Introduction
Testicular enhancement surgery aims to increase the visible size of the testicles within the scrotum using implants. The goal is to create the appearance of a single pair of enlarged testicles—those being the implants themselves.
This is best achieved using a displacement technique, in which the implants are large enough to camouflage or displace the patient’s natural testicles from view. For optimal results, the implants should be at least 75% longer and 100% greater in volume than the natural testicles. This method is highly effective, particularly in older men who have experienced testicular atrophy.
While most patients seek the appearance of two larger testicles, a rare exception involves individuals who specifically desire the appearance of four testicles—a so-called “four-ball scrotum.” Typically, this is an outcome surgeons try to avoid, as it occurs when implants are too small to adequately conceal the natural testicles. Such cases often result from the use of standard (e.g., 5 cm) implants rather than custom-designed, larger ones.
For those rare patients intentionally seeking a four-testicle appearance, implants equal in size to the natural testicles can be placed. This represents a non-displacement approach to testicular enhancement.
Case Study
A young male patient with normal-sized testicles specifically requested a four-testicle appearance. Preoperative ultrasound measured his natural testicles at 4.5 cm, which falls within the normal to upper-normal size range.
Custom implants measuring 4.5 cm were fabricated with a hollow inner chamber and a small connecting channel extending from one end. Through a 3 cm midline scrotal incision, pockets were created, and the implants were inserted using a funnel delivery system. The implants were packed with Vancomycin antibioticpowder using the open channel into the hollow chamber.
After multilayer closure with resorbable sutures, immediate scrotal fullness was observed. Initially, the four distinct testicles were not visible. However, as postoperative swelling subsides and the scrotal tissues relax and conformed around the implants, the four separate testicle contours will become apparent.