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Background: The empty scrotal syndrome (ESS) is an aesthetic description for when the male scrotum has no visible testicles even though they are present. This can occur for the obvious reason that the testicles are either undescended or are very small due to atrophy from aging or hormonal supplementation. A less common reason is testicular retraction  due to an overactive cremaster muscle.

The cremaster muscle is a thin layer of two different types of muscles that covers the testicles and spermatic cord . As an involuntary muscle it creates the well known cremaster reflex pulling the testicles upward as a protective response. This cremaster reflex can become overactive in some men creating chronic muscle spasms and discomfort. (orchialgia) It can also cause persistent testicular retraction, without pain, making the scrotum less full with no testicular show. Recent anatomic studies have shown that the cremaster muscle is thicker than normal when the reflex is overactive  

Treatments for an overactive/thickened cremaster muscle consists of the regular application of heat, regular stretching/testicular pull down, Botox injections (Scrotox) and microsurgical subinguinal cremaster muscle release. From a pure aesthetic standpoint Botox (Scrotox) injections are popular with the intent of creating increased aesthetic scrotal fullness. It can make the testicles appear bigger and create a smoother scrotal appearance. The ‘problem’ with Botox injections is that its effects are short-lived (3 months) and each treatment is not inexpensive. 

Case Study: This male had persistent testicular retraction with an empty appearing scrotum which was not associated with pain. He had been through a previous ineffective cremaster muscle release procedure to get his testicles to have a naturally lower scrotal position. He now opted for testicle implants to create better testicle show. A side by side implant technique was chosen with a 5.5cm implant size.

Under general anesthesia and through a 3cm low scrotal incision submuscular pockets were developed on each side. His natural testicles were seen high in the scrotum. One key part of the testicle implant procedure is to maintain a midline segment of tissue between the two implant pockets to a avoid creating a single implants pocket where both implants touch and move around like ball bearings.

The implants were placed, covered with antibiotic powder and closed in four layers with resorbable sutures.

While the placement of implants provides an obvious method of enhancing the appearance of the testicles, it also has other biologic effects. The other effect with implants in testicular retraction is to release the cremaster and dartos muscles low in the scrotum and maintain their stretch by implant displacement. Like all side by side testicle implant patients the goal is to overwhelm the size of the natural testicles so that only the implants show. Having natural testicle retraction should ensure that occurs.

Key Points:

1) Retracted testicles can improve the appearance of the empty scrotal syndrome. (ESS)

2) Unsuccessful cremasteric releases prove that implant expansion would be the remaining scrotal augmentation option . 

3) A low midline raphe incision ensures that the implants are positioned below the natural testicles and can push up on the natural testicles making the side by side implant technique an effective augmentation method.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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