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Background: Like many body structures aging affects their appearance over time. The male scrotum is no exception. As an envelope of skin, fascia and muscle that surrounds the dangling testicles the influence of a lifetime of friction between the thighs and the effects of gravity are bound to affect the scrotal appearance.

But the biggest influence on scrotal appearance is the size of the testicles. Testicular size does change over time and atrophy is common as their importance in youth become less important later in life. But the more recent use of testosterone hormone supplementation has the most profound influence. By disrupting the neural connection between the brain and testicles they will stop producing natural testosterone and shrink. Average loss of testicular size over time is reported to be about 50%. 

With the loss of testicle size, whether the scrotal tissues shrink as a result or merely become a loose empty sac, a disruption of the size relationship between the penis and scrotum results. While there is no anthropometric studies that clearly define what the penis-scrotum size relationship the patient perception of it is ultimately what matters.

Thus the older male on testosterone represents the most common patient who seeks testicular enhancement. If the testicles are small enough the side by side implant technique works best with few complications. The choice of implant size is a balance between natural testicle size, an adequate implant size for testicle displacement and the patient’s aesthetic desires.If we make the generalized assumptions that the average atrophied testicle size is around 3cms and applying the minimum 75% size increase rule then the minimum implant size would be 5.5cms.   

Case Study: This older male (mid 70s) had a small scrotum due to testicular atrophy with a size around 3.0cms. Interestingly the scrotum skin was tight and not lax. The testicles could not be seen as of they also had excessive retraction.

Under general anesthesia and through a low midline raphe incision bilateral pockets were developed with preservation of a midline septum of soft tissue for 5.5cm side solid testicle implants. The natural testicles were identified in a very high position around the base of the penis. After implant placement and covering them with Vancomycin antibiotic powder a four layer closure was done with resorbable sutures. 

His immediate intraop appearance showed an increase in scrotal size. Over time the testicle implants will drop down as the scrotal skin relaxes.

Technically the side by implant technique is not really side by side per se. It is really a high-low relationship with the implant eventually sitting lower in the scrotum than that of the natural testicles. They then assume the dominant appearance in the scrotum as the smaller natural testicles tethered by the neurovascular cord are pushed upward.

Key Points:

1) Testicular retraction/atrophy due to aging and hormonal supplementation can lead to penile-scrotal disproportion.

2) The side by side tecsticular enhancement technique needs a minimum 75% increase in implant size over that of the testicles to be successful.

3) The low midline scrotal incision ensures a low implant position in the scrotum.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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