Abstract
Background:
With the increasing prevalence of overweight and obesity, adult-acquired buried penis is more common in recent years. Many surgical techniques have been reported. However, none is the gold standard.
Objective:
To evaluate the safety and efficacy of combining suprapubic liposuction and modified Devine’s technique for penile lengthening in adult patients with buried penis due to obesity
Methods:
From September 2015 to June 2018, 26 consecutive suitable patients (mean age: 33 ± 5.7 years, mean body mass index: 29 ± 5.4 kg/m2) with a buried penis received suprapubic liposuction and modified Devine’s technique for penis release in our medical centre. A retrospective study was conducted. Their penile length from tip to the skin (flaccid) was measured pre- and post-operatively. The amount of liposuction was also recorded accordingly.
Results:
The mean length of the follow-up on the 26 patients is 18 ± 7.1 months (range 3-33 months). The average amount of liposuction is 450 ± 90.2 mL. The average penile length measured preoperatively, post-operatively (on table), and 3 months after the operation is 2.9 ± 1.3, 7.4 ± 2.1, and 5.3 ± 1.8 cm, respectively. The post-operative penile length had significantly increased by 4.5 ± 1.6 cm (on table) and 2.4 ± 0.7 cm (3 months post-operation) with a P value <.05. No patient had difficulties in sexual intercourse or urination post-operatively. None of the patients were dissatisfied with their surgical outcomes.
Conclusions:
The combination of suprapubic liposuction and modified Devine’s technique is a safe and effective method for releasing the buried penis of adults with satisfying outcomes.
Keywords: penile lengthening, liposuction, Devine’s technique, buried penis, adult
Abstract
Contexte :
Avec la prédominance croissante du surpoids et de l'obésité, le pénis enterré adulte-acquis est plus commun ces dernières années. Beaucoup de techniques chirurgicales ont été rapportées. Cependant, aucun n'est l'étalon-or.
Objectif :
Évaluer l'innocuité et l'efficacité de la combinaison de la liposuccion suprapubique et de la technique modifiée de Devine pour l'allongement du pénis chez les patients adultes avec un pénis enterré en raison de l'obésité
Méthodes :
De septembre 2015 à juin 2018, 26 patients appropriés consécutifs (âge moyen : 33 ± 5.7 ans, indice de masse corporelle moyen : 29 ± 5.4 kg/m2) avec un pénis enterré ont reçu une liposuccion suprapubique et modifié la technique de Devine pour la libération du pénis dans notre centre médical. Une étude rétrospective a été menée. Leur longueur pénienne de la pointe à la peau (flasque) a été mesurée avant et postopératoirement. La quantité de liposuccion a également été enregistrée en conséquence.
Résultats :
La durée moyenne du suivi sur les 26 patients est de 18 ± 7.1 mois (gamme 3-33 mois). La quantité moyenne de liposuccion est de 450 ± 90.2 ml. La longueur pénitenelle moyenne mesurée de façon préopératoire, postopératoire (sur la table) et de 3 mois après l'opération est de 2.9 ± 1.3, 7.4 ± 2.1 et 5.3 ± 1.8 cm, respectivement. La longueur du pénis postopératoire avait considérablement augmenté de 4.5 ± 1.6 cm (sur la table) et de 2.4 ± 0.7 cm (3 mois après l'opération) avec une valeur P < 0.05. Aucun patient n'a eu des difficultés dans les rapports sexuels ou la miction postopératoire. Aucun des patients n'était insatisfait de leurs résultats chirurgicaux.
Conclusions :
La combinaison de la liposuccion suprapubienne et de la technique modifiée de Devine est une méthode sûre et efficace pour libérer le pénis enterré des adultes avec des résultats satisfaisants.
Introduction
The buried penis, with the penile shaft partially or entirely covered under the subcutaneously fat of suprapubic area or lower abdomen, is common in adults who have substantial weight gain or morbid obesity. With the accumulation of fat tissue and looseness of the abdominal skin, the lower abdominal skin and soft tissue expand or migrate over the penis and make the penis comparatively shorter or buried,1 thus it is called adult-acquired buried penis (AABP).
The prevalence of AABP is increasing as morbid obesity becomes more and more prevalent.2,3 It is thought to be caused by the contraction of dartos fascia and excess fat between the shaft of the penis and the skin1: With longstanding incontinence, chronic inflammation of local tissue deprives the dartos tissue of its elasticity, and the surrounding penile skin becomes a dense fibrous ring buried within the suprapubic fat pad.2
A buried penis leads to not only hygienic issues while voiding but also dissatisfaction of achieving sexual intercourse.4,5 A male’s self-esteem can also be affected by external genitalia images. Such feelings may invade his interaction with his sexual partners and other social associates.6
Numerous surgical techniques for releasing buried penis have been introduced. These procedures mainly aim to extract the penis from the suprapubic fat pad by tacking the surrounding tissue down to fixed structures or reducing the volume of the fat pad through weight loss,2 lipectomy,7 and liposuction.8 Meanwhile, Z-plasty,9 skin grafting,2 and different local flaps10 are used to cover the penile skin defect when necessary. However, there is not yet a standard method for releasing buried penis that is universally accepted.11 We combined suprapubic liposuction with a modified Devine’s technique to release the buried penis for suitable patients and also evaluated the patients’ surgical outcomes.
Subjects and Methods
Consecutive patients with a buried penis undergoing suprapubic liposuction and a modified Devine’s technique, during the period from September 2015 to June 2018, were included. Inclusion criteria were adult patients complaining of the indrawn penis or small-sized penis, patients with an acquired buried penis due to substantial weight gain or morbid obesity, and patients who have excess fat tissues in the suprapubic area or lower abdomen. Exclusion criteria were patients with a history of any penile or urethral surgery other than circumcision and patients with evidence of any psychological or mental disorder.
Preparation
During the preoperative examinations, all patients had a short penis with/without primroses, and the penile shaft was palpated and visualized when applying pressure on both sides of the shaft base. Skin to tip penile length (flaccid) in supine position was measured.
Before surgery, the lower abdominal and suprapubic area for liposuction was marked when the patient is in an upright position. Lines drew from the bilateral anterior superior spine to the pubic tubercle, and the upper bound of liposuction area was limited to the level of anterior superior spine. Spinal anaesthesia was used, and antibiotics were administered 30 minutes before the surgery.
Liposuction
Then the operation site was infused using a solution that consisted of 1000 mL of normal saline with 10 mL of lidocaine (0.2 g) and 1 mL of epinephrine (1 mg). Small incisions (<0.5 cm) were made 3 cm inside of the anterior superior spine bilaterally. Liposuction was performed using a standard blunt cannula (diameter = 3 mm) connected to a vacuum constriction device, and the blunt cannula moved in the subcutaneous level from deep to superficial layer in a sector shape. Liposuction must be performed carefully in suprapubic area, without touching the base of penile shaft and pubis in case of damaging the penile shaft and penile suspensory ligament. And special attention must be paid when it comes to the inguinal area; the blunt cannula must move parallel to the spermatic cord to avoid cord injury, and new incisions in inguinal area could be made if needed to protect the spermatic cord.
Modified Devine’s Technique
The wrapping stenosis of the prepuce was cut open, and dissection of adhesion between prepuce and glans penis was made until the coronary sulcus to expose the glans penis. A complete circular incision was made 0.5 to 0.8 cm below the coronary sulcus until the Buck’s fascia was reached. Along the avascular space outside the Buck’s fascia, incision of the subcutaneous tissue and the hypogenetic cords was made until the base of the penile shaft was degloved. The subpubic suspensory ligament of the penis was partially divided to extend to enough length. After the careful hemostasis, the dermal tissue under the suprapubic skin was anchor sutured to the Buck’s fascia at the base of penile shaft. Sutures were made at the 2- and 10-o′clock position with a 4-0 polypropylene to provide an anchorage. Then the degloved penile skin was partially cut off distally for a proper length. Finally, the skin was closed with an interrupted 5-0 absorbable suture.
Dressing
A urethral catheter was located for 1 day in case the dressings get wet by urine, and the penile shaft is covered with petrolatum gauze, normal gauze, and elastic bandage (as shown in Figure 1). Pressure was placed over the lower abdomen and suprapubic area with a girdle for 1 month (as shown in Figure 2).
Figure 1.
Wound dressing immediately post-operation.
Figure 2.
Pressure was placed with a girdle.
Post-Operative Complications
Post-operative complications such as edema, ecchymosis, hematoma, poor wound healing, wound infection, and so on, were observed and recorded during the perioperative period and were reported by patients through phone or clinic meeting after discharge until 3 months post-operation.
Evaluation of Surgical Outcomes and Patients’ Satisfaction
We measured the flaccid skin to tip penis length in supine position post-operatively both on the table and 3 months later. The degree of patients’ satisfaction was determined on a scale of 1 to 5 in a questionnaire: 1 = very dissatisfied; 2 = dissatisfied; 3 = neither satisfied nor dissatisfied; 4 = satisfied; and 5 = very satisfied.
Statistical Analysis
All statistical analyses were conducted using SPSS, version 21.0 for Windows (SPSS Inc, Chicago, Illinois). T-test was used to reveal the changes from pre- and post-operative data. A P value <.05 was considered as statistically significant.
Results
Consecutively, 26 adult male patients were included from September 2015 to June 2018, with the mean age of 33 ± 5.7 years (age group: 19-46 years), the mean body mass index (BMI) of 29 ± 5.4 kg/m2, and the mean length of penile shaft of 2.9 ± 1.3 cm (flaccid in supine position). Patients’ information is shown in Table 1.
Table 1.
Patients’ Information.
| Age (years) | Weight (kg) | Height (cm) | Body Mass Index (kg/m2) | Penile Length Preoperativelya (cm) | |
|---|---|---|---|---|---|
| Mean ± standard deviation | 33 ± 5.7 | 89.5±13.1 | 175 ± 19.3 | 29 ± 5.4 | 2.9 ± 1.3 |
a Skin to tip penile length (flaccid) in the supine position.
The pre- and post-operative appearances of 1 patient are shown in Figure 3. The area for liposuction was marked before the operation with the red line (from the anterior superior spine to the pubic tubercle). The penile length has significantly increased post-operatively.
Figure 3.
The front view (above, left) and lateral view (below, left) before the operation, the area for liposuction is marked with red line. The front view (above, right) and lateral view (below, right) 1 month after the operation; the penile length had obviously increased.
The mean length of the follow-up on the 26 patients is 18 ± 7.1 months (range: 3-33 months); the mean amount of fat removed by liposuction is 450 ± 90.2 mL (range: 353-560 mL); the mean length of penile shaft post-operation (on table) is 7.4 ± 2.1 cm, with an increase of 4.5 ± 1.6 cm (155% increase compared to the preoperation); the mean length of penile shaft post-operation (3 months) is 5.3 ± 1.8 cm, with an increase of 2.4 ± 0.7 cm (83% increase compared to the preoperation). The result of the follow-up is shown in Table 2. The increase of penile length was most obvious immediately post-operation and partly relapsed 3 months later. We believe it is because the post-operative swelling of the penis partly increased the penial length. However, the suprapubic region was not influenced so much by edema because of the girdle patients wore when we measured the penial length immediately post-operation.
Table 2.
The Details of Patients’ Procedure and Follow-Ups.
| Amount of Liposuction (mL) | Penile Lengtha Post-Operatively on Table (cm) | Penile Lengtha 3 Months Post-Operatively (cm) | Follow-Up Duration (months) | |
|---|---|---|---|---|
| Mean ± standard deviation | 450 ± 90.2 | 7.4 ± 2.1 | 5.3 ± 1.8 | 18 ± 7.1 |
a Skin to tip penile length (flaccid) in the supine position.
There was a significant increase of the penile length after the operation with a P value <.05 (Tables 3 and 4). The penile length measured post-operatively on the table was much longer than the preoperative length, mainly because of the edema of penis and the effect of anaesthesia and surgical procedure, which caused penis erection to some degree. With the improving edema, the penile length then fell back. However, the extent of increase in penile length exists persistently.
Table 3.
Descriptive Analysis of the Extent of Increase in Penile Length Preoperation, Post-Operation on the Table, and 3 Months Post-Operation.
| Mean ± Standard Deviation | |
|---|---|
| Increase in length on table (cm) | 4.5 ± 1.6 |
| Percent increase in length on table (%) | 155% |
| Increase in length at 3 months (cm) | 5.3 ± 1.8 |
| Percent increase in length at 3 months (%) | 83% |
Table 4.
Comparison Between Penile Length Preoperation, Post-Operation on the Table, and 3 Months Post-Operation.
| P Value | |
|---|---|
| Preoperative length | |
| Post-operatively on table | <.01 |
| 3 months post-operatively. | .014 |
| Post-operatively on table | |
| 3 months post-operatively | .027 |
Post-operative complications include edema (19 patients, 73%), ecchymosis (7 patients, 27%, as shown in Figure 4), hematoma (1 patient, 3.8%), wound infection (0 patient), and poor wound healing of prepuce (2 patients, 7.7%). Patients with poor wound healing were found to have short prepuce after degloving, and thus, the tension of suture is relatively larger. Both the 2 patients’ wound healed finally after changing dressings for 2 weeks without further medical intervention. Moreover, 5 patients (19%) experienced no complications post-operation. None of the patients had difficulty in sexual intercourse or urination post-operatively. None of the patients was on hormonal therapy before and after the operation.
Figure 4.
Post-operative complication: subcutaneous ecchymosis.
Most patients had a positive feedback toward their result of the operation, with the mean grade of 4.5 ± 0.7.17 patients (65%) who were very satisfied with the outcome. Six patients (23%) were satisfied with the outcome. Three patients (12%) were neither satisfied nor dissatisfied with the outcome. No patients were dissatisfied nor very dissatisfied with the outcome (Table 5).
Table 5.
Descriptive Analysis of Post-Operative Patient Satisfaction.
| Satisfaction | Grade | Count | % | Mean ± Standard Deviation |
|---|---|---|---|---|
| Very satisfied | 5 | 17 | 65 | 4.5 ± 0.7 |
| Satisfied | 4 | 6 | 23 | |
| Neither satisfied nor dissatisfied | 3 | 3 | 12 | |
| Dissatisfied | 2 | 0 | 0 | |
| Very dissatisfied | 1 | 0 | 0 |
Discussion
Illouz’s research showed that specific sites of the body were target zones for the abnormal accumulation of “privileged” fat and the suprapubic region in males was included.12 Among adults, with weight gain and loosen of the lower abdominal skin, the skin and fat underneath would migrate and cover the shaft of the penis and make it look like being buried.
As the overall prevalence of overweight/obesity is increasing in China in recent years,13 AABP is more and more common.14 Most of the patients coming to the clinic complained of urinary dribbling due to the drawing back of the glans penis, while a small number of the patients complained of their small penis.4,5 As a consequence of the sexual shyness in Asian culture, Chinese patients with AABP rarely came to the clinic in the past. Nevertheless, with the popularization of online health-care consultation, more and more patients come to our hospital for surgery after making online appointments.
Historically, urological surgeons and plastic surgeons have developed numerous methods for the treatment of buried penis. These procedures focus mainly on the 2 goals: reduce the suprapubic fat pad and extract the penile shaft.
Lipectomy may be the most direct way to reduce the volume of the fat pad. As a traditional method, open surgical excision of fat tissue of the lower abdomen and the suprapubic area has been proved effective years ago and widely used.2,7 However, this method usually causes serious damage to the surgical area and leaves obvious scars on the skin. As an alternative, suprapubic liposuction is more welcomed by patients nowadays because of the smaller invasion and the faster recovery. It has been proved a safe and successful procedure; according to a retrospective study, the mean increase of penile length at 3 months post-operation is 1.1 ± 0.38 cm (P < .001).8 However, patients undergoing liposuction usually complain of skin stiffness of the operated area in varying degrees, which is nearly inevitable. In our experience, thorough preoperative education, meticulous procedure, and proper pressure dressing after the operation can considerably improve this situation.
For extracting the penile shaft from the suprapubic fat pad, Devine’s technique is a classic operation to resect the inelasticity sarcolemma and lengthen the penis by dissecting the suspensory ligament under the pubic. The penis can be increased about 2 to 4 cm after surgery.14 However, this technique always leaves skin defect at the pubic area. Thus, different preputial flaps and scrotal flaps are used.10,15-18 Split-thickness skin grafting is also a common choice for the reconstruction of penile skin defect.2,19 Our modified Devine’s technique makes the incision along the avascular space outside the Buck’s fascia with a clear operation field and removes the hypogenetic dartos tissue completely, which allows flexible movement of the penile shaft. Cutting off the stretching cords subcutaneously of the distal penis can also correct phallocampsis at the same time.
Releasing the suspensory ligament is the most widely accepted surgical technique for penile elongation.20 The suspensory ligament can be accessed through a V-Y incision or a subcoronary circumcision technique.21 However, the outcomes of this technique have not been always satisfying. The mean increase in flaccid stretched penile length was 1.3 ± 0.9 cm according to a retrospective study.20 However, many patients in early studies had a recurrence following surgery, which resulted in penile shortening.22
For AABP patients with adiposities in the suprapubic area and lower abdomen, solitary liposuction may not reach the expected effect of releasing the buried penis completely because the traction of dartos fascia still exists. Nevertheless, the solitary Devine’s technique also has difficulty to achieve a better outcome, as the suprapubic fat may prevent the penile shaft from full exposure. Thus, we combined the 2 methods for the treatment of AABP that is caused by obesity in China. In our experience, for patients with severe obesity (BMI ≥ 30 kg/m2), the fat tissue in suprapubic area and lower abdomen may be too much for liposuction if the patient requires the penile lengthening. In this situation, the suprapubic lipectomy may be a better choice.
Conclusions
The combination of suprapubic liposuction and modified Devine’s technique is safe and effective for penile lengthening. It is especially suitable for patients with fat accumulation in suprapubic area due to weight gain and obesity, and the phimosis can be treated at the same time. This method has better surgical outcomes in penile lengthening than using liposuction or traditional Devine’s technique alone. We recommend this operation for AABP patients who have suprapubic adiposities and phimosis.
Footnotes
Authors’ Note: This study was performed in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Peking University People’s Hospital (Beijing, China). All patients had provided a written informed consent before the operation.
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by the Specialized Research Fund for the Doctoral Program of Higher Education, China [grant number 20120001120056], Beijing Municipal Natural Science Foundation, China [grant number 7194327] and National Natural Science Foundation of China [grant number 81472393].
ORCID iD: Peiyang Zhang 
https://orcid.org/0000-0001-6698-5402
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