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Background: The scrotum is a unique male structure that is essentially a dual-chambered sac of hanging skin and smooth muscle. Its main components are the testes and epididymis along with some spermatic fascia. It hangs outside the body for functional reasons which are primarily the regulation of testicular temperature as well as protection from internal abdominal pressure. With age and other factors the scrotal skin may increase and hang lower along with ‘sagging’ testicles. 

How much the scrotum should hang from the base of the penis is not an exact aesthetic measurement. Whether it hangs excessively is often a matter of personal preference or can certainly be considered excessive if the amount of hanging skin causing chaffing of the inner thighs or chronic scrotal skin irritation. With excessive scrotal skin often comes very low hanging testicles which can affect one’s quality of life with difficulty in finding clothes to fit or even going to the bathroom.

The only solution for scrotal sagging/low hanging testicles is scrotoplasty or a scrotal lift, a surgical tightening procedure that removes scrotal skin.  Most commonly done by a vertical elliptical excision it essentially has a hammock effect to lift and tighten the scrotum. In doing so the testicles are elevated in position as the scrotum is vertically shortened. How much scrotal skin removal and lift is done is determined on an individual basis based on how small or large one wants the scrotum to be.

Case Study: This male had a history of trauma to the scrotum which resulted in a large amount of swelling and resultant loose skin. He also had a history of a prior left testicle removal years previous to the trauma so his one remaining testicle hung exceptionally low. He desired a significant scrotal reduction with the goal of having a scrotal size no larger than a chicken egg. 

Prior to surgery the planned amount of vertical skin resection was marked in both the standing and sitting positions. This was a full length resection which started several centimeters down from the base of the penis and extended all the way back to the scrotal-perineal skin junction. Under general anesthesia in the operating room when stretching out the penis the extent of the marked resection was 22cms long and 12cms at its greatest width.

The skin was initially excised with a scalpel along the marks and then the skin removed off of the fascia with electrocautery. The lower 2/3s of the closure was performed by multiple layers of fascia plication and skin closure. At the established location of where the new shape of the hanging sac began, closure was done at the dermis and skin only to allow the scrotal contents to ‘herniate’ into the new scrotal position. All sutures used were resorbable.

By definition a scrotal size reduction is a lift which reshapes the scrotal sac. Hw much skin is removed and its pattern of removal will dictate the final size of the sac. Most patients can help determine the amount of skin resection by simple digital plication. But as the resection gets larger this can become a less reliable indicator since the scrotal skin is so elastic. On the one hand one wants to avoid over resection since you can’t put skin back but, conversely, under resection with some persistent excessive hanging is also to be avoided. (although preferable to over resection as more can always be removed secondarily) Having a descriptor of the desired postoperative scrotal size is a helpful intraoperative aid, as illustrated in this case, where such a size reduction may be thought to be too extreme.

Case Highlights:

1)  Scrotal reduction removes excessive hanging skin with or without testicle plication.

2) It may be necessary to extend the scrotal reduction onto the perineum to adequately remove all of the posterior scrotal skin.

3) How small the scrotum can become depends on the patient’s goals for a round shape and is controlled by the vertical extent of the resection.

Dr. Barry Eppley

World Renowned Plastic Surgeon

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