Discussion
Phimosis is a clinical condition in which the foreskin, due to adherences or fibrotic preputial ring, cannot be pulled back over in order to expose the glans penis.
Phimosis can be classified into two groups: congenital and acquired.
The first type is usually seen in young children and could be considered physiological.
Acquired phimosis is mostly seen in adolescents and adults. Apart from discomfort during coitus in adult life, if the distal preputial ring is too narrow it can cause ballooning during voiding, making it difficult to maintain penile hygiene leading to chronic balanoposthitis.
This chronic condition leads to the development of adhesions between the glans and the inner leaf of the preputium and also the development of a fibrotic ring, severely narrowing the opening of the prepuce.
In 1996 Kayaba et al. [
3] classified phimosis condition in four grades according to the level of preputial retractability.
Type I the preputial retractability is totally absent.
In Type II the preputial opening allows only exposure of the external urethral meatus.
In Type III the preputium can be partially retracted from the apex to the middle of the glans.
In Type IV the preputium can be retracted allowing the exposure to above the crown of the glans, because of adhesions between the inner leaf of the preputium and the corona.
Despite the various techniques of preputial plasty described in literature [
4‐
6], the most performed surgical treatment is still the conventional circumcision.
This should be preferred if the preputium becomes scarred from previous attempts to release the glans or in the presence of balanitis xerotica obliterans.
Differing from reconstructive surgery, cosmetic surgery was developed by surgeons especially for people who felt the need to improve on nature, to improve the results of previous injuries or interventions by surgery.
Until 30 years ago, penis size either nonerected or erected was not mentioned in literature.
Cosmetic surgery for the penis cannot and should not be compared to rhinoplasty, breast augmentation, or breast reduction surgery, where obtained results are generally very acceptable.
Unfortunately, the expectations of patients of augmentation phalloplasty are far greater than the real results that can be obtained with the current surgical techniques.
When performed on a normal-looking penis which has an average size, a penile cosmetic procedure yields aesthetically less than the desired result. An increase of 2–4 cm should be considered a success.
The historical Kinsey report showed that only 5% of men have an erection of less than 9 cm and that 1% are very well endowed with an erection of longer than 20 cm [
7].
A more recent study by Ponchietti et al. [
8] of penile size in 3300 young Italian men showed these differences in a large sample: flaccid penile length: 5–13 cm (average 9.0 cm), stretched penile size: 7.5–17.5 cm (average 12.5 cm), flaccid penile circumference: 8.5–11.5 cm (average 10 cm).
Another study by Wessels et al. [
9] found that the average length of a flaccid penis was 8.8 cm, stretched length 12.4 cm and erect length 12.9 cm.
Khan et al. [
10] asserted that men referred with penile disease had a marginally shorter penile length. In his study, men affected by penile disease, showed a flaccid length of 8.37 cm, a penopubic length of 9.97 cm and a stretched length of 13.70 cm.
In literature several surgical techniques have been described for penis augmentation, such as section of the suspensory ligament of the penis, lipectomy or liposuction of prepubic fat, inverted V-plasty of the radix of the penis and fat grafting of the penis [
11].
Anyway is widely understood how a penis enlargement surgical or non surgical procedure is highly contraindicated in patients affected by uncorrected penile pathological conditions.
In 2011 Montag and Palmer [
12] published a review about abnormalities of penile curvature and size, stating that these conditions can be related both to phimosis itself, because of the thickening of the Buck’s fascia, and also to scar contraction after circumcision.
Many factors such as genetic predisposition, history of non-gonococcal urethritis, smoking habit, fibrotic lesions of the genital tract or previous urologic surgical procedures can lead to formation of asymptomatic fibrous cords at the level of penile fascia, with various degrees of contraction [
13‐
15].
The suspensory apparatus of the penis is part of the deep fascia of the abdominal wall, it consists in the fundiform ligament, the suspensory ligament proper and the arcuate subpubic ligament.
The fundiform ligament is superficial and not adherent to the tunica albuginea, whilst the suspensory ligament proper bridges between the symphysis pubis and the Dartos and Buck’s fascia of the corpora cavernosa, it splits to surround the penis and then unites and blends inferiorly with the Dartos’ fascia forming the scrotal septum.
In our paper we described an ancillary technique in circumcision procedure in which we performed a release of the areolar tissue of the preputial skin, inducing a relaxation of the adherences of the Buck’s fascia of penis.
In this way the corpora cavernosa are decompressed and, in our opinion, that is the reason why the circumference of the penis is significantly lengthened after the procedure.
The technique we described does not differ in its rationale from scar revision and nerve decompression procedures [
16,
17].
For what concerns the gain in terms of penile length, the rationale should be related to the fact that Buck band is in continuity with the suspensory ligament of the penis, consequently its surgical release determines an elongation of the penis shaft.
After surgery the mean of gain of circumference observed was 0.95 + 0.71 cm, while in terms of length was 0.7 + 0.56 cm.
These data are comparable to the results obtained by other penis enlargement techniques, but to date there is no evidence of a contraction of the buck band in healthy patients, and therefore there is no evidence that this operation can lead to an increase in penis size even in healthy patients.
Further studies will be necessary to verify these premises in order to determine the real effectiveness of the technique also in penile cosmetic surgery.
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