Background: The scrotum is thin external sac that is composed of skin and muscle. (aka a fibromuscular cutaneous sac) It has two testicles that have separate compartments divided by a septum of tissue. This septum is more robust than most realize usually being 5 to 6mms thick. These two compartments are evidenced externally by the visible midline raphe seen down the midline of the scrotum. This raphe connects to the septum underneath it.
When replacing the testicles with implants it is important to try and keep the two compartment scrotal concept, particularly in bilateral replacements. With loss of one testicle an implant will develop encapsulation and by this natural process will develop its own compartment. But with the loss of both testicles and subsequent implant replacements one large mega compartment will develop if the implants touch during placement. Despite having two implants two separate compartments will not develop. Rather one single compartment with two implants moving around inside can lead to chronic seromas. (fluid collections)
The need for bilateral testicle implants is not uncommon in side by side testicular enhancements. Even with the existing testicles in place it is usually very possible to keep a tissue septum between the two implants. The more challenging but far less common situation is when the scrotum is devoid of natural testicles or implants, the so called empty scrotal sac. (ESS) The only time I have seen ESS is when both testicles have been removed and replaced with implants…which were then lost due to infection.
Case Study: This male presented with ESS with loss of bilateral implants two years previously due to infection. His testicles had been removed due to atrophy/small size.
Under general anesthesia a midline raphe incision was made and bilateral pockets were developed [reserving a midline septum off tissue despite all of the scar tissue. The left 6.5cm implant was placed first and the right 6.5cm implant second.
Each implant had a separate primary closure over it followed by a three layer midline closure with resorbable sutures. Despite the large size of the implants the closure was not overly tight.
When any size or type of bilateral testicle implants are placed it is paramount to try and keep a midline septum of soft tissue between the implants. This will allow for each implant to form a separate capsule. This is usually quite easy to do in a non-scarred scrotum even with natural testicles intact. But in the empty scrotum, which is empty for a reason, there is bound to be considerable scar tissue present. This is more challenging but with dissection sharply turned to the sides once past the incision it can usually can be accomplished. What raises the bar on this challenge is when custom testicle implants are used which are always bigger than 5.0cms. and occupy more intrascrotal space.
Key Points:
1) The empty scrotum can occur from testicle removals or loss of testicular implant replacements.
2) The empty scrotum because of its origin will have considerable scar tissue that can limit how much new implant expansion can be done.
3) In bilateral testicle implant placements effort should be made to keep a soft tissue partition between the two implants.
Dr. Barry Eppley
World-Renowned Plastic Surgeon