Complications and Management of Penile Girth Enhancement with Acellular Dermal Matrix
Tingmin Xu MD; Guoxi Zhang Prof; Wenjun Bai Prof; Qing Li Prof; Anpu Yang PhD; Qiushi Lin PhD; Tao Xu Prof; Xiaowei Zhang Prof
FIRST PUBLISHED: October 24, 2019 – The Journal of Sexual Medicine
Penile size has been a source of anxiety for many men, even if its length and girth measurements fall into a normal range. These men may seek penile girth enhancement (PGE) surgery.
The use of acellular dermal matrix (ADM) in PGE surgery has become more frequent over the years. This study focused on common complications associated with this filler.
Materials and Methods
Clinical records were reviewed for 78 men who underwent PGE with ADM between June 2016 and January 2019. The men ranged in age from 21 to 66 years, with an average age of 31 years.
Surgery was described as follows:
All patients were placed in the supine position. Under local or spinal anesthesia, a circumferential subcoronal incision was used for penile degloving. The incision was deepened through the skin and Colles’ fascia, and down to Buck’s fascia, which was preserved. The shaft was then degloved down to the root of the penis. One or 2 layers of ADM (10 × 10 cm, J-1 ADM, Beijing J.Y. Life Tissue Engineering) were cut according to the penis size and several mesh-like incisions were made in the penile shaft to guarantee vessel regeneration. The modified ADM was then wrapped around the penile shaft from the coronal sulcus to the root. These grafts were then sutured to Buck’s fascia with 4-0 vicryl from the root to the coronal sulcus of the glans. A pressure bandage was then used to wrap the penis with moderate compression to avoid shifting of the grafts, hematoma, and/or edema of the penile shaft. Antibiotic prophylaxis was administered the night before surgery and continued for 1 week after surgery. Patients were instructed not to have sexual intercourse for 2 months after surgery.
After a three-month follow-up period, the average penile circumference increased by 1.1 centimeters. About 72% of the patients experienced complications, and ADM removal was necessary in 7 patients (9%)
The following complications were reported:
|Type||# of patients affected||% of patients affected||Description|
|Erectile discomfort||47||60.26%||“dragging sensation during erection”|
|Delayed healing||12||15.38%||skin cracking and graft exposure|
|Unobvious effect||10||12.82%||disappointment with thickness|
|Wound hematomas||8||10.26%||oozing of blood and swelling of surrounding skin|
|Foreskin edema||7||8.97%||swelling of distal end of foreskin|
|Skin necrosis||3||3.85%||always on dorsal side above graft, skin turned dark red, then black and necrotic|
|Wound infection||4||5.13%||often secondary to skin necrosis|
Erectile dysfunction and Peyronie’s disease were not reported as complications in this group of patients
Most complications began within 10 days of surgery and resolved within 60 days.
Seventy patients (90%) said they would be unwilling to have the surgery again.
- Foreskinedema was the most common complication. Generally caused by lymphostasis, foreskinedema generally begins within 3 – 5 days of PGE surgery and lasts for varying durations. In this study, 88.46% of the patients had this complication after 2 weeks. The rate dropped to 38.46% at the 4-week follow-up and was again reduced to 8.97% at the 12-week point. Foreskinedema may be treated with compression.
- Hematoma may be caused by “excessive intraoperative separation and incomplete homeostasis.” Hematoma may be managed with regular pressure dressing.
- Delayed healing. Some of the patients with short foreskin “developed high tension around the wound” which limited blood supply. As a result, wounds did not heal and skin cracked. With daily dressing changes, wound healing occurred for 7 of the 12 affected patients; the remaining 5 men had to have the ADM surgically removed.
- Penile skin necrosis. “We hypothesize that the suspensory ligament of the penile root was disconnected during incision, as well as the dorsal capillary network from the abdominal wall to the penis, resulting in poor blood supply and necrosis of the skin on the dorsal side of the penis.” Reconstruction with a bipedicle scrotal flap was conducted for these patients with satisfactory results.
- Infections. The most common flora were Staphylococcus aureus or Escherichia coli. It’s possible that urine contaminated the wound and nocturnal penile tumescence caused tension. Infection risk can be reduced with routine dressing and topical antibiotics.
- Erectile discomfort had the highest incidence of all complications and “nearly always manifested as traction during erection.” For some men, this complication lasted for six months after surgery. ADM is “less mobile than the penis during erection.” Four patients with this complication underwent ADM removal.
- Dissatisfaction with results. ADM thickness is about 1 mm to 2 mm, and sometimes 2 to 3 layers are needed for desired results. In some cases, men’s expectations were not met. The treatment can also be expensive.
Another filling material, hyaluronic acid, has been shown to be effective and safe. It is “an ideal filling material for soft-tissue augmentation” and has a low incidence of complications. However, surgeons working with hyaluronic acid should have “relatively advanced surgical skills.”
“In summary, this study showed that even with standardized surgical methods and rigorous postoperative care, ADM use in PGE results in a high complication rate and poor patient satisfaction. Thus, ADM is not an ideal or safe method for PGE.”