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Background: Aging affects all body structures and the testicles are no exception. Testicular size does change with aging in the smaller direction. The natural effects of aging on testicle size can be increased by the hormonal influence of testosterone which is a frequent older male supplement. Once testicle size gets small enough the scrotum can appear ‘empty’. (Empty sac syndrome) This is the result of not only a smaller testicle size but the cord attachment to it which naturally pulls it upward and away from the bottom half of the scrotal sac.

Testicular enlargement for the empty sac syndrome can be done by two methods: direct and indirect. From an implant standpoint this can be described as a wraparound (direct) and a side by side displacement approach. (indirect) With existing testicles present it is logical to assume that trapping the existing testicles would be the preferred approach. While such a concept is appealing it is not without complications which are primarily disengagement. (the implant pulls away from the testicle) Unfortunately this is not rare which makes the side by side technique worth considering since this is not a complication that it has.

The displacement or side by side technique can be effective based on two principles, one obvious and one less so. From a sized standpoint if the implant is significantly bigger than the natural testicle then it becomes the dominant structure in the scrotum. (obvious effect) Secondarily the testicle implant has no superior attachment (cord) to pull it upward. This lack of an attachment allows it to passively sit lower in the scrotum, keeping the natural testicle up high and away effectively displacing it. (non-obvious effect)

Case Study: This middle aged male had testicular atrophy in which the testicles could not be palpated. The scrotum felt empty although there were testicles present. It was presumed the testicle size was 3.5cms or less. He opted for a side by side enlargement method choosing 5.5cm size.  

Under general anesthesia and through a small midline raphe incision scrotal pockets were dissected out keeping a septum of tissue between the two sides. The right testicle was seen and it was small (2.5cm) and was highly positioned. The 5.5cm implants were placed and posed no problems for a tension-free 4 layer closure.

Small retracted testicles can make the scrotum look and feel empty. The side by side testicle implant displacement technique can be effective as the implants are placed low and will develop a more visible position once the swelling subsides and the tissues relax. Their lack of a cord attachment makes this an inevitable postoperative sequelae. The implants must be large to adequately fill the scrotum and I would consider the 5,5cm size to be the smallest that should be used for this enlargement technique.

Case Highlights:

1) Aging and testosterone supplementation can shrink the natural size of the testicles to the point where the scrotum may appear and feel empty. (Empty Sac Syndrome)

2) With non-palpable testicles implants any the very upper range of normal size can be effective as a side by side enhancement technique.

3) A low midline raphe incision and the non-attached nature of testicole implants is what makes the side by side technique effective for some patients.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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