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Background: One technique of testicular enhancement is known as a side by side displacement method. In this approach testicle implants are placed below the existing testicles in the scrotum which, by by their size, becomes the dominant structure seen…hiding or displacing the smaller natural testicles. An approach which on the surface seems unlikely to work but does.

There are two reasons why the side bye side technique is effective, one controlled by the implant design and the one a natural effect that distinguished the natural testicle from an implant. In regards to the latter the natural testicle is attached and tethered by a cord (neuromuscular pedicle, thus they naturally want to be pulled up and ride higher in the scrotum. Conversely an implant has no such tether so they naturally by weight and gravity will always sit lower. 

From an implant design standpoint the key is having an implant that is large enough to have a displacing effect. How much larger the implant needs to be than the natural testicle is not known precisely but my experience is that a minimum of 50% and more ideally 75% size is needed. This is predicated having a good idea of what the natural testicle and if there are any significant differences between the two sides. A preoperative ultrasound is useful for establishing the exact size of the natural testicles.        

Case Study: This male desired to have testicular enhancement with the size by side approach. Ultrasound imaging determined that a 75% increase in size required the implants to be 5.5cms in length on the right side and 5.2cms on the left. But also looking at the shape of the natural testicles including the epididymis showed they were different than the traditional implant shape of the width being 0.7 that of the length. Rather  the width was different being 4.8cm in side view and 0.4 width in the craniocaudal view for the right implant (56cc volume) and 4.4cm and 3.9cm for the left implant. (47cc volume)  This means that the shape of the implants are not perfectly round but more elliptical in shape.

Under general anesthesia and through a midline raphe incision, he had a naturally wide long white raphe which looked like a scar but wasn’t, implant pockets were creating bilaterally preserving  a thick midline septum of tissue.

After the placement of Vancomycin powder a 4 four layer midline closure was done with resorbable sutures.

The side by side displacement technique works by adequate size and volume of implants that push the natural smaller testicles up and out of the way. With a 75% volume increase needed to do so satisfactorily the minimum implant size for most patients is 5.5cms which assumes that the natural testicle implants size is around 3.0cms. Larger natural testicle sizes will push implant volumes into the 6.0cm size or larger.

In this case study the use of ultrasound imaging established a 3D assessment of natural testicle shape which translated into unique implant shapes that mimicked that of the natural testicles only bigger. Does this make for better implant displacement of the natural testicles? Maybe but presently unknown. But the concept of knowing precisely what the natural testicle size and shape is certainly has value.   

Key Points:

1) The side by side technique for testicular enhancement relies on implants large enough to satisfactorily push aside/hide the smaller natural testicles.

2) Preoperative ultrasound assessment of the natural testicle dimensions provides valuable insight into the design of the custom testicle implants.

3) In placing custom testicle implants a midline septum of tissue should be maintained between the two implant pockets.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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