Background: In penile enlargements it is not uncommon to augment the underlying scrotum either at the same time or secondarily to maintain penile-scrotal proportions. In testicular size enhancements there are two different implant approaches, side by side and some form of wrap around implant. Each has their advantages and disadvantages and neither approach is perfect.
In the side by side implant technique a pair of implants is placed amongst the existing testicles. The goal is that the implants become the dominant visible testicles by pushing aside (displacing) the natural testicles. To be effective in that goal the implants have to be large enough to become the most visible structure in the scrotum. While it is not an exact science as to how much bigger the implant has to be than the natural testicles, and there are other factors such as the amount of scrotal skin that also comes into play, but it is fair to say that just a little bigger is not enough. When this is done all four implants and testicles are seen like a bag of grapes. (aka a four pack)
It has been my experience with the side by wide testicular enhancement technique that the implant needs to be at least 50% bigger than the natural testicle. The implant has the advantage that it is not attached by a cord so it will naturally sit lower than the testicles. But the implants also have to be big enough so that the natural testicles does not ride up over the top of the implant and are still seen.
Case Study: This young male had a penile implant with the placement of two ‘displacing’ silicone testicle implants four years previously. The implant size was 5.0cms. His natural testicles were 4.5cms. This resulted in a ‘4 ball’ appearance. To improve the displacing effect of the implants custom designs were done of 7.5cms.
Under general anesthesia and through a small midline raphe incision, the testicle implants and the testicles were compared side by side with minimal difference between them. Comparing the removed implants to the new pair the size difference could readily be seen.
The existing testicle implants were removed and the capsules expanded superiorly, inferiorly and laterally. The two implants pockets were kept separate as they were expanded/stretched. The new 7.5 implants were placed and their capsules closed after the introduction of antibiotic powder. A three layer soft tissue closure was then done with resorbable sutures.
The changes from a 4 pack to a larger 2 pack scrotal appearance was created due to the greater displacing effect of the larger implants.
With the 50% increase in testicle implant size the much smaller natural testicles are more readily hidden.
Case Highlights:
1) In the side by side testicular implant enhancement technique the implant must be at least 50% bigger than the natural testicles to be effective. If not the scrotum will show all 4 occupants in it equally.
2) For visual improvement the testicle implant replacements in this case were 7.5cm compared to the indwelling 5.0cm size.
3) In the implant replacement the capsule needs to expanded and the existing testicle pushed back as far posteriorly and superiorly as possible.
Dr. Barry Eppley
World-Renowned Plastic Surgeon