Why and for whom ?
The harmony and proportion between the different body parts also has their raison d’être in the noblest organs, thus the proper application of techniques for reconstitution of external genitalia by the plastic surgeon, who has the precise anatomical knowledge, allows people healthy with the desire to improve their external appearance, undeniable benefits in self-esteem even on occasions, with a direct impact on their life of personal interrelation.
There are wide variations in the shape and size of the penis, however the relevance of its dimensions is a matter that has been debated since the dawn of time across multiple cultures, remaining in our days as a focus of interest, favored by the Currently wide availability of images. The opposite situation, generates frequent insecurities and hesitations in self-esteem, especially when the exhibition of some real lack or on the contrary subjective, as in the costume complex, is inevitable; circumstance that many men cope with or endure throughout their existence.
This interest does not decrease with the passage of age, therefore it does not necessarily imply in all cases, abandonment for the care of the noble parties. At the same time, the search for some kind of help in numerous cases is carried out covertly, circumstances prone to marketing and fertile to the proliferation of remedies of doubtful scientific relevance.
In other men, our intervention aims to repair the undesirable consequences, the result of some malformation from birth, acquired conditions that result in shortening or deviation of the penis, including accidental mutilation or previous tumor disease, in addition to correcting the undesirable consequences of some interventions.
Recommendations before treatment
It is useful to prepare a written list of questions to avoid forgetting any, since it is important to clarify with the surgeon, all the doubts that can be lodged about the procedure that is going to be performed, instead of maintaining the ignorance as protection against preoperative fear.
Make provision in advance of the list of medications and products for cures prescribed in the pre-operative consultations , and have ample clothes that allow housing both your genitals without rubbing, as well as the appropriate dressings or bandages that we will apply during the postoperative period. recent.
Who can be candidates for these treatments?
The most timely decision results from realistic and balanced deliberation, by presenting different alternatives, weighing benefits against inconveniences, understanding the proposed techniques, possible added operating gestures, and respecting the necessary convalescence.
To obtain objective and effective advice, it can be complemented with the participation of the experienced psychologist. In addition, forming a multidisciplinary approach, in patients who require it as for example in cases of impotence, we have the opinion of the urologist interested in andrological issues. In glandular disorders, endocrinological consultation is necessary
1. Elongation phalloplasty (penis enlargement): It is performed by partial release of the ligaments that fix the corpora cavernosa to the pubis, sometimes complemented with displacements of the skin of the bags or scrotum, and in some cases with pubic liposuction. The increase obtained is variable, ranging according to individual characteristics, between 1.5 and 4 cm, but sometimes we can obtain additional length, through the daily use of correct traction maintained after 2 weeks postoperatively, for 6 months.
There are different approaches of the previous section, in this way some patients operated by others, come presenting deformities “in giba” of the base of the limb, undesirable irregularities and hair on the back of the penis, in addition to delay in the healing of the wound, circumstances that on the one hand we correct or we can redirect, while on the other we prevent not using techniques that favor these complications. It should be anticipated that the angle of erection in standing attitude is modified, from a more vertical preoperative position, to the less elevated postoperative, although without interfering in the relationship capacity.
2. Thickening phalloplasty in resting attitude: There are adequate techniques for each particular case, such as fat grafts taken previously from the abdomen or thighs; others use skin and fat grafts, or even dermal collagen grafts. The first can atrophy causing distortions, irregular nodules, and alterations in its consistency. The seconds remain to a greater extent, although they may result in shortening and curvature. However , the techniques that provide pubic tissue flaps do not have these drawbacks.
We have also applied vein grafts to the corpora cavernosa, improving the thickening of the penis in erection between 1.5 and 2 cm.
Depending on the type of procedure indicated and in patients considered suitable, we combine lengthening with thickening of the penis at rest or even in erection. Some techniques require a 6 month delay. Other thickening methods that use grafts of foreign materials can modify the sensitivity of the virile organ.
Most of these treatments can be performed under local anesthesia associated with sedation on an outpatient basis, that is to say without admission, or with a short stay during the morning. Other techniques will require one-night postoperative admission. The period of convalescence depends on the procedure performed, although it can be established between 3 and 5 days, time for the most immediate reviews. Sutures tend to reabsorb spontaneously. The reestablishment of relationships is delayed until 4 weeks after the intervention.
The question of the sizes: We must establish a maximum in the dimensions of the member, which is its “constant” variability, in any case, the following intervals of normality taken from the scientific literature can be contemplated (in no case of pretended racial studies, of doubtful rigor and method: At rest, length measured from the dorsal base in symphysis to the end of the glans, 10-11 cm, and circumference in its intermediate portion, 8-9 cm. In erection, length 15-16 cm, and circumference 10-12 cm
3. Correction of hidden penis: The consequences of cutaneous or adipose surpluses of pubis and abdomen are more frequent, aggravated by radical circumcision in childhood, which hinder the localization itself, resulting in an invisible penis that even forces you to sit down to urinate.
There are congenital forms, which associate the former with the presence of tissue that retracts inwards.
This condition can be improved by liposuction, with or without removal of excess tissues, and fixation of residual tissues at the root of the erectile bodies.
4. Phimosis, primary or secondary treatment, and elongation of the frenulum of the foreskin: In the first case, the narrowness of the foreskin usually from birth prevents externalizing the glans. In other cases it can also be acquired by scars. This prevents complications associated with paraphimosis (constriction of the glans per retracted foreskin ring), infection and glans cancer (50% suffer from phimosis).
We perform as conservative release of the foreskin as possible. We can also treat recurrence situations due to insufficient previous treatment, and even concealment of the penis by aggressive circumcision.
5. Correction of congenital curvature of the penis: They appear in 1 of every 300 male births.
During erection, deviations to any of its sides are possible, considering their correction in cases that interfere with acceptable relationships. We can get your straightening by applying sutures on the convex side.
6. Treatment Peyronie’s disease or plastic induration of corpora cavernosa:
The most frequent induration between 40 and 60 years of age can promote the formation of plaque, resulting in curved erection and shortening. More than 30% of cases tend to worsen, indicating their treatment when it makes relationships difficult.
We obtain better results, eliminating plaque and filling its defects with dermal, venous or other thigh grafts. In cases where turgid erection is impossible, implants may be indicated.
7. Congenital testicular absence, or acquired by its subsequent loss: By implantation of silicone gel prosthesis or saline. The first ones of greater consistency.
8. Scrotal rejuvenation: Some men develop pendulum appearance of the bags over time and possible maceration of the skin folds. Its correction implies reducing the excess by restoring its normal relations with the penis.
9. Readaptation of ambiguous genitals: Remodeling to allow the relationship life of intersex patients, whose external genitalia are insufficiently suited to their personal orientation.
10. Other restorative treatments: Correction of sequelae of previous interventions and anomalies in the position of the urethral orifice, ventral or dorsal, release of scars or peno-scrotal flanges, which require the new supply of healthy tissues.
11. Gynecomastia treatment: Breast development in men, which can be resolved through access with minimal scars, usually under general anesthesia of short duration and with a stay limited to one morning.
MOST COMMON INTERROGANTS:
In the interventions on the member, is their function or erogenous sensitivity altered ?:
Urinary capacity is primarily respected, while that with respect to sexual intercourse, the erection angle is changed from a position Preoperative more vertical, until postoperative, less high, but without interfering with the ability of relationship.
Transient changes in sensitivity to inflammation are common. Transient changes in sensitivity are common, due to inflammation, after most interventions; other more lasting alterations are extraordinary
When can sexual intercourse resume?
In the techniques of lengthening, thickening, and hidden penis, they must be delayed at least until the full course of the following 4 weeks.
In the correction of phimosis and frenulum, the most immediate inflammation resolved, towards 2 weeks.
What other inconveniences can I expect?
Inflammation of the penis and / or testicles may last for the first 2 or 3 weeks. The discomforts are usually not intense, inhibiting their appearance during the first days with oral analgesics. The postoperative period of some surgery may require the temporary use of a probe for suture protection.
Are they very long interventions?
Most of them at all, although it varies according to each particular case; for example , penis enlargement, phimosis correction, short frenulum, and testicular prosthesis implant, are especially fast techniques.
When does work reintegration occur?
It depends on the techniques used, but at least 1 week’s work leave is recommended. In case of performance of activities with particularly intense physical effort, prolong another week.
Can several interventions be done together?
It depends on the problems to be treated and the techniques recommended in each case. For example, it is common to associate penis enlargement and enlargement in the same procedure, without the complications of fatty grafts, nor to delay the second surgery as required by skin and fat grafts by 6 months.
Hidden penis correction and phimosis should not be associated, as this last condition could be aggravated.
What is monitoring and care in the recent postoperative?
Most of these procedures are performed on an outpatient basis, during the day surgery regime, in whose postoperative period the abstention from sports activity and relationships must be observed during the first month.
The first review and cure the next day; thereafter, removing possible drains around 48-72 hours, giving recommendations to generally start the washing and drying of the intervened region. Sutures can be checked by 8 or 10 days. In the meantime bandage is recommended to reduce inflammation.
Are surgeries performed for sexual identity reorientation?
The comprehensive and adequate treatment of gender dysphoria is subject to international protocols (www.symposion.com/ijt/soc-01/index.htm), and involves periods of both hormonal and psychiatric preparatory treatment for a period of about 2 years, as a stage prior to any surgery, the results of which may be irreversible. Although aesthetic results are generally acceptable, they can sometimes be debatable.
What types of anesthesia may be necessary?
The majority of treatments such as lengthening, thickening of the penis (by fatty grafts or also of skin), correction of curvatures both from birth and acquired in adulthood (La Peyronie disease ), testicular implants, scrotal rejuvenation, as well as correction of Phimosis and elongation of the frenulum in collaborating adult patients are contemplated on a regular basis, under intravenous sedation and local anesthesia on a walking basis.
The thickening of the penis in erection with vein grafts, correction of hidden penis, ambiguous genitals, and more complex repair surgery, under general anesthesia and hospital admission for at least the first 24 hours, for requiring a longer operating time.
The definitive decision of the type of anesthesia corresponds to the medical team, although the preferences that can be made compatible with the act to be performed are always considered, adjusting in each patient to their individual needs.
What can be the risks in this type of specific interventions?
Any intervention involves common risks that are considered general, others that depend on the anesthetic technique used, and finally the specific risks derived from both the procedure itself and the area treated.
General risks: Immediate (first 24 to 48 hours), hemorrhage, with or without hematoma (usually prevented by drainage), edema or swelling (cold prevention); Some usually delay its appearance sometimes up to three weeks, such as: seroma or accumulation of clear fluid, local infection, separation of wound edges (dehiscence), skin loss. Intolerance reactions to suture material or cures such as: adhesives, antiseptics. Finally, the skin scar that in most cases is short, can be visible or thickened, evolving at least during the first 11 months.
Anesthetic risks: From those derived from local anesthesia (such as local pain in the puncture area), less invasive versus epidural, or even general anesthesia, with possible nausea and / or vomiting during the first 12-24 hours. The availability of adequate means in the operating room can reverse major complications such as medication intolerance reactions.
Specific risks: Sensitivity modifications of the skin and penis, usually temporary due to the most recent inflammation. In some cases, due to the complexity of the problem to be treated, the possible need for reintervention should also be considered, also due to the occurrence of early or late complications such as scar contractures, or due to dissatisfaction with the results. Occasionally during convalescence, a stage of transient disillusionment may occur, which is resolved by obtaining results.
EXTERNAL GENITALS: ANATOMIC REMEMBER in ADULT VARON
Penis: Located immediately below pubic symphysis, cylindrical morphology, and constituted by an internal or perineal posterior portion, while another anterior or free.
Variable dimensions, accepting guidance data according to Testut, at rest, length measured from symphysis to glans limb: 10-11 cm, and circumference in its intermediate portion, 8-9 cm. In erection, length 15-16 cm, and circumference 10-12 cm.
Formed by three erectile bodies wrapped in white or albuginea fibrous leaf, two dorsal and lateral or cavernous bodies, of basal length 15-16 cm, and in erection 20-21 cm, interconnected in their middle plane, except in their origin or pillars; while one ventral, middle or urethral, located between the previous ones: spongy body, with enlargements in its origin or bulb of the penis, in its beginning already crossed by urethra, and cone-shaped distal expansion called glans, covered by cutaneous-mucous fold or foreskin, whose frenulum generally originates 8-10 mm behind the urinary meatus. It houses the portion called spongy urethra.
The posterior end, or root, is fixed to the pelvic wall on the one hand, by inserting corpora cavernosa into ischio- pubic branches , and on the other by fibroelastic ligaments: fundiform ligament , originating in the lower part of the alba or middle line of the abdomen, which separates into two halves on each side of the limb, and suspensory ligament originating in the anterior surface of the pubic symphysis, from where it reaches the back of the penis in a fixed transition to mobile, through medium fibers that bind to the albuginea of corpora cavernosa, and lateral fibers that contour it constituting a webbing. Behind there are very thick and short connective fibers or fibrous ligament of Luschka.
Among the muscles of the perineum (set of soft parts that close the pelvis, crossed by rectum, urethra and genitals) anterior or genital with erectile function, stand out ischiocavernosus , finally flattened belly extended to the root of the corpora cavernosa through a fibrous leaf, which It ends before the insertion of the bulbocavernosum. Both act on erection and ejaculation by compressing corpora cavernosa, expelling arterial blood to the anterior portion of the penis.
Bag: Cutaneous and fibromuscular sac, inferior and posterior with respect to the penis, with prominent line in its middle portion or rafe resulting from the fusion of its primitive duplicity. Made up of 6 successive robes: Rough skin (scrotum); smooth muscle ( damage ) that when contracted, especially in the cold, frowns to the previous one and conforms with the superficial fascia or Cooper, the partition between both testes, incomplete in humans, while continuing in its most anterior part with the superficial abdominal wall fascia or Scarpa fascia , and behind with the perineal or Colles superficial fascia. Muscle or cremaster with reflex, fibrous, and finally vaginal function: a serous membrane with two leaves, parietal and visceral that lines the lower edge of the teste.
Testis: Even organ, sperm generator and internal secretion gland, continued upwards by the first segment of sperm or epididymis, and vas deferens. They are located under the penis, between the thighs, generally, the left somewhat more declining, consistent with the right-handed predominance (inverted in left-handed), with the ability to migrate to the inguinal ring due to the contraction of the dartos and cremester.
In case of lack of unilateral development it is called monorchidism, and an abnormality if it is bilateral. The anomalies in the position or ectopia condition its function, denominating its absence, usually unilateral, cryptorchidism. Average dimensions: length 45 mm, height 70 mm, and weight 20 gr. With age, about 20 to 40% of its volume can atrophy. In its posterior end, scrotal ligament is inserted, fibromuscular lamina that fixes it to its coverage.
1. L. Testut and A. Latarjet . Treaty of Human Anatomy, 9th edition, 1976. Volume IV, urogenital apparatus. Salvat editors. Chapter II, pp 1.001-1.168.
2. KL Moore. Anatomy with clinical orientation, 2nd edition, 1985.