Comment to: Trans-scrotal Suspensory Ligament Release: A Novel Technique for Penile Length Augmentation

We read with great interest the article titled ‘‘Transscrotal Suspensory Ligament Release: A Novel Technique for Penile Length Augmentation’’ by Karimian and al. [1] Penile size concerns are prevalent among men, leading to dissatisfaction, anxiety, and disorders when the esthetic ideals are not respected. Inferior dimensions of the penile shaft could be responsible of urinary abnormalities, sexual dysfunction, high discomfort, and psychological distress. In the article, the authors analyzed a novel technique to enable penile lengthening by combining the release of the fundiform and suspensory ligaments with V-Y flaps at the scrotal and suprapubic region. We congratulate with the Authors for their interesting technique, but we have some elements to discuss. The technique appears very interesting, especially the scrotal approach for releasing the ligaments with the aim of concealing scars. However, regarding the need to recruit skin to elongate the penile shaft, we believe that V-Y flaps may present some limitations: limited skin availability, suprapubic skin differing from penile skin, and potential retraction over time. Several techniques have been described for the penile skin shaft recruitment. Free flaps, due to their bulky nature, might represent poor esthetical outcomes and unnatural appearance, producing some difficulties during penetration. Basing on like-to-like principles, local flaps, harvested from the scrotum, seem to be the most suitable solution for penile skin shaft recruitment. In fact, the skin of the scrotum shows similar color, adequate thickness, optimal pliability, suitable elasticity, and appropriate consistency, able to provide a large amount of tissue and obtaining satisfactory outcomes in terms of esthetic and functional result, avoiding also mismatch disorder. Moreover, the multi-origin vascular system providing the scrotum is supported on each side by four different vessels: the anterior and lateral scrotal artery, the lateral branch of posterior scrotal artery, and the septal scrotal artery. [2–5] These vessels running through Dartos fascia render the scrotal Dartos-myo-cutaneous flap an axial flap, allowing safely a single surgical operation, primarily closure of the donor site, avoiding discomfort related to a second procedure and the vascular network of the scrotum allows a large amount of customized tissue, harvesting in a single step.