an extended escutcheon and a low-hanging penis, while achieving minimal or no real length gain.

Malpractice is a major consideration in penis enlargement surgery. Most malpractice carriers will not insure penile fat injections. Depending on the physician and the insurance carrier, dermal-fat grafts may be covered. Liability largely depends on adequate informed consent. Patients should be advised that these operations are investigational and require an extensive consent form to be signed. They must understand that penis enhancement techniques are evolving and that results are still being compiled.

Extensive physician consultation before surgery is imperative, and a “factory” approach is unethical. No two patients are anatomically alike, and thus, a “standard” approach to penile enhancement surgery is not in the best interest of the patient. Many referred patients present with persistent pain, bizarre-appearing V flaps, penile shortening, and massive fat injections with lumps. Some men have become emotional cripples, physically and psychologically unable to perform sexually. Obviously, a man seeking penile enlargement surgery has self-esteem issues, and therefore, a disastrous result may leave him further devastated. Dissatisfied male aesthetic patients have a greater propensity towards violence, so the physician must carefully screen these patients and perform good work for the protection of both the patient and himself.

The male with the concealed penis definitely benefits from a suprapubic lipectomy, release of the suspensory ligament, and a possible Z-plasty of the penoscrotal junction. Such reconstructive cases to restore normal sexual functioning may be covered by insurance.

The necessity for understanding plastic surgical principles to achieve satisfactory results cannot be overemphasized. Knowledge of the principles of flap design and surgical technique is necessary to prevent flap necrosis, wound disruption, “dog-ear” formation, unsightly genital distortion, and poor scar formation. Urologists should study these principles and techniques before performing such operations. Meticulous, time-consuming surgery will help prevent major problems and patient dissatisfaction.

Penis enlargement surgery is effective with low morbidity and high patient satisfaction. As new techniques evolve, demand will continue to increase.