Geoffrey 2 C. Gurtner, Peter C. Neligan, Daniel Z. Liu – Plastic Surgery Principles. 2-Elsevier (2018)

739
Non-invasive modalities
harvest during autologous transfer. Based on innovations in
cataract surgery,38 this new category of lipoplasty uses tar-
geted liquefaction of adipose tissue called tissue liquefaction
liposuction (TLL). TLL uses a stream of warm (37–55°C),
minimally pressurized (300–1100 psi), pulsed saline that is
emitted inside of the distal end of the liposuction cannula and
remains inside the cannula until it is aspirated. Subcutaneous
fat and non-fat tissue are drawn into the cannula through the
side aperture(s) and are impacted by the saline stream within
the interior lumen of the cannula (Figs. 29.14 & 29.15). This
stream causes a phase transition of fat from a solid to a liquid,
while non-fat tissue is unaffected and remains intact. The
mechanical and thermal energies within the saline stream are
low-level energies that work in synergy to achieve the
minimum threshold of energy required to selectively liquefy
fat tissue while remaining below the threshold of energy to
liquefy non-fat tissues such as blood vessels, nerves, and con-
nective tissue.39 The saline delivered with TLL remains entirely
within the cannula and, therefore, no soft-tissue distortion
and minimal disruption of the surrounding connective tissue
network occurs.
Early clinical results with TLL have been favorable. Patients
experience less bruising, swelling, and pain postoperatively
in comparison to suction-assisted lipoplasty (SAL) and UAL.
This is likely due to the tissue selectivity of TLL and the
non-selective nature of SAL and UAL. The flow characteristics
of the pulsed, heated saline allows the liquefied fat to move
temporary pore in the adipocyte cell membrane through
which lipids are released into the interstitial space and slowly
removed by the lymphatic system.33
The Zerona laser has five rotating independent diode laser
heads, each of which emits 17 mW of 635-nm laser light. This
laser was the first non-invasive aesthetic device to receive
Food and Drug Administration (FDA) market clearance in the
US for circumferential reduction of the waist, hips, and thighs
following completion of a placebo-controlled, randomized,
double-blind, multisite clinical investigation evaluating 67
participants.36 An average reduction of 3.51 inches across
patients’ waist, hips, and thighs in as little as 2 weeks was
seen in this study.36,37
Pre-procedure preparation
Patient assessment is performed in the standing position such
that fat is dependent.
Between treatments, patients are instructed to walk 30 min
per day and drink 1 L of water per day. Patients are also
instructed to take a supplement called Curva that contains
niacin among other homeopathic substances designed to
increase lymphatic flow. Smoking and alcohol cessation are
encouraged.
Technique
The Zerona unit has a number of diodes, which are placed
within 6 inches of the patient’s body. Treatments typically last
20 min in the waist, hips, and thighs in both the supine and
prone position. The center diode is positioned 4–12 inches
above the abdomen and centered in the midline. The four
remaining diodes are positioned over the lateral abdomen
and thigh. Following treatment in the supine position, the
diodes are repositioned in a similar fashion in the prone posi-
tion.36 Treatments are conducted 48 h apart in order to opti-
mize the transitory pore.
Depending on the habitus of the patient, the current Zerona
protocol calls for 6–12 treatments. On average, patients receive
one treatment every 48 h over a period of 2 weeks for a total
of nine treatments. It is possible to combine Zerona with other
more focal, ablative, fat reduction technologies to enhance the
overall volume reduction and contouring effect.
Complications
Complications with LLLT can include thermal skin injury, but
these instances are rare. Patient dissatisfaction due to unreal-
istic expectations is not uncommon.35
Conclusion
LLLT is a unique technology in non-invasive body contour-
ing. Volume reduction is achieved without triggering apopto-
sis. This represents a truly non-invasive modality leading to
patient satisfaction in appropriate candidates. Future goals
will aim to optimize the efficiency of this non-invasive therapy
and expand patient candidacy.
Tissue liquefaction lipoplasty
Tissue liquefaction technology for purposes of body contour-
ing and lipoplasty was approved by the FDA in 2010 (Fig.
29.13). This technology was later approved by the FDA for fat
Fig. 29.13  Base unit of HydraSolve machine. (Courtesy of Hydrasolve, Tustin, CA;
with permission. Reproduced from Afrooz PN, Pozner JN, DiBernardo BE. Clinics in
Plastic Surgery, 2014-10-01, Volume 41, Issue 4, Pages 789–804, Copyright
© 2014 Elsevier Inc.)

740
SECTION II
CHAPTER 29 • Energy-based devices in body contouring
an electromagnetic field over a large area that specifically
targets the deep tissue layer where the energy is optimally
absorbed. Vanquish utilizes a proprietary frequency that is
delivered wirelessly and falls under the “industrial, scientific,
and medical” (ISM) band that is reserved internationally for
the use of radiofrequency energy for purposes in these areas.
This technology was designed to emit energy based on dif-
ferential electromagnetic impedances of tissues within the
body. Tissue with higher impedance has higher resistance to
the flow of the electromagnetic field, thereby increasing the
temperature in that tissue relative to the surrounding tissue
with lower impedance.39
The frequencies utilized by Vanquish are best suited for the
impedance of adipocytes in the deep tissue layer. The device
selectively heats adipose tissue, so the depth of penetration
varies based on the thickness of adipose tissue as well as the
distance between the applicator and the body. The closer the
applicator is to the body, the more superficial the penetration.
Conversely, the further the applicator is from the body, the
deeper the penetration. To achieve heat efficacy in the fat
layer, the applicator should be placed such that the applicator
is not touching the skin but is spaced approximately 10 mm
away from the skin surface.39
This device was initially tested in animals followed by
human clinical trials.43 Forty-one subjects aged 18–68 years
received four 30-min abdominal and flank treatments at
weekly intervals. Thirty-five patients completed the study.
There were no adverse events reported, and 89% of patients
reported that the treatment was comfortable or very comfort-
able. A decrease in abdominal circumference was achieved in
32 of 35 patients (91.4%). This decrease in circumference
ranged from 1–13 cm with an average of 4.93 cm. Seventy-one
percent of patients reported to be satisfied or very satisfied
with the results.44 Ongoing studies are examining longer treat-
ments and shorter treatment intervals.
Summary
The strong patient demand for safer, less invasive body con-
touring procedures will inevitably drive technology toward
more effective modalities that minimize downtime and recov-
ery, while improving results. The future of body contouring
will likely stratify patients into more distinct categories such
as those requiring aggressive surgical excision, minimally
invasive liposuction techniques with adjunctive energy-
delivering modalities or mesotherapy, and non-invasive
techniques achieving volume reduction and skin tightening
through additional energy-delivering modalities.
With proven safety and efficacy, the future of minimally
invasive and non-invasive body contouring is very promis-
ing. However, judicious patient selection cannot be overem-
phasized, and these procedures should not be over-promoted.
Currently, the most ideal candidates for these types of proce-
dures are those who are accepting of a mild to moderate
result.
By incorporating these technologies into a plastic surgery
practice, the ability to offer a multifaceted approach to body
contouring will ultimately lead to greater patient and physi-
cian satisfaction and is undoubtedly an emerging model
of minimally invasive and non-invasive body contouring
surgery.
through the aspiration tubing without clogging or vapor
locks. In comparison to the traditional stroke rate, TLL extracts
fat most efficiently when the cannula motion is slowed to
approximately one-half to one-third of the traditional rate.
This facilitates a more efficient process with greater precision
and less surgeon fatigue. Tumescent fluid is still recommended
for TLL prior to treatment.39
TLL has been effective in harvesting fat for autologous fat
grafting. In a nude rat model, human fat extracted by TLL was
comparable to traditional, syringe-aspirated fat.40 Further-
more, microscopic studies of fat harvested by TLL demonstrate
97% viability.41 The lipoaspirate contains small clusters of
adipose tissue containing approximately 100–400 adipocytes
per functional unit.42 Clinical applications in fat grafting have
been successful. Fat harvested by TLL may have some poten-
tial advantages including less blood and oil contamination, as
well as less fibrous tissue within the lipoaspirate compared to
traditional methods of fat harvest. Fewer contaminants may
lead to reduced inflammation and promote improved fat graft
survival.
Radiofrequency
Radiofrequency devices have recently been marketed for fat
reduction and body contouring although there is no direct
FDA approval for fat reduction. Radiofrequency (RF) use in
body contouring is based on data that demonstrated a 60%
loss of adipocyte viability following heating of adipose tissue
to 45°C with radiofrequency energy. Limitations of RF devices
include the lack of uniformity and consistency in tissue
heating, and pain and discomfort with skin heating.
Vanquish (BTL Aesthetics, Boston, MA) is a new device that
offers selective RF utilizing multipolar technology that emits
Fig. 29.14  Cannula for HydraSolve machine. (Courtesy of HydraSolve, Tustin, CA;
with permission. Reproduced from Afrooz PN, Pozner JN, DiBernardo BE. Clinics
in Plastic Surgery, 2014-10-01, Volume 41, Issue 4, Pages 789–804, Copyright
© 2014 Elsevier Inc.)
Fig. 29.15  Schematic diagram of subcutaneous fat and non-fat tissues drawn into
the cannula through the side apertures, which are then impacted by the saline
stream within the interior lumen of the cannula. This stream causes a targeted
phase transition of fat from a solid to a liquid, while non-fat tissue remains intact.
(Courtesy of HydraSolve, Tustin, CA; with permission. Reproduced from Afrooz PN,
Pozner JN, DiBernardo BE. Clinics in Plastic Surgery, 2014-10-01, Volume 41,
Issue 4, Pages 789–804, Copyright © 2014 Elsevier Inc.)

741
Summary
5. Scuderi N, Devita R, D’Andrea F, et al. Nuove prospettive nella
liposuzione la lipoemulsificazone. Giorn Chir Plast Ricostr ed Estetica.
1987;2:33–39.
6. Zocchi ML. Clinical aspects of ultrasonic liposculpture. Perspect
Plast Surg. 1993;7:153–174.
13. DiBernardo BE. Principles of new invasive modalities. In: Rubin JP,
Jewell ML, Richter DF, et al., eds. Body Contouring and Liposuction.
Philadelphia, PA: Elsevier Saunders; 2013:534–542.
14. DiBernardo BE. Recognition and management of complications
of fat and cellulite treatments. In: Katz BK, Sadick NS, eds.
Body Contouring. Philadelphia, PA: Elsevier Saunders; 2010:
183–192.
16. Garcia O Jr. Ultrasonic liposuction. In: Rubin JP, Jewell ML, Richter
DF, et al., eds. Body Contouring and Liposuction. Philadelphia, PA:
Elsevier Saunders; 2013:543–558.
17. Zocchi ML. Metodo di trattamento del tessuto adipose con energia
ultrasonic. Congresso del Societa Italiana di Medicina Estetica.
Rome, Italy, 1988.
18. Zocchi ML. New prospective in liposculpturing: the ultrasonic
energy. Proceedings of the 10th ISAPS Congress. Zurich,
Switzerland, 1989.
19. Update from the Ultrasonic Liposuction Task Force of the American
Society for Dermatological Surgery. Dermatol Surg. 1997;23:210–214.
30. Rosales-Berber I, Diliz-Perez ES, Allison J. Accumulative abdomen
fat layer reduction from multiple Zeltiq cryolipolysis procedures.
American Society for Laser Medicine and Surgery 2010 Annual
Meeting. Phoenix, AZ, 2010.
32. Jewell ML, Jewell JL. High intensity focused ultrasound and
non-invasive body contouring. In: Rubin JP, Jewell ML, Richter DF,
et al., eds. Body Contouring and Liposuction. Philadelphia, PA:
Elsevier Saunders; 2013:559–571.
39. Borab ZM, Godek CP. Tissue liquefaction liposuction for body
contouring and autologous fat transfer: a retrospective review over
3 years. Eplasty. 2016;16:e36.
41. Data on file. Adipose tissue cell viability of four fat harvesting
modalities. Andrew Technologies LLC, April 2011.
42. Data on file. Comparison of lipoaspirate clump size between
HydraSolve and syringe fat Harvesting methods. Andrew
Technologies, September 2011.
Sadick NS, Shapiro M. Mesotherapy for body contouring and cellulite.
In: Rubin JP, Jewell ML, Richter DF, et al., eds. Body Contouring and
Liposuction. Philadelphia, PA: Elsevier Saunders; 2013:572–579.
Access the complete reference list online at

741.e1
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15. DiBernardo BE. Treatment of cellulite using a 1440-nm pulsed laser
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17. Zocchi ML. Metodo di trattamento del tessuto adipose con energia
ultrasonic. Congresso del Societa Italiana di Medicina Estetica. Rome,
Italy, 1988.
18. Zocchi ML. New prospective in liposculpturing: the ultrasonic energy.
Proceedings of the 10th ISAPS Congress. Zurich, Switzerland, 1989.
19. Update from the Ultrasonic Liposuction Task Force of the American
Society for Dermatological Surgery. Dermatol Surg. 1997;23:210–214.
20. Graf R, Auersvald A, Damasio RC, et al. Ultrasound-assisted
liposuction: an analysis of 348 cases. Aesthetic Plast Surg.
2003;27:146–153.
21. Lawrence N, Coleman WP III. The biologic basis of ultrasonic
liposuction. Dermatol Surg. 1997;23:1197–1200.
22. de Souza Pinto EB, Abdala PC, Maciel CM, et al. Liposuction and
VASER. Clin Plast Surg. 2006;33:107–115, vii.
23. Cimino WW, Bond LJ. Physics of ultrasonic surgery using tissue
fragmentation: part I. Ultrasound Med Biol. 1996;22:89–100.
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Phoenix, AZ, 2010.
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technologies with an emphasis on high-intensity focused
ultrasound. Aesthetic Plast Surg. 2011;35:901–912.
32. Jewell ML, Jewell JL. High intensity focused ultrasound and
non-invasive body contouring. In: Rubin JP, Jewell ML, Richter DF,
et al., eds. Body Contouring and Liposuction. Philadelphia, PA:
Elsevier Saunders; 2013:559–571.
33. Neira R, Arroyave J, Ramirez H, et al. Fat liquefaction: effect of
low-level laser energy on adipose tissue. Plast Reconstr Surg.
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non-invasive approach for body contouring: a randomized,
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37. Avci P, Nyame TT, Gupta GK, et al. Low-level laser therapy for fat
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extraction. Curr Opin Ophthalmol. 2004;15:40–43.
39. Borab ZM, Godek CP. Tissue liquefaction liposuction for body
contouring and autologous fat transfer: a retrospective review over
3 years. Eplasty. 2016;16:e36.
40. Davis K, Rasko Y, Oni G, et al. Comparison of adipocyte viability
and fat graft survival in an animal model using a new tissue
liquefaction liposuction device vs. standard Coleman method for
harvesting. Aesthet Surg J. 2013;33:1175–1185.
41. Data on file. Adipose tissue cell viability of four fat harvesting modalities.
Andrew Technologies LLC, April 2011.
42. Data on file. Comparison of lipoaspirate clump size between HydraSolve
and syringe fat harvesting methods. Andrew Technologies, September
2011.
43. Weiss R, Weiss M, Beasley K, et al. Operator independent focused
high frequency ISM band for fat reduction: porcine model. Lasers
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2014;13:291–296.

SECTION II • General Aesthetic Surgery
30 
Aesthetic genital surgery
Gary J. Alter
SYNOPSIS
■ Male and female aesthetic genital surgery can greatly
enhance confidence if a real or perceived deformity
exists.
■ Many new genital surgeries have been developed.
■ In the male, penile enlargement surgery can result in severe
deformities, which can often be reconstructed.
■ Hidden penis, penoscrotal web, and scrotum reduction surgeries are
very successful with a low complication rate.
■ Labia minora and clitoral hood reduction performed by the “extended
central wedge” excision gives a natural appearance with very high
patient satisfaction.
■ Mons pubic lifting and labia majora reduction, with or without fat
excision, increase self-esteem.
■ As with all aesthetic surgeries, genital surgery requires the same
meticulous attention to detail.
Introduction
Identity and self-esteem are intimately related to a person’s
image of his or her genitalia. Self-esteem can be impaired if a
person feels inadequate compared with a perceived ideal. A
normal man may consider his penis to be too small or a
woman may judge her genital appearance as unsightly. These
feelings develop from self-comparisons with pornographic
photos or videos, media attention, or comments from a sexual
partner or friend.
Patient awareness has led to significant demand for aes-
thetic genital surgery. Recently, new techniques to enhance the
appearance of male and female genitalia have been developed,
based partially on improved reconstructive pediatric and
adult surgical procedures. Considerable aesthetic improve-
ment in the genital appearance is now possible. The surgery
is challenging and requires strict attention to detail and
meticulous technique.
Male genital aesthetic surgery
Introduction
Several procedures are now available to enhance or improve
the aesthetic appearance of the penis or scrotum. Penile
lengthening is performed by releasing the suspensory liga-
ment of the penis followed by the use of penile weights or
stretching devices. Penile girth is increased by either injecting
fat or by inserting dermal fat grafts or allografts such as acel-
lular dermal matrix into the dartos fascia. Penoscrotal webbing
may be corrected with one or several Z-plasties, usually
combined with excision of the web skin. An enlarged, low-
hanging scrotum can be reduced and lifted. The hidden or
buried penis is corrected with a suprapubic lipectomy, pos-
sible upper pubic skin resection, and stabilization of pubic
and penoscrotal skin.
Men are very resistant to psychiatric evaluation prior to
penile enlargement surgery. Many of the men presenting for
penile enlargement have significant generalized self-esteem
issues, so refusal to perform the surgery may be justified. The
psychological motivations of a man with a hidden penis,
penoscrotal webbing, scrotal enlargement, or true congenital
deformities are different from those of a man with a normal-
sized penis who desires only enlargement, so his care is
usually more rewarding for both the patient and the surgeon.
Measurements
Schonfeld and Beebe1 determined that the length of the fully
stretched flaccid penis correlated closely with the erect penis.
The dorsal length from the junction of the penopubic skin to
the tip of the glans in the fully stretched flaccid penis corre-
lated closely to the erect penis. Erect girth or circumference
correlated with girth measurements of the flaccid penis
according to a more complicated ratio.
Da Ros and Teloken et al.2 performed artificial erections on
150 Caucasian men, measuring penis length from the center
  Access video lecture content for this chapter online at expertconsult.com

743
Male genital aesthetic surgery
Once the diagnosis is made, the possible procedures are
discussed with the patient, as well as risks and benefits.
Penoscrotal webbing and extensive suprapubic fat and pubic
descent may not be presenting complaints, but the physician
must describe these abnormalities and possible corrective
surgery. Each individual is evaluated to determine the best
method to achieve his goals, since several procedures are
available depending on the patient’s anatomy. He must have
a realistic understanding of the design and limitations of the
surgery in order to prevent misconceptions and dissatisfac-
tion. Exaggerated promises lead to patient disappointment,
depression, and hostility; therefore, honesty, clear communi-
cation, and compassion are mandatory for both patient and
physician. Because not all malpractice carriers will cover
physicians for penile enlargement procedures, verification of
coverage is recommended.
Anatomy
The suspensory ligament of the penis is a thick, triangular
band extending from the linea alba and the upper portion of
the symphysis pubis and arcuate ligament to the dorsal
midline of the penis.4 It derives from the outer investing fascia
of the abdomen and divides into a sling at the junction of the
fixed and mobile portions of the penis. In addition, thickened
bands of Scarpa’s fascia, called the fundiform ligaments,
firmly attach to the rectus fascia above the pubic symphysis
and extend onto the dorsal and lateral penis, possibly restrict-
ing penile excursion.5
The skin of the penis is thin, and hairless (more distal) and
has loose connections with the deeper structures of the penis.
No adipose tissue is present under the skin. The superficial or
subcutaneous fascia of the penis (dartos fascia) is continuous
with the Scarpa’s and Camper’s fascias of the lower abdomen
and extends to the corona of the penis. The dartos fascia
contains scattered smooth muscle cells. Branches of the super-
ficial external pudendal vessels provide the blood supply to
the dartos fascia and skin. The internal pudendal system,
which includes the deep dorsal arteries and veins and the
cavernosal and urethral vessels, usually communicates with
the external pudendal system only at the glans and corona.6
Because the dartos fascia is highly vascular, it provides an
excellent tissue bed for grafts. Buck’s fascia invests the shaft
of the penis deep to the dartos fascia. The dorsal nerves of the
penis supply erogenous sensation to the glans penis. The deep
dorsal vessels and the dorsal nerve travel in the pudendal
canal along the ischial ramus and then pass ventrally along
the margin of the inferior ramus of the pubis in the deep peri-
neal pouch. The neurovascular bundles pierce the perineal
membrane 12 inch from the symphysis pubis and continue
within Buck’s fascia of the penis. Each of the two deep dorsal
arteries lies between the deep dorsal vein in the midline and
the dorsal nerves of the penis laterally.
Penile enlargement
Penile lengthening
Penile lengthening is achieved by releasing the suspensory
ligament of the penis and the postoperative use of penile
weights or stretching devices (Fig. 30.1A).7–10 The ligament is
released only one fingerbreadth by cutting directly on the
of the pubic bone to the tip of the glans and penis circumfer-
ence at the corona and base. Average penis length was 5.7
inches; 18 were shorter than 4.7 inches and 18 longer than 6.3
inches. Circumference at the base of the penis ranged from 3.5
to 5.9 inches (average 4.7) and at the coronal groove from 3.2
to 5.5 inches (average 4.4).
Wessells et al.3 compared the relationship between penile
length in the flaccid stretched and in erect states and also
concluded that there was a positive relationship. The average
flaccid stretched penile length was 11 cm, while the average
erect penile length was 12.5 cm. The correlation between
stretched length and erect length was r2 = 0.769. Average
flaccid circumference was 10 cm with an average erect cir-
cumference of 12.5 cm, and, therefore, correlation was not
favorable for circumference. They also state that a thick pubic
fat pad decreases visible flaccid penile length but not func-
tional penile length during intercourse.
Patient selection/examination
The patient is evaluated both standing and supine to deter-
mine variations that change with gravity. While standing, the
penis is checked for concealment owing to descent of the pubic
fat pad and escutcheon from gravity, since supine positioning
often eliminates this abnormality. A protuberant abdomen
with excess skin and fat may overhang the penis and function-
ally interfere with sexual intercourse, so the patient may need
an abdominoplasty or panniculectomy in addition to a supra-
pubic lipectomy and skin excision. The amount of suprapubic
fat between the pubic symphysis and the skin should be evalu-
ated to determine potential length improvement from supra-
pubic lipectomy or liposuction. Penis position must be checked
to see if it is partially encircled by the scrotum. The underside
of the penis should be examined for penoscrotal webbing that
causes an aesthetically or functionally shorter penis. Supine
measurements are taken from the pubic bone and from the
skin over the pubis to the tip of the glans on full stretch while
the penis is at 90° to the abdomen. Circumference is measured
at the base and corona with the penis on full stretch. The penis
should be palpated for Peyronie’s plaques, which are firm
scars on the tunica albuginea.
It is important to question and evaluate function prior to
penile surgery. Urinary and orgasmic function should be
normal and are not affected by these procedures.
The patient is asked if he has any erectile difficulties or
penile curvature. Most men have some minor curvatures, but
these are not bothersome and are not an issue. However, if
girth surgery is considered, any known or suspected curvature
should be documented. The patient is asked to present pho-
tographs showing his erect penis from various angles. If the
patient is unwilling to present photographs, an erection
can be obtained, and then photographed, by patient self-
stimulation or by intracavernosal injection of prostaglandin
E1. This pharmacologic agent is injected with a 30-gauge
needle transversely into the cavernosal bodies at the base of
the penis. The injected dosage usually is 10 µg in the normal
male. The patient should be cautioned about the possibility of
priapism and the necessity for mandatory reversal of the
erection if it persists longer than 4 h. The erection can be
immediately reversed with a low-dose intracavernosal injec-
tion of phenylephrine, which is routinely performed to reverse
a pharmacologic erection at the end of surgery.

744
SECTION II
CHAPTER 30 • Aesthetic genital surgery
Suspensory ligament release alone may rarely increase
flaccid penile length 1–2 cm, but often no gain is achieved.
Real flaccid and erect length gain may be obtained by using
penile weights or penile stretching devices. Patients can use
these devices without undergoing ligament release, but the
ligament release frees more of the penis to be expanded,
thereby possibly increasing the amount of eventual length
gain. A patient should not undergo release of the suspensory
ligament unless he is willing to use the stretching devices.
Approximately 1 week after surgery, the patient suspends the
weights or devices from the end of the penis several times
daily over a period of months to years, stretching the corporal
bodies. The amount of weight required as well as the duration
and frequency of use are still evolving. Other devices are
available to produce constant penile stretching and traction.
The amount of length gain achieved is controversial, and
most patients probably do not achieve any significant increase
even with stretching devices. Actual length gains of several
inches are rare, but may occur if a suprapubic lipectomy
is also performed on thick subcutaneous tissue. However,
anecdotal flaccid as well as erect increases of several inches
have been reported by some compulsive weight-users. In fact,
a 12- to 1-inch gain is considered very successful, albeit very
uncommon.
An occasional patient may complain of penile shortening
after release of the suspensory ligament. Since there is a dead
space between the pubic symphysis and the corpora, it is
possible for the corpora to reattach in a shortened position.
This dead space can be filled by a proximal or distal based fat
flap transposed from the medial spermatic cord (Fig. 30.4).
However, most doctors tell the patients to stretch the penis
after the release without filling the space.
Penile instability is very rare after suspensory ligament release
and usually results from an overly aggressive release of the
periosteum throughout the length of the midline pubic sym-
physis. The release is usually performed through a 3–4 cm
lower transverse incision just above the penopubic junction,
but many surgeons advance infrapubic skin onto the penis
using a VY advancement flap (Fig. 30.1B,C).11,12 This VY flap
theoretically increases penile length or gives the penis the
appearance of increased flaccid length, which may occur if the
patient has a shortage of penile skin. Penile length gain is
disputed in most cases, and the VY flap can actually cause the
penis to appear either longer or shorter in the flaccid state. The
VY flap is based distally at the penopubic junction varying
from a small (2–3 cm) to a large base. The larger flap encom-
passes the entire dorsal base of the penis and part of the
scrotum, which causes interruption of a significant portion of
the proximal penile dartos fascia and skin. The blood supply
and lymphatic drainage of the penis is thus partially inter-
rupted, which can cause healing complications such as flap tip
loss, poor wound healing with wound dehiscence, and post-
operative swelling. Healing problems predispose to hypertro-
phic or wide scars, which create hairless pubic scars and
depressions (Figs. 30.2A & 30.3A). The large VY flap also
advances thick, hair-bearing tissue onto the penis, which fre-
quently creates an unnatural hump at the penile base and the
appearance of a low-hanging penis.13–16 The penis can appear
surrounded by the scrotum (scrotalization) with an overhang-
ing large pubic fat pad, which makes the penis look shorter and
hidden. A VY flap can also create “dog-ears” at the distal scrotal
flap incision. Smaller VY advancement flaps cause less frequent
problems, but wound and aesthetic complications also occur.
Outcomes
It is difficult to interpret the results of penile lengthening,
because no standardized measurement technique exists, and
no mainstream studies have been published.
Fig. 30.1  Method commonly used for penile lengthening that often causes penile deformities. (A) The suspensory ligament is released. (B) A large VY advancement flap
is designed. (C) The flap is advanced, resulting in hair on the proximal penile shaft, bilateral dog-ears, and a lower-hanging penis.
A
6XVSHQVRU\OLJDPHQW
GLYLGHG
B
C

745
Male genital aesthetic surgery
corporal bodies from the ischiopubic rami. If the release is limited
to one fingerbreadth on the midline of the pubic symphysis, this
will not occur. Dorsal nerve or vessel injuries are prevented by
staying directly on the pubic periosteum of the midline of the
symphysis with the penis on full stretch and by not releasing the
corpora laterally. A mild decrease in the elevation of the erection
can occur with release but is not problematic.
Fig. 30.2  Complete reversal of VY
advancement flap. (A) The scar is marked
for excision. The marking at the base of the
VY flap on the left is the estimated location
for the reapproximation of the flap to the
pubic hairline. (B) Complete reversal of the
VY flap resulting in a semicircular incision
line. Hair on the VY flap is aligned with the
pubic hair.
A
B
Fig. 30.3  Patient who had release of the suspensory ligament, a large VY advancement flap, and fat injections. (A) The deformity shows a low-lying penis, hair on the
proximal shaft, bilateral dog-ears at the penoscrotal junction, a short-appearing penis, wide pubic scars, and fat in the shaft. (B) Reconstruction after partial reversal of the
VY advancement flap, correction of the VY dog-ears, scar revisions, and selective removal of fat. Complete reversal of the VY flap was not possible due to previous partial
loss of a portion of the VY flap.
A
B
Girth increase treatment
Techniques to increase penile girth are in a constant state of
evolvement and are associated with the largest incidence of
complications. The difficulty of achieving girth enhancement
is the necessity to create a symmetrical, relatively cylindri-
cal phallus. Any graft that may resorb can cause visual or

746
SECTION II
CHAPTER 30 • Aesthetic genital surgery
Fat injections
Autologous fat injections into the dartos fascia are still used
by some physicians to increase penile thickness. The fat is
moveable and gives a somewhat spongy texture to the penis.
Less than 50% of injected fat normally survives in other parts
of the body. Ideally, small amounts of fat (10–20 cc) are injected
in multiple tunnels. Small amounts of total injected fat produce
only minimal girth gain but do not have much risk of compli-
cations. Complications include asymmetry of the sides of
the penis, nodules with bulging and concavities, and loss of
penile rigidity due to an overabundance of fat (Figs. 30.3
and 30.5A).
Dermal and dermal fat grafts
Girth enlargement is also performed by inserting either
dermal or dermal fat strips into the dartos fascia or by wrap-
ping dermal fat sheets circumferentially between the dartos
and Buck’s fascias.7–10 The strips can be placed through either
a partial circumcision incision or a transverse pubic incision.
The sheet graft, which is not commonly performed, is usually
placed through a hemi-circumcision incision and wrapped
about 80% of the circumference of the penis with the urethra
left uncovered. The grafts are sutured proximally and distally
to prevent migration. Usually, the dermal fat grafts “take”
well and provide circumference girth increase from 2–4 cm.
However, difficulties with penile immobilization and the
thickness of the grafts increase the risk of poor “take” and
subsequent severe complications such as restriction of erec-
tion with penile shortening or penile curvature. The procedure
is far more invasive than fat injections and requires several
hours of surgery. Donor site scars from the buttock crease,
suprapubic region, or flanks can be very unsightly. Nodules
and fat reabsorption are less common with dermal fat grafts
than fat injections. Significant penile edema and induration
exist for 6 weeks post-operation, and relatively normal texture
returns in 4–6 months. Wrapping a sheet of dermal fat grafts,
rather than inserting strips, provides smooth texture with less
risk of ridges and displacement. Penile skin loss has been seen
with dermal fat grafts.
Fig. 30.4  Bilateral fat flaps from the medial spermatic cords are transposed to the
midline to fill the dead space at the penile base.
Fig. 30.5  (A) Patient with large volume of injected penile fat that is causing obvious convexities. (B) Circumcision incision reveals diffuse fat deposits (C). Residual fat
after contouring (D). Penis appearance after closure. It is very difficult to achieve ideal symmetrical contouring.
A
B
C
D
functional deformities. Thus, many techniques have been
used with varying success.
Simultaneous lengthening and girth enhancement proce-
dures are not performed by some physicians because weight
use needs to be delayed several weeks owing to penile swell-
ing and discomfort, which risks premature ligament reattach-
ment. Moreover, the complication rate increases if both
operations are performed simultaneously, resulting in wound
problems and decreased graft survival. A girth procedure is
sometimes performed once length is achieved.

747
Male genital aesthetic surgery
Allograft dermal matrix grafts
Alloderm use for girth expansion was motivated by the
unpredictability of dermal fat graft “take” with its cosmeti-
cally unappealing donor site scars. Layers of Alloderm are
inserted in a plane above the Buck’s fascia and stabilized
proximally and distally. Theoretically, the Alloderm is a matrix
for the ingrowth of tissue and becomes integrated into the
area. However, this does not always occur, so the Alloderm
can be isolated within a capsule. Since Alloderm does not
stretch, the patient may complain of loss of length or curva-
ture. Patients may also complain of an unnatural feel of the
penis, displacement of the Alloderm, asymmetry, and visual
and palpable deformities. Many cases of infected Alloderm
have occurred resulting in chronic infections and chronic skin
sinuses with or without skin loss.
True corporal girth increase can be obtained by making
lengthwise incisions through the tunica albuginea at the 3 and
9 o’clock locations and then patching these defects with
Alloderm or long saphenous vein grafts.17 This procedure was
derived from penile straightening operations for Peyronie’s
disease. However, most of the results are anecdotal with no
large series. The risk of erectile dysfunction is theoretically
possible if infection or poor healing occurs, since the erectile
chamber is violated.
Other techniques to increase girth are being tried by using
tissue engineering with biodegradable scaffolds.18 In addition,
silicone injections have be used for many years, sometimes
with disastrous long-term complications. Recently, penile
girth has been performed with polymethylmethacrylate
(PMMA) injections, but no good series has been published.
Reconstruction of penile enlargements
Patients present with a diverse array of deformities and
reconstructive issues.15,16 They may have a combination of
penile lengthening with VY flaps and/or fat injections, or
penile lengthening with Alloderm, etc. The patient must pri-
oritize his reconstructive goals, because complete correction
of all the deformities may not be possible at one operation, if
at all. He may want only limited fat or Alloderm removal,
partial or no VY flap reversal, or minimal scar revisions.
Realistic expectations must be emphasized.
Reversal of VY advancement flap
The most common repair is partial or complete reversal of the
VY advancement flap with excision of the wide scars (see Figs.
30.2 & 30.3).14–16 Reversal and scar revision eradicates the
unsightly dorsal penile hump and proximal penile hair-
bearing tissue by redraping the penis with the normal shaft
skin. The penile skin is elevated to its normal position by
aligning the hair on the “V” flap with the pubic hair. The
suprapubic concavity and unsightly scars are usually also
corrected by partially or completely reversing the VY flap,
excising scar tissue, mobilizing Scarpa’s fascia and skin from
both sides of the vertical scar, and approximating the wound.
Complete VY reversal resulting in a semicircular incision is
ideal, but it is often impossible or undesirable. Part of the flap
tip may have necrosed after the first procedure or must be
excised on this revision to prevent tip flap loss. The patient
may have had multiple circumcisions after fat injections
stretched the penile skin. Therefore, the adequacy of shaft skin
needs to be determined intraoperatively to ensure that com-
plete reversal of the flap does not shorten the penis (either real
or illusory) and restrict an erection. A pharmacologic erection
achieved by intracavernosal injection of prostaglandin E1
helps to determine skin adequacy. No restriction of erection
should occur by pulling on the erect penis. If there is inade-
quate penile skin for complete reversal, partial reversal is
performed, which results in an inverted Y-shaped scar with a
shorter vertical limb (Figs. 30.3B & 30.6). The resulting “Y”
scar is more noticeable than the scar from complete reversal.
Reversing the VY flap can cause scrotal dog-ears, which are
usually followed along the lateral scrotum. The method of
closure and dog-ear excision is determined by judging the
tightness of the penile skin, taking care not to restrict an
erection. Do not eliminate skin discrepancy or dog-ears by
making a circular incision through the skin and dartos fascia
at the penile base, since prolonged lymphedema or skin loss
can occur. Alternatively, the dog-ear is excised from the mid-
portion on the lateral side of the incision, creating a lateral
dart instead of following the dog-ear medially around the
penile base (see Fig. 30.6).
Excision and scar revision require meticulous skin closure
without tension, thus reducing the potential for redeveloping
a hypertrophic scar. A suction drain is used. Despite careful
wound closure, minor healing problems often occur at the
common junction of the flaps of the “Y” with the partial
reversal. In addition, some spreading of the scar is common.
Re-release of the suspensory ligament is performed only if
the patient complains of penile shortening, since the risk of
injury to the dorsal neurovascular structures is increased. In
order to prevent reattachment of the corpora bodies to the
symphysis in a shortened position, a fat flap or flaps trans-
posed from spermatic cord lipomatous tissue should be placed
between the corpora and the pubic symphysis (see Fig. 30.4).
Fat removal
Most patients with fat injections do not want complete
removal of the fat. They usually complain of nodules or penile
asymmetry with various concavities or convexities. Removal
of fat nodules and/or penile contouring is performed through
a limited or complete circumcision incision, a medial raphe
incision, or part of a previous VY incision (see Fig. 30.5). Shaft
incisions are cosmetically unacceptable and unnecessary.
Deforming or firm fat deposits are removed first followed by
contouring of the residual fat. Over-resection of fat creates
unsightly concavities, so perform contouring by removing
small increments of the deforming fat.
Complete removal of most of the fat can lead to significant
complications, so attempts to dissuade the patient from this
should be made. If performed, complete fat removal or exci-
sion of large diffuse areas of injected fat is usually performed
through a circumcision or hemi-circumcision incision. The fat
deposits are removed, preserving as much dartos fascia as
possible, even if some fat remains. Despite all attempts to
leave dartos fascia, a high complication rate occurs; lymph-
edema may persist for up to 6 months, skin attachment to the
Buck’s fascia may occur, and fibrous attachments from the
dorsal corpora to the pubic subcutaneous tissue and skin can
shorten the penis. These skin and fibrous attachments may
necessitate Kenalog injections. However, another difficult
operation may be required to release this scar tissue and

748
SECTION II
CHAPTER 30 • Aesthetic genital surgery
or Buck’s fascia. Leave as much dartos fascia as possible to
prevent skin adhesions to Buck’s fascia. Unilateral or bilateral
spermatic cord fat flaps are usually used to fill dead space at
the penopubic junction to prevent penile shortening (see Fig.
30.4). Closed-suction drains are used.
transpose unilateral or bilateral fat flaps to fill the dead space
or the area of the skin attachment.
If VY flap reversal is performed, simultaneous removal
of fat nodules or deforming fat deposits is limited. Fat is
removed through a several centimeter tunnel on one or both
sides of the most distal aspect of the VY incisions without
undermining the V flap and/or through a limited circumcision
incision. One side of the penis must be kept relatively inviolate
to assure adequate lymphatic and blood drainage. However,
a proximal medial raphe incision in a patient with a large
VY flap reversal may injure the remaining non-traumatized
proximal dartos fascia. Removal of large diffuse fat deposits
should rarely be done at the same time as the VY reversal,
since further flap disruption and dartos fascia injury decrease
vascularity of the flap and possibly prolong edema. This large
fat removal should not be done earlier than 6 months after
VY flap reversal, allowing time for revascularization of the
scarred areas.
Dermal fat graft and Alloderm removal
Dermis, dermal fat grafts, and Alloderm present with a variety
of different problems, including penile shortening, curvature,
and areas of induration.3 Removal of the grafts are performed
though one or a combination of circumcision, median raphe,
or low pubic incisions. An indurated, scarred graft that is not
adhered to the Buck’s fascia can be removed without much
difficulty, thereby correcting the deformity (Fig. 30.7).
However, the graft may be extensively adhered to the Buck’s
fascia, so extreme care must be used to prevent injury to the
dorsal neurovascular structures. Loupe magnification is
usually necessary. Removal of the scarred dermal graft or
Alloderm may eliminate the deformity, curvature, or penile
restriction, but full return of penile length or straightening
may not occur due to permanent scarring of the skin, dartos,
Fig. 30.6  Partial reversal of VY advancement flap. (A) The VY
flap is reversed as much as possible while preserving penile
length. (B) Dog-ears are removed by making lateral darts. The
can also be removed by extending the incision along the lateral
scrotum.
A
B
Fig. 30.7  Alloderm was elevated off the Buck’s fascia without much difficulty. Fat
flaps will be placed at the penile base to prevent scar formation with penile
restriction (see Fig. 30.4).

749
Male genital aesthetic surgery
of this chapter. An enlarged scrotum can cause discomfort or
a loss of self-esteem. Reduction of the scrotum can be per-
formed in many ways, but the preferred technique maintains
the normal sack-like appearance. If a varicocele or hydrocele
is present, it should be corrected first or at the same time to
prevent recurrent scrotal stretching.
Preliminary markings are made with the patient in the
standing position in front of a mirror and are checked intra-
operatively with the patient in the lithotomy position. The
design of the excision depends on the anatomy of the scrotum
with care to result in normal scrotal shape. If the patient has
a significant penoscrotal web, this should be marked first.
Usually, the scrotum is reduced by a horizontal excision of the
mid to upper scrotum, which connects to the vertical peno-
scrotal incision line as an inverted “T”. Alternatively, in order
to better hide the scars, the web may be excised separately
with a posterior scrotal U-excision that does not connect with
the penoscrotal incision.
The markings depend on whether the patient has a signifi-
cant penoscrotal web. If so, the patient is given a pharmaco-
logic erection with prostaglandin E1 intraoperatively prior to
making final markings. The web is bunched in the midline
without causing tightness around the penile circumference
(Fig. 30.9B–D). Markings are then made for a transverse
crescent excision of upper and mid-scrotum angling up
towards each pubic region. If the skin is bunched at the
penoscrotal junction, lateral dog-ears usually do not occur. If
they do, then an inverted “V” on the right and left lateral
scrotum is marked, creating a downward incision. The skin
and underlying dartos fascia are excised. The closure may be
adjusted to maintain normal scrotal shape (Fig. 30.9E). The
dartos is reapproximated with 4-0 reabsorbable sutures, and
the skin is closed with a subcuticular reabsorbable suture. A
Penrose or closed-suction drain is placed.
Meticulous hemostasis is important, since a hematoma is
the most common complication. There is often a color and
tissue mismatch between the two sides of the incision line,
which can make the eventual scar more noticeable. Therefore
the patient must be shown this preoperatively so that he will
not be surprised after surgery. Most patients are extremely
pleased with the result, both for aesthetic and comfort reasons
(Fig. 30.9F,G).
Hidden penis
The terms “hidden”, “concealed”, and “buried” all refer to a
penis in which the functional and visual penile length is
obscured (Figs. 30.10, 30.11A, 30.12A,B, & 30.13A).22–41 Penile
corporal length may be normal but not visible. Congenital
buried penis is uncommon. More often, the penis shaft may
be buried below the surface of the pubic skin by a large
suprapubic fat pad, obesity, or pubic skin and fat descent from
aging or weight loss.39 Other causes of a hidden penis are
an overly aggressive circumcision, an abdominoplasty with
aggressive release of dartos fascia attachments to Scarpa’s
fascia, or penile lengthening using an ill-advised large pubic
VY advancement flap. Buried or hidden penis has severe
effects on self-esteem, causing the patient to avoid locker
rooms, sport participation, and sexual intimacy. Chronic
dampness from a buried penis can cause penile inflammation
and destruction of penile skin such as balanitis xerotica oblit-
erans (lichen sclerosis). This section describes the surgical
Postoperative care
Any significant fat removal or degloving of the penis usually
requires a small closed-suction drain placed through a pubic
stab incision. The dressing used around the penis after any of
these surgeries is crucial to recovery, since it will help prevent
hematomas and swelling that can lead to secondary deformi-
ties. A thin Duoderm dressing is loosely wrapped around the
penis followed by a loose Coban wrap. This dressing is not
removed for a minimum of 2 days but frequently longer. It is
then replaced with a circumferential loose Tegaderm wrap.
Drains are kept until they cease draining.
Outcomes
Reconstruction of the complications of these procedures is
challenging. These patients are often psychologically devas-
tated, since they started with self-esteem issues that led to
their initial penile enlargement operation. Thus, the recon-
structions must be done with extreme care in order to regain
the patient’s penile form, function, and psychological health.
The outcome for most patients with reconstruction is usually
satisfactory to achieve their goals. There is a low complication
rate if meticulous technique is used. However, more than one
operation is often necessary. The vast majority of these patients
are able to resume normal sex lives without being self-
conscious after correction of their deformities.
Penoscrotal web
Scrotal skin extending onto the ventral penile shaft causes an
obtuse angle to the penoscrotal junction, thereby obscuring
the normal definition to the junction of the scrotum and penis
(Fig. 30.8A). The penis appears longer with more functional
length if the penoscrotal junction is well defined. The cause
of this webbing maybe congenital but is more often caused by
over-resection of the ventral penile skin during circumcision.
Webbing can cause discomfort during intercourse or when
wearing a condom.
A mild web is eliminated using a single or double Z-plasty
with the vertical limb centered along the median raphe at the
penoscrotal junction.19,20 Transposition of the flaps lengthens
the shortened web and sharpens the penoscrotal junction,
which gives the appearance of more ventral length. If the
patient has a more severe penoscrotal web with significant
excess skin, then the web is excised along the median raphe
(Fig. 30.8B,C). The amount of skin that can be excised without
causing circumferential penile constriction is determined by
giving the patient a pharmacologic erection with an intracav-
ernosal injection of prostaglandin E1. The excess is then
removed and a Z-plasty at the penoscrotal web is made,
which prevents a recurrent web re-forming from a scar con-
tracture (Fig. 30.8D,E).
A VY advancement flap can also be used to eliminate a
penoscrotal web but care must be taken to prevent scrotal
dog-ears.21,22
Scrotal enlargement
The scrotum can be enlarged and low-hanging secondary
to increased laxity from aging, congenital enlargement, or
stretching secondary to a scrotal hydrocele or varicocele (Fig.
30.9A). Enlargement from lymphedema is beyond the extent

750
SECTION II
CHAPTER 30 • Aesthetic genital surgery
and skin to the corporal bodies dorsally and ventrally to
assure success.39
Surgical technique
Examining the patient in the standing position is required for
an accurate diagnosis.
If the patient has excess pubic fat, it should be removed
and restricting bands of Scarpa’s fascia released to increase
penile visual and functional length. Moreover, aging and
weight gain and loss causes suprapubic skin and fat to
technique to correct the buried adult and pediatric penis on
the patient with adequate penile shaft skin. Treatment of
inadequate shaft skin with skin grafts or local flaps is beyond
the scope of this chapter.42,43
Surgery is partially derived from the principles and tech-
niques used to correct the pediatric buried penis. These
patients usually have inadequate attachments of the Buck’s
fascia to the skin and dartos fascia, so the corporal bodies
telescope proximally without the skin and dartos covering.
Since the corporal bodies may bury into the pubic fat or into
the scrotum, it is necessary to reattach and stabilize the dartos
Fig. 30.8  Patient with severe penoscrotal web almost certainly caused by an overly
aggressive circumcision. The circumcision scar is relatively proximal on the shaft.
(A) Side view showing severe penoscrotal web and relative deficiency of normal
penile skin. (B,C) Skin to be excised. Markings are made with a pharmacologically
induced erection. (D,E) Penis after skin excision with obvious elimination of the web.
Notice the Z-plasty at the penoscrotal junction and the drain.
A
B
C
D
E

751
Male genital aesthetic surgery
is made well above the level of the pubic hair, usually just
inferior to the panniculus fold (Fig. 30.14).39,44 It is uncommon
to remove more than a few centimeters of transverse skin
because the pubic skin retracts somewhat with fat removal.
Not infrequently on patients with obesity, part of the pannicu-
lus fat and skin needs to be excised to prevent a steep drop-off
at the incision line. An escutcheon length of 7–8 cm should
remain.
Fat is incised to the rectus fascia and the flap of skin and
fat is elevated off the rectus fascia to the pubic symphysis
between the external rings. The pubic, inguinal, and upper
scrotal areas are infiltrated with the usual tumescent fluid.
The pubic area is uniformly liposuctioned to eliminate the fat
pad with fat tapering in the inguinal areas and upper scrotum
descend, concealing the penis when the patient is standing.
Combining fat and skin excision in the aging male with pubic
flap stabilization provides a more attractive and youthful
appearance to the escutcheon while increasing visual, and
often functional, penile length. On occasion, the patient may
not have significant pubic fat or skin descent (see Fig. 30.13).
In these cases, the patient undergoes an incision at the peno-
pubic junction with stabilization of the dorsal penile skin to
the tunica albuginea of the penis (see below). Evaluate the
penoscrotal junction, since the ventral penis must be stabilized
to this skin, oftentimes with correction of a penoscrotal web.
Preoperative markings are made with the patient standing
to determine the amount of excess skin. If excess skin is
excised to raise the escutcheon, a transverse crescent incision
A
B
C
D
Fig. 30.9  A 27-year-old man for scrotum
reduction due to excess skin and laxity.
(A,B) Notice that the scrotum hangs lower
than the penis and that he has a large
penoscrotal web. (C) The area to be excised
is verified with a pharmacologically induced
erection. The penoscrotal web is bunched
first with tacking sutures. The horizontal
excision is then stapled closed and
adjusted for an asymmetrical scrotum.  
(D) Skin to be excised (different patient but
similar situation).

752
SECTION II
CHAPTER 30 • Aesthetic genital surgery
E
F
G
(E) The scrotum at the termination of the procedure. There are Z-plasties at the
penoscrotal junction. There are no lateral dog-ears because the penoscrotal web was bunched in the midline.
(F,G) The result at 3 12 months. The scars are difficult to see. The scrotum does not hang lower than the
penis, and the web is eliminated.
Fig. 30.9, cont’d
to prevent a pubic concavity. A 1–2 cm layer of subcutaneous
fat with its fibrous tissue is kept on the dermal side. Frequently,
limited sharp dissection of fat is also performed to remove
excess fat resistant to liposuction, especially at the penopubic
junction. Suprapubic fat removal is contoured to match the
abdominal side of the incision. Some medial spermatic cord
fat is removed, but overly aggressive fat removal in the ingui-
nal regions can cause genital lymphedema and injury to the
superficial sensory nerves of the genitalia. The buried corporal
bodies are seen and freed from the deep subcutaneous tissue.
The suspensory ligament is occasionally partially released. In
order to prevent adhesion of the released penis to the pubic
symphysis after suspensory ligament release, a fat flap from
the lipomatous tissue adjacent to a spermatic cord can be
transposed to fill the space (see above).
Tacking this fibrofatty tissue of the suprapubic skin to the
rectus fascia maintains the upward position of the escutcheon
and stabilizes dorsal penile skin to the penis (Fig. 30.14B). In
order to prevent the corporal bodies from retracting under the
penile skin into the scrotum and pubis, tacking sutures of
No.1 polypropylene (Prolene) sutures on a CTX needle are
placed from the fibrous fatty tissue of the flap to the rectus
fascia. A No.0 Prolene on a CT needle may be used on a child.
A pharmacologic erection is created by an intracavernosal
injection of prostaglandin E1. Care is then taken not to restrict
the erection during placement of the sutures. The first row of

753
Male genital aesthetic surgery
(PDS) or Ethibond sutures on an SH needle are placed at the
penoscrotal junction on each side of the urethra horizontally
from tunica albuginea to ventral subdermal dartos fascia just
inferior to the lateral penoscrotal junction.39,44 These sutures
stabilize the ventral penile skin to the corpora and prevent
retraction into fat or scrotum. Care must be taken not to cause
excessive skin dimpling from the tacking sutures, but some
dimpling is necessary. The dartos fascia and skin are closed
(Fig. 30.16).
The patient with no pubic skin excess and mild pubic fat
does not need a transverse upper pubic incision (see Fig.
30.13). Instead, tacking is performed from the dorsal penopu-
bic subdermal tissue to the proximal dorsal tunica albu-
ginea.45,46 A 3–4 cm incision is made just cephalad to the
penopubic junction. Dissection proceeds to the dorsal corporal
bodies. A pharmacologic erection is induced. Longitudinal
blunt dissection is performed at the 10 and 2 o’clock location
of the Buck’s fascia of the penis lateral to the dorsal arteries,
and, preferably, lateral to the dorsal nerves. No cutting is
performed that could transect the dorsal nerves. Once the
tunica albuginea is visible in each of the two locations, two
2-0 Ethibond sutures on an SH needle are placed next to each
other (Fig. 30.17A,B). Each of the two sutures on each side is
then placed through the subdermal tissue of the penopubic
three sutures is placed between the external inguinal rings
near the pubic symphysis to the subdermal tissue 1–2 cm.
cephalad to the penopubic junction. Usually three or four
rows of three sutures are placed. Try to prevent excessive
dimpling or a deep suprapubic concavity. A closed-suction
drain is placed from the pubic symphysis, around the right
side, and under the deep closure of the wound.
Despite suprapubic tacking, the corpora still tend to retract
into the scrotum if the ventral skin is not stabilized (Fig.
30.15). Many of these patients also have penoscrotal webbing,
which is corrected at the same time (see above). A midline or
Z-plasty incision is made at or just inferior to the penoscrotal
junction and dissection is performed through the dartos fascia
to the corpus spongiosum and tunica albuginea. A pharmaco-
logic erection is induced. Two 2-0 tacking polydioxanone
Fig. 30.10  The typical hidden or buried penis. (A) The penis is buried in the
pubic fat and scrotum. (B) The penile shaft skin is not firmly attached to the
corporal bodies, so the corporal bodies telescope proximally inside the pubis and
scrotum.
A
Glans
B
Penile skin
Glans
Fig. 30.11  (A) A 32-year-old obese, uncircumcised man with a severe buried
penis. (B) View at 3 months postoperatively revealing a normal-sized penis. Notice
that the pubic skin and fat were excised, which elevates the penopubic skin.
A
B

754
SECTION II
CHAPTER 30 • Aesthetic genital surgery
Fig. 30.12  (A,B) A 45-year-old modestly overweight male with relative hidden penis. He was not obese but had lack of attachments of the penile skin to the Buck’s fascia.
(C,D) Two months after a suprapubic dermatolipectomy with liposuction and tacking of the pubic and penoscrotal skin. Notice the mild pubic concavity.
A
B
C
D
Fig. 30.13  A 14-year-old boy with relative hidden penis. He had no significant pubic skin ptosis and a small pubic fat pad. He was treated with penopubic and penoscrotal
tacking and pubic liposuction. (A) Pre-operation. (B) Post-operation at 3 months. He still has residual edema of his penile shaft, which should resolve in another several
months.
A
B
junction to stabilize the skin to the tunica. All four sutures are
then tied. A No.10F round closed-suction drain is placed and
brought out through a separate stab incision. If mild fat is
present, then pubic liposuction is performed with care not to
disturb the tacking sutures. The wound is then closed. These
patients usually also need penoscrotal tacking. The erection is
reversed with intracavernosal injection of phenylephrine at
the end of the procedure.
At the conclusion of any hidden penis procedure, the penis
should be prominent and inward pressure on the glans should
not allow the penis to bury into the scrotum or abdomen.
Outcomes
Hidden penis surgery is very successful. Patient self-esteem is
dramatically improved as most patients have been tormented

755
Male genital aesthetic surgery
throughout life by this malady. Complications include an
overly concave pubic area, which is much less common
with the use of liposuction to remove most of the pubic fat.
Tacking sutures in the pubic and scrotal region may not
hold over time in a minority of cases, so some skin dimpling
during initial placement of the tacking sutures is probably
necessary to assure adequate skin stabilization to the corporal
bodies. The dimpling usually resolves in several months. The
penopubic tacking procedure is usually used if secondary
surgery is needed on patients in whom the pubic tacking
sutures did not successfully hold. Repeat penoscrotal tacking
may occasionally be necessary, but this is a relatively minor
procedure.
Fig. 30.14  (A) A low transverse incision is made below the panniculus line. Skin
excision depends on whether skin excess is present. Pubic fat is removed with
liposuction and excision. (B) The pubic flap is stabilized to the rectus fascia with
rows of tacking sutures.
A
Glans
External inguinal ring
First row of 3 sutures
taken from the subdermal
tissue 1-2 centimeters
cephalic to penopubic
junction and placed to the
rectus abdominal fascia
between the external rings
Lower rectus abdominis fascia
B
Fig. 30.15  An incision is made at the penoscrotal junction. If a web is present,
correction is done with a Z-plasty and/or skin excision. Tacking sutures are taken
bilaterally from the tunica albuginea proximal to the penoscrotal junction to the
subdermal skin.
Urethra
Anchoring sutures
Penoscrotal junction
Tunica albuginea
Fig. 30.16  The patient at the end of surgery with stabilization of the pubic skin to
the rectus fascia and of the ventral penile skin to the tunica albuginea. The penile
skin and corporal bodies are now stabilized as one synchronous unit.
Skin closure within
or just below
panniculus fold
Three rows of pubic
tacking sutures
Drain
Drain
Four ventral tacking
sutures at penoscrotal
junction lateral to
skin closure

756
SECTION II
CHAPTER 30 • Aesthetic genital surgery
Female genital aesthetic surgery
Introduction
Female aesthetic genital ideal is a function of cultural influ-
ences or each woman’s personal concept of beauty. In recent
years, women are more aware of their genital appearance due
to the popularity of genital hair removal and the proliferation
of pornographic photographic material. Therefore, women
compare themselves to others and create an aesthetic ideal. If
a woman feels deformed or abnormal, she will have resulting
embarrassment or loss of self-esteem.47–50 These women fre-
quently refrain from social and sexual situations that may
require visualization of their genitals, including wearing tight
swimsuits, group showers, or sexual intimacy. They often
avoid gynecological exams and are too self-conscious to
mention their concerns to the doctor, who frequently dismisses
them. There is no standard of genital aesthetic ideal. However,
most consider ideals as (1) symmetrical labia minora that do
not protrude past the labia majora, especially when standing;
Fig. 30.17  Penopubic tacking on a patient with relative hidden penis and no
significant pubic ptosis or fat pad. (A) Tacking sutures are placed in the tunica
albuginea at the penopubic junction. Two sutures are placed each at the 10 and 2
o’clock positions. The dorsal arteries and dorsal nerves are bluntly dissected away
for suture placement. The marks are the locations at the penopubic junction where
the sutures will be placed. (B) The tacking sutures are placed from the tunica
albuginea to the subdermis at the penopubic junction.
A
B
(2) a clitoral hood that is reasonably short and non-protuberant
with no extra folds; (3) full labia majora without redundant
skin but not overly fatty which can cause an unsightly bulge
in clothes; and (4) a mons pubis that has mild fullness but
does not protrude in clothes.51 Due to surgical innovations,
these results can be achieved in most cases. Reassurance
concerning normal variations of the labia may be adequate to
allay some women’s insecurities, but others seek surgical
correction, which achieves improved confidence.
In addition, many women with enlarged labia minora or
majora or clitoral hood complain of discomfort during sexual
intercourse, with exercise, or when wearing tight clothing.
Massively enlarged labia cause difficulty with hygiene,
interfere with sexual intercourse, hamper urinary self-
catheterization, and cause chronic inflammation.
Anatomy
Knowledge of the vulvar anatomy is necessary to prevent
clitoral injury and loss of sensation (Fig. 30.18). The glans
clitoris is visible under the prepuce, which is an extension of
the clitoral hood. The clitoral body is attached to the pubic
symphysis by the suspensory ligament and then each corporal
body diverges inferior and lateral to attach bilaterally to the
ischiopubic ramus. The frenula are folds of skin extending
from the glans clitoris to merge with an extension of the cli-
toral hood to form the labia minora.
The external genitalia have extensive blood supply.52 It
consists of branches from the external superficial pudendal
artery, the internal pudendal artery, and frequent contribu-
tions from the internal circumflex artery. The external super-
ficial pudendal artery anastomoses with the posterior labial
artery, a branch of the internal pudendal artery, in the labium
majora. Multiple arterial arches in the labium minora arise
from this initial anastomosis, which provide a rich blood
supply.
Labia minora reduction
Labia minora enlargement is congenital in most cases, but
some women claim enlargement with age, after childbirth,
chronic irritation, or hormones.53–57 Labia minora reduction is
indicated in girls as young as 12 years old, when the enlarge-
ment severely affects self-esteem or causes discomfort. Fear
of embarrassment of one’s genitals is a powerful antisocial
force. Most women want straight, thin, light-colored, sym-
metrical labia minora.
Most physicians correct protuberant or asymmetrical labia
minora by excising or trimming the abnormal areas using a
scissor, knife, clamp, or laser and oversewing them.47,53–58 The
advantages of this technique are the short operative time and
the creation of light-colored labial edges. Disadvantages
include elimination of the normal labial edge with the replace-
ment of a longitudinal scar line that is often irregular and
scalloped, the higher incidence of chronic discomfort, and a
relatively high incidence of asymmetry and over-resection. In
addition it is often difficult with the trimming technique to
maintain the normal transition between the frenulum of the
clitoris, the clitoral hood, and the labium. Other surgeons
have reported W-plasties to reduce the protruding labia or
S-shaped labial incisions, but these also eliminate the normal
labial edge.59,60 The ideal for any cosmetic procedure is to

757
Female genital aesthetic surgery
protrusion, symmetry, location of hyperkeratotic darkened
skin, the presence of extra folds, and the amount of clitoral
glans size and exposure. Evaluate the posterior introitus for a
high posterior lip or for gaping due to a previous episiotomy.
A large “V” or central wedge is excised from the most pro-
tuberant portion of each labium (Fig. 30.19A,B). The wedge
is adjusted when asymmetry is present. Excellent symmetry
can usually be achieved even in very asymmetrical patients.
Usually, the most darkly pigmented skin is removed.
The operation is usually performed under general or
regional anesthesia in the lithotomy position. The upper labial
incision of the wedge is usually placed at or just posterior to
the convergence of the glans frenulum with the clitoral hood.
The amount of labium excised is determined to achieve a
straight, non-redundant labium that can be closed without
tension and without causing an overly tight introitus, which
is usually ensured by placing two fingerbreadths in the
vagina. The medial “V” extends internally to terminate distal
to the hymeneal ring. The lateral “V” is curved anterior in a
hockey-stick design to eliminate a dog-ear and to excise a
redundant lateral clitoral hood or lateral hood folds (Fig.
30.19C). Thus, the medial and lateral “V”s are asymmetrical.
On rare occasions, another unilateral or bilateral posterior “V”
is necessary to achieve symmetry or adequate reduction.
Conservative infiltration of the labia is performed with
lidocaine with epinephrine and Marcaine after marking. The
skin and vaginal mucosa are de-epithelialized with care to
leave as much subcutaneous tissue as possible, because a
preserve normal anatomy including the normal labial edge.
The removal of medial and lateral de-epithelialized labial
ellipses eliminates the protrusion, but the total length of the
labium remains elongated.48 The extended central wedge
technique, which excises a wedge or “V” of the most protu-
berant labium and reapproximates the edges, preserves the
normal anatomy of the labial edge.61 Its only disadvantages
are a longer operative time, more surgical expertise, and
occasional persistence of darker labial pigment.62,63 Other
physicians have reported the use of an inferior wedge, but
this maintains the thickness of the labium and has a higher
complication rate.64–66 Another variation of a central wedge
using a Z-plasty has also been reported.67,68 A custom flask
labiaplasty has been helpful for very large labia minora.69
Another variation for clitoral hood and labia minora reduc-
tion called a composite reduction labiaplasty has also been
described.70
Surgical technique
Preoperatively, the woman is examined in the lithotomy posi-
tion with her head elevated. While using a mirror to visualize
her genitalia, she indicates her concerns. The proposed
surgical plan for central wedge excision is explained and
illustrated.61
Labia minora vary greatly in length, thickness, and
form. Therefore, the surgical markings vary depending on
the anatomy. The clitoral hood is evaluated to determine
Fig. 30.18  Female external genitalia.
Mons veneris
Anterior commissure
Posterior commissure
Anus
Clitoral hood
Prepuce of clitoris
Glans of clitoris
Frenulum of clitoris
Urethral orifice
Skene’s ducts
Labium majus
Labium minus
Vaginal orifice
Bartholin’s duct
Hymen
Vestibule

758
SECTION II
CHAPTER 30 • Aesthetic genital surgery
lateral clitoral hood is closed with running 5-0 Monocryl in
the subcutaneous tissue and a running subcuticular 5-0
Monocryl on the skin. The only suture line on the leading
edge of the labium is a small transverse line (Fig. 30.19E). If
possible, the labia should protrude only slightly past the
introitus, but this may not be possible if the labia are mas-
sively enlarged.
If the clitoral hood has extra vertical medial folds or medial
hypertrophic skin, these can be excised with vertical ellipses.
In this case, the lateral “V” labial excision can stop at the
labial sulcus. Occasionally, the patient may have redundant
good subcutaneous tissue closure is mandatory to prevent
dehiscence of the closure or perforations. The subcutaneous
tissue of the anterior and posterior labium is reapproximated,
usually in two layers, with 5-0 Monocryl on an atraumatic TF
needle (Fig. 30.19D). Loupe magnification is usually necessary
to achieve accurate approximation. The internal and external
subcutaneous dog-ears are excised. The labial edges and
medial and lateral closures are reapproximated with inter-
rupted, vertical mattress 5-0 Monocryl on a TF needle. Running
sutures can be used on the deepest portion of the medial
incision line or occasionally on the most lateral labium. The
A
B
C
D
Fig. 30.19  A 47-year-old underwent labia
reduction and lateral clitoral hood
reduction. (A) Pre-operation. (B) Internal
“V” markings with the labia open.  
(C) External hockey stick “V” marking
extending along the lateral clitoral hood to
the anterior hood. (D) The completed right
side compared to the left side.

759
Female genital aesthetic surgery
E
F
(E) Post-operation.
(F) Post-operation with the labia open.
Fig. 30.19, cont’d
horizontal folds, which can be excised with a conservative
transverse ellipse. However, this can result in overexposure
of the glans clitoris that can cause hypersensitivity or an
unacceptable aesthetic appearance. More aggressive clitoral
hood reduction with clitoral repositioning (clitoropexy) can be
performed but is beyond the scope of this chapter as is clitoral
glans and shaft reduction.
If the introitus is too tight or if the posterior lip is too high,
a midline incision can be made at the 6 o’clock position with
a careful aesthetic closure of the resulting dog-ears. If a peri-
neoplasty or posterior vaginal repair or tightening is per-
formed at the same time as a large labia minora reduction,
care needs to be taken to ensure that the introitus is not overly
tight. This can usually be prevented by delaying the perineal
and vaginal repair distal to the hymeneal ring until the labia
reduction is completed, which allows for introital adjustments
during this closure.
Outcomes
Patients heal well with normal-appearing labia minora (Figs.
30.19F, 30.20, & 30.21). The most common complications are a
slight separation of the labial edge closure or a small perfora-
tion, but these occur in less than 2% of cases if the above
guidelines are followed. Major dehiscence is rare if performed
as stated. A minor separation or perforation can be easily
repaired in 4–6 months under local anesthesia. Chronic scar
discomfort and interference with intercourse are very rare and
can be corrected. On occasion, the labia can stretch or the scars
may spread, which can easily be reduced. If the labia still
protrude too far after maximal “V” excision, then medial and
lateral elliptical excisions can be performed later, but this is
seldom necessary.
The central wedge technique is a major advance over trim-
ming or techniques requiring long suture lines along the labial
edges. Patient satisfaction with the central wedge and most
other carefully performed techniques easily exceeds 90%.
Labia majora reduction
The youthful labia majora have fullness with no significant
excess skin. Protuberance can either result from an overly
fatty, full majora or a majora with excess skin or a combination
of both (Fig. 30.22). Excess hanging skin can be congenital,
postpartum, or caused by weight loss or aging. Excess protu-
berant fat can be congenital or due to weight gain. These
women should also be evaluated for significant mons pubis
lipodystrophy or descent. If the woman has a deficiency of
fullness, fat can be injected into the majora. The majora are
over-filled with fat with the knowledge that some of the fat
will eventually resorb.
The patient for labia majora reduction is marked preopera-
tively under her supervision with a hand mirror while stand-
ing and lying in the lithotomy position.7 Depending on the
patient, she may need skin and/or fat excision. The skin
excess is removed bilaterally from the medial portion of each
labium as a crescent excision extending from the anterior to
the posterior labial commissures (Fig. 30.23A).44,51 The medial
incision line is usually placed in the labial sulcus at or just
lateral to the medial hairline of each labium, but it can be
placed slightly more medial if a reasonable skin match is
present. Skin excision depends on each woman, but it is
usually mandatory to leave at least 1.8 cm of pigmented
labium lateral to the lateral excision line, which usually
ensures preservation of enough skin to prevent introital
gaping while fully abducting the legs. If in doubt, be conser-
vative. The amount of crescent excision varies depending on
symmetry and whether skin excess extends posteriorly. The
anterior and posterior incision lines should not meet in the
midline but should extend laterally in a fusiform manner. Fat

760
SECTION II
CHAPTER 30 • Aesthetic genital surgery
Fig. 30.20  A 50-year-old woman
underwent labia minora and lateral clitoral
hood reduction. (A) Pre-operation.
(B) Post-operation at 3 months.
A
B
Fig. 30.21  A 44-year-old woman
underwent labia minora and medial-lateral
clitoral hood reduction. (A) Pre-operation.
(B) Post-operation at 3 months.
A
B
removal from the majora is usually not performed. If fat is to
be removed, the location and amount is determined preopera-
tively. Over-resection can result in an aged appearance.
Surgery is performed in the lithotomy position usually
under general anesthesia. Local anesthetic with lidocaine and
Marcaine with epinephrine are injected. After symmetry is
checked, the skin excisions are made and checked again for
symmetry. If fat is to be excised, superficial Colles’ fascia is
opened, and fat is conservatively removed with electrocautery
using meticulous hemostasis to prevent a hematoma. The
superficial Colles’ is then closed with a running 4-0 Monocryl
suture (see Fig. 30.23B). Drains are used only if a very large
volume fat excision is performed. The subdermal tissue is
closed with 5-0 Monocryl catching some superficial Colles’
fascia to eliminate dead space. The skin is closed with a
running subcuticular closure of 5-0 Monocryl.
Complications are unusual. Hematomas are rare and asym-
metry can occur. Contrast of the color and tissue texture between

761
Female genital aesthetic surgery
have tried to correct this deformity through mons elevation in
association with an abdominoplasty or by just lifting the pubic
area, but these attempts often fail. The use of a midline incision
to eliminate the excess pubic skin and fat results in an unsightly
vertical or inverted “T” scar. A natural pubic lift with mons
reduction can be achieved with a combination of horizontal
skin excision; undermining of the mons fat pad; liposuction of
the mons pubis, upper labia majora, and inguinal regions; and
fat excision of the residual deforming fat pad. Stabilization of
the fibrofatty tissue of the pubic skin flap to the rectus fascia
by tacking sutures prevents recurrent pubic descent.44,51
The patient should be evaluated in the standing position.
The location of the anterior labial commissure should be at
the pubic symphysis, so manual elevation of ptotic skin and
panniculus helps determine the amount of skin excision
required to achieve this lift. No more than several centimeters
of skin excision are usually necessary, since the pubic skin will
modestly contract after fat removal. An escutcheon length of
7–8 cm should remain from the anterior labial commissure
to the incision line. Over-resection of skin can give an abnor-
mally elevated appearance to the anterior commissure. The
the medial and lateral skin is common, so the location of the
incision lines are placed to minimize this contrast. Patients
generally do not object if they are counseled preoperatively.
Care must be taken not to overly resect labia majora skin,
which can cause a gaping introitus with resulting vaginal
dryness, discomfort in clothes, and an aesthetic deformity.
Extreme care must be taken in patients who have had or
anticipate a medial thigh-lift. Loosening of the thigh-lift
Colles’ fascia tacking sutures can cause posterior migration of
the thigh skin, which can pull the majora laterally and open
the introitus.
Labia minora and majora reduction can be performed at
the same time with the minora performed first.
Mons pubis descent and lipodystrophy
A protuberant mons pubis fat pad without skin excess can be
reduced with liposuction through bilateral groin incisions.
The patient with massive weight gain or large volume weight
loss may have a very protuberant mons pubis fat pad with
excess skin and ptosis (Figs. 30.24A,B & 30.25A,B). Physicians
Fig. 30.22  A 40-year-old woman underwent labia majora reduction with skin removal only. (A,B) Pre-operation. (C,D) Post-operation at 5 months.
A
B
C
D

762
SECTION II
CHAPTER 30 • Aesthetic genital surgery
A
Excess fat removed
Proposed incision
B
Drain
Subcuticular stitch closes skin
Closure of the superficial
Colles’ fascia.
The subdermal closure catches
Colles’ fascia
Fig. 30.23  (A) Illustration of the skin crescent removed from the medial labium majus. The shape depends on the amount of excess skin, but the incision lines should not
meet in the midline. Fat is excised. (B) The closure is performed in layers. Colles’ fascia is closed if fat is removed. A drain is placed if a large amount of fat is removed.
The subdermal layer is closed while also catching Colles’ fascia to reduce dead space. The skin is closed with a subcuticular suture.
horizontal incision is placed just inferior to the panniculus
fold or at a previous abdominoplasty scar. The incision line
extends just long enough to remove the redundant skin
without causing a dog-ear. On rare occasions, the incision may
extend to both anterior superior spines.
The surgery is performed supine if only a mons pubis lift
is performed. If a simultaneous labia majora reduction is to be
done, then the patient is placed in the lithotomy position with
both areas prepped. The upper incision is made and carried
down to the rectus fascia. The flap is dissected to the pubic
A
B
Fig. 30.24  A 19-year-old woman with a large pubic fat pad and excess skin. She underwent a pubic lift and pubic fat removal. (A,B) Pre-operation.

763
Female genital aesthetic surgery
Fig. 30.25  (A,B) A 34-year-old woman underwent pubic lift and labia majora reduction. The patient has a protuberant mons fat pad and enlarged labia majora. (C,D) Ten
months after pubic lift. She could benefit from more pubic liposuction but declined.
A
B
C
D
C
D
(C,D) Post-operation at 2 months.
Fig. 30.24, cont’d
symphysis and fat elevated off the rectus between the external
rings. The inferior incision of the crescent is made and removed
along with some pubic fat (Fig. 30.26A). The pubic flap, upper
labia majora, and inguinal areas are infiltrated with the usual
tumescence fluid. The pubic flap is liposuctioned and residual
fat is sharply excised, leaving a flap thickness of 1–2 cm. The
surrounding areas are suctioned to prevent a pubic concavity.
The majora can be liposuctioned at this time or an open fat
resection can be done from above followed by bilateral inser-
tion of closed-suction drains. Tacking sutures of No.1 Prolene
on a CTX needle are placed from the pubic flap to the rectus
fascia and closure is done similarly to that of hidden penis (see
above) (Figs. 30.14 & 30.26B).
Labia majora skin and fat excision can be performed simul-
taneously with a pubic lift. However, this should probably not
be done if the patient has had a previous medial thigh-lift.

764
SECTION II
CHAPTER 30 • Aesthetic genital surgery
Fig. 30.26  (A) A small amount of fat is excised and tapered to the pubic symphysis. Most fat is removed with liposuction. The thickness of the pubic flap cephalad
matches the abdominal side. (B) Three rows of tacking sutures are usually placed with care to minimize dimpling. The pubic region along with the labia majora and anterior
labial commissure are pulled up. A closed-suction drain is placed from the pubic symphysis along the right side, then under the deep closure.
A
Rectus fascia
Excision of excess fat tapers to symphysis
Ptotic labia majora
B
Rectus fascia
Three rows of sutures maintain
elevated position of flap
Drain
Drain
The previous thigh-lift incision added to the medial labia
majora and pubic lift incisions can theoretically cause vascular
insufficiency to the remaining majora and lateral perineal
skin. In these cases, the patient can return later for the labia
majora reduction.
The patient should be told that a pubic concavity or incom-
plete correction might result. Over-elevation of the pubis can
cause an abnormally high location of the anterior labial com-
missure and a short escutcheon. The patients are generally
very happy with the outcome as long as good judgment is
used and the limitations and expected outcome are explained
preoperatively (see Figs. 30.24 & 30.25).
Conclusion
Over the past decades, innovative techniques have been
developed to successfully treat a variety of genital aesthetic
deformities. Often, these procedures enable men and women
to overcome psychologically crippling feelings of low self-
esteem. Unfortunately, misinformation is widespread. Male
and female aesthetic genital techniques will continue to evolve
with more data and experience. Most patients achieve sub-
stantially improved self-esteem, justifying the continued
exploration for new and better methods.
9. Alter GJ. Penile enhancement surgery. Tech Urol. 1998;4:70–76.
15. Alter GJ. Reconstruction of deformities resulting from penile
enlargement surgery. J Urol. 1997;158:2153–2157. This paper is the
most comprehensive article describing reconstruction of deformities of
penile enlargement surgeries.
16. Alter GJ. Reconstruction of the penis for complications of penile
enlargement surgery. In: Graham SD Jr, Keane TE, eds. Glenn’s
Urologic Surgery. Philadelphia, PA: Wolters Kluwer/Lippincott
Williams & Wilkins; 2010:537–543.
39. Alter GJ, Ehrlich RM. A new technique for correction of the hidden
penis in adults and children. J Urol. 1999;161:455–459. This article is
the first paper to outline ventral tacking sutures but also discusses pubic
tacking techniques. The discussion explains indications and pitfalls.
42. Pestana IA, Greenfield JM, Walsh M, et al. Management of the
“buried” penis in adulthood: an overview. Plast Reconstr Surg.
2009;124:1186–1195.
44. Alter GJ. Pubic contouring after massive weight loss in men and
women: correction of hidden penis, mons ptosis, and labia majora
enlargement. Plast Reconstr Surg. 2012;130:936–947. This graphic
article updates and illustrates the technique for correction of hidden or
buried penis in the usual pediatric and adult patient.
47. Hodgkinson DJ, Hait G. Aesthetic vaginal labioplasty. Plast Reconstr
Surg. 1984;74:414–416.
48. Choi HY, Kim KT. A new method for aesthetic reduction to the
labia minora (the deepithelialized reduction labiaplasty). Plast
Reconstr Surg. 2000;105:419–422.
51. Alter GJ. Management of the mons pubis and labia majora in the
massive weight loss patient. Aesthet Surg J. 2009;29:432–442. This is
the only article that explicitly explains and illustrates the techniques for
correction of the protuberant or ptotic mons pubis and also the method for
labia majora reduction.
61. Alter GJ. Aesthetic labia minora and clitoral hood reduction using
extended central wedge resection. Plast Reconstr Surg. 2008;122:
1780–1789. This is the seminal article on the central wedge or “V”
excision labioplasty with methods and results in 407 patients. It also
discusses the advantages and disadvantages of alternative techniques.
Access the complete reference list online at

764.e1
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women: correction of hidden penis, mons ptosis, and labia majora
enlargement. Plast Reconstr Surg. 2012;130:936–947. This graphic
article updates and illustrates the technique for correction of hidden or
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764.e2
SECTION II
CHAPTER 30 • Aesthetic genital surgery
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65. Munhoz AM, Filassi JR, Ricci MD, et al. Aesthetic labia minora
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66. Alter GJ. Aesthetic labia minora reduction with inferior wedge
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67. Giraldo F, Gonzalez C, de Haro F. Central wedge nymphectomy
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68. Alter GJ. Central wedge nymphectomy with a 90-degree Z-plasty
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