International Journal of Impotence Research (2008) 20, 519–529

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REVIEW
Penile size and penile enlargement surgery: a review
BE Dillon1, NB Chama1 and SC Honig2,3
1
Mount Sinai School of Medicine, New York, NY, USA; 2Urology Center, New Haven, CT, USA and 3Division of Urology,
University of Connecticut, Farmington, CT, USA

Penile size is a considerable concern for men of all ages. Herein, we review the data on penile size
and conditions that will result in penile shortening. Penile augmentation procedures are discussed,
including indications, procedures and complications of penile lengthening procedures, penile
girth enhancement procedures and penile skin reconstruction.
International Journal of Impotence Research (2008) 20, 519–529; doi:10.1038/ijir.2008.14;
published online 22 May 2008

Keywords: penis; penile shortening; penile augmentation; penile lengthening; penile girth
enhancement

Introduction Association sanctioned procedure, and typically

Throughout history, the penis has defined masculi-
nity. Discussion of the penis has been deemed taboo,
socially unacceptable; and at other times, it is the
topic of lighthearted conversation and jokes. Length,
girth and function, however, have been an issue for
men throughout history. This is apparent in the first
book of the Old Testament, Genesis, where Abraham
is told, ‘Every male among you shall be circumcised.
You shall be circumcised in the flesh of your
foreskins, and it shall be a sign of the covenant
between me and you.’1 The ancient Greeks were also
fixated on the penis, as recorded by Kallixeinos of
Rhodes in 275 BC, who described a ‘golden phallus,
180 feet long’. The phallus was topped with a
golden start and was carried through the streets
during a festival in Alexandria, all the while people
sung to it and recited poems.1
Kelley and Eraklis2 performed the first recorded
penile augmentation in 1971 for the treatment of
microphallus in the pediatric population. Subse-
quently, the adult population began to show interest
in the procedure for cosmetic and psychological
reasons, similar to that seen with reconstructive
breast surgery and augmentation. Penile augmenta-
tion procedures are not an American Urological
Correspondence: Dr SC Honig, Division of Urology,
University of Connecticut, 330 Orchard Street, Suite 164,
New Haven, CT 6511, USA.
E-mail: stan.honig@gmail.com
Received 6 November 2007; revised 3 April 2008; accepted
7 April 2008; published online 22 May 2008
both plastic surgeons and urologists perform penile
enlargement procedures. The purpose of this paper
is to summarize the available literature on penile
size, discuss conditions that contribute to penile
shortening, and to highlight the indications, proce-
dures and complications of penile enlargement
surgery.
Penile size
Paintings and writings by the ancient Greeks, as
early as 200 BC suggest that they believed that a
smaller penis was superior.1 However, over the
course of time, with the various sexual revolutions
this belief has changed and for most men, larger is
better and comparisons to the rest of the general
population matter. This is evident in the terms
‘phallic identity’ and ‘phallocentrism’. ‘Phallic
identity’, as described by Vardi, is the concept of a
man seeking identity in his penis, which a focus on
bigger is better. Similarly, ‘phallocentrism’ is the
concept that the penis is central to a man’s identity.3
Penile size has been suggested to correlate to
certain physical characteristics. There has been
some data suggesting no correlation between shoe
size and penile length by Shah and Christopher in a
small 2002 study. They studied 104 men from 54 to
87 years of age. All penises were measured on full
stretch and the foot size of each patient was
recorded. After linear regression analysis, there
was no statistical correlation between stretched
penile length and shoe size.4
 Penile size and penile enlargement surgery
BE Dillon et al
520
Figure 1 Penile length from pubopenile skin to meatus and fat
pad depth from pubic bone to pubopenile skin. Reprinted with
permission from Journal of Urology.
Specifics of measurement of penile size is im-
portant in comparing data in different papers.
Although there is no standard technique for measur-
ing penile size, there appears to be a consensus
among researchers that penile length should be
measured on the dorsum of the penis beginning
from the pubopenile junction to the tip of the glans
(Figure 1).5 This measurement applies to the flaccid,
stretched and erect states. In addition, measure-
ments of penile girth should be obtained from the
middle of the penile shaft, in all three states. For the
purpose of clarity of nomenclature, a flaccid penis is
one that is unstimulated or not aroused, and would
be seen when the man is in the normal anatomical
position. Flaccid stretched is when the flaccid penis
is pulled to its maximal distance. Lastly an erect
penis is one that is maximally stimulated, either
through visual, tactile or pharmaceutical manipula-
tion.
To date, there have been few studies published on
penile size. The first reported study was conducted
by Loeb in 1899, where he examined 50 subjects, age
ranging from 17 to 35 years. He measured the penis
only in the flaccid state and found the average size
to be 9.41 cm.6 It was not clearly stated how
measurements were made. In 1942, Schonfeld and
Bebe looked at the normal variability of penile size,
both length and girth of the penis from birth to
maturity. With respect to penile length, measure-
ments were recorded only in the stretched state,
however they looked at penile girth in both the erect
International Journal of Impotence Research
and flaccid conditions. They found that the average
stretched length was approximately 13.1 cm (13.26
for 61 men aged 17 years, 13.11 for 71 men aged 18–
19 years and 13.02 for 54 men aged 20–25 years). In
addition they found the average girth of the flaccid
penis (location of measurement not mentioned) to
be 8.5 cm, and the average girth of the erect penis to
be 15.8 cm.7
In 1948, Kinsey published his hallmark paper on
penile length, which until 2001 was the largest
published series. Kinsey examined men between the
ages of 20 and 59 and measured subjects in both the
flaccid and the stretched flaccid states. He found
that the average flaccid length was 9.7 cm and the
average stretched length was 16.74 cm.8
Nearly 50 years later in 1992, Bondil et al.9
studied 905 men from age 17 to 91 years, to examine
the ‘extensibility’ of the penis. Penile length was
recorded in three conditions; flaccid, maximal
flaccid stretched and flaccid after stretch. The
maximal flaccid stretched length was achieved by
pulling on the glans three times, allowing for ‘tissue
viscoelasticity.’ After the penis was measured at its
maximal flaccid stretched length, it was then
remeasured in its flaccid length, which they defined
as ‘flaccid after stretch’. Lengths were found to be
10.7 and 16.74 cm in the flaccid and stretched states,
respectively.9 They concluded that extensibility
decreases with age.
In 1992, da Ros and colleagues published the first
series examining the length of the erect penis. The
study was conducted in a group of Caucasian men
who were interested in penile lengthening. 150 men
were enrolled in the study and were given an
intracavernosal injection of papaverine and prosta-
glandin to achieve erection, after which measure-
ments were obtained. Measurements of girth were
taken both proximally and distally. The authors
found that the average erect length in their 150
subjects was 14.5 cm, proximal girth 11.92 cm and
distal girth 11.05 cm.10 After data were collected,
and information was shared about the ‘normal’
ranges of penile length, men were no longer
interested in penile lengthening surgery.
In 1999, Bogaert and Hershberger11 investigated
the relationship between sexual orientation and
penile size. The authors had two cohorts, of 935
homosexual men and 4187 heterosexual men with a
mean age of 30 in both groups. Self-reported penile
length was performed in five measurements; esti-
mated erect size, flaccid penile length, erect penile
length, flaccid girth and erect girth. The authors
reported that there was a significant difference in
both penile length and girth in this self-reported
mailed questionnaire population. The average flac-
cid homosexual penis was 10.41 cm as compared to
9.83 cm for heterosexual men. The average erect
penis was 16.40 and 15.60 cm for homosexual men
and heterosexual men, respectively. Furthermore,
flaccid penile girth measurements were 9.75 cm for

homosexuals and 9.40 cm for heterosexuals. Lastly,
erect girths measured 12.57 and 12.19 cm in homo-
sexual men and heterosexual men, respectively.11
The validity of self reported measurements needs to
be considered when evaluating these data.
Wessells et al.5 published their data regarding
penile length and indications for penile augmenta-
tion. They examined penile lengths in 80 men with a
mean age of 54 years. Patients were excluded if they
had any penile abnormalities (that is, disease,
history of urethroplasty or congenital deformities).
Measurements were taken in the flaccid, stretched
and erect conditions. Measurements of the erect
penis were obtained by injections with prostaglan-
din E1, and in some cases of incomplete erection
phentolamine/papaverine were added to achieve
full erection. The average flaccid length was 8.85 cm
(s.d. ¼ 2.38); average stretched length 12.45 cm
(s.d. ¼ 2.71) and the average erect length 12.89 cm
(s.d. ¼ 1.31). Girth was recorded midshaft in the
flaccid condition and erect conditions at 9.71 cm
(s.d. ¼ 1.17) and 12.30 cm (s.d. ¼ 1.31), respectfully.5
The largest study on penile length was published
in 2001 by Ponchietti et al.,12 with a sample size of
3000 Italian men. The goal of their study was solely
to determine the variability in penile size. Subjects
ranged from age 17 to 19 years and measurements
were recorded in the flaccid and flaccid stretched
states. Flaccid circumference was recorded in the
middle of the shaft. Mean flaccid length was 9.0 cm
(s.d. ¼ 2.0), mean stretched length was 12.5 cm
(s.d. ¼ 2.5) and mean circumference was 10.0 cm
(s.d. ¼ 0.75).
Schneider et al.13 looked at the relationship
between penile size and problems associated with
condom use. Their experimental population con-
sisted of 111 men aged 18–19 years. Measurements
were carried out in the flaccid length, and subjects
were given calipers to measure penile width, not
circumference. The average self reported flaccid
Penile size and penile enlargement surgery
BE Dillon et al
521
penis measured 8.60 cm (s.d. ¼ 1.50), whereas the
average erect penis was 14.48 cm (s.d. ¼ 1.99).13
In 2005, Awwad et al.14 published his series of
patients examining penile size in Jordanian men
with and without erectile dysfunction. In the 271
‘normal’ subjects aged 17–83 years, they found that
flaccid length was 9.3 cm (s.d. ¼ 1.9), stretched
length 13.5 cm (s.d. ¼ 2.3) and penile girth 8.9 cm
(s.d. ¼ 1.5). Table 1 summarizes all the aforemen-
tioned studies12 (Table 1).
After reviewing these data, some conclusions can
be drawn regarding penile length and girth. With
respect to penile length, average penile size is B9.0–
9.5 cm in the flaccid state, whereas the maximally
stretched flaccid length is B14.5–15 cm. Average
erect penile length ranges from 12.8 to 14.5 cm and
the average penile girth is B10.0–10.5 cm. What is
the significance of these findings? Most of the
papers had standard deviations of B2 with respect
to penile length and standard deviations of B1
when looking at penile girth. By applying these
findings, one might be able to assess the patients
who are 2 s.d. below the average size. This appears
to be the patients who have a flaccid penile length
o5 cm, or mid shaft penile girth o8.0 cm.
These data give reconstructive surgeons a starting
point as to when penile augmentation might be
deemed medically necessary or appropriate.
Conditions causing penile shortening
Penile shortening is a phenomenon that is asso-
ciated with certain medical and surgical conditions.
These conditions include prostate cancer patients
treated with radical prostatectomy, Peyronie’s
disease and congenital anomalies. There is also
some evidence that erectile dysfunction may be an
independent risk factor for shortening.

Table 1 Summary of penile size articles

Authors Year Number of Age Flaccid length Stretched length Erect length Flaccid girth Erect girth
subjects range (cm) (cm) (cm) (cm) (cm)

Loeb 1899 50 17–35 9.41 — — — —

Schonfeld and 1942 196 17–25 — 13.1 — 8.5 15.8
Bebe
Kinsey 1948 2770 20–59 9.7 16.74 — — —
Bondil 1992 905 17–91 10.7 16.74 — — —
De Ros 1994 150 — — — 14.5 11.05/11.92
Wessells 1996 80 21–82 8.85 12.45 12.89 9.71 12.30
Bogaert 1999 935a — 10.41 — 16.40 9.75 12.57
4187b — 9.83 — 15.60 9.40 12.19
Ponchietti 2001 3300 17–19 9.0 12.5 — 10.0 —
Schneider 2001 111 18–32 8.60 — 14.48 — —
Awwad 2005 271 17–83 9.3 13.5 — 8.9 —

a
Homosexual men.
b
Heterosexual men.

International Journal of Impotence Research

 Penile size and penile enlargement surgery
BE Dillon et al
522
There have been several studies that have eval-
uated penile length after radical retropubic prosta-
tectomy (RRP). In 2001, Munding et al.15 examined
penile length in 31 men who underwent RRP by a
single surgeon. All men had erections that were
sufficient for penetration preoperatively. Penile
measurements were recorded in triplicate on all
patients in the holding area prior to surgery. These
were performed in the stretched flaccid condition
only, from the tip of the glans to the pubopenile
skin. The same measurements were taken again 3
months postoperatively. No erect measurements
were recorded, nor was penile girth recorded. They
demonstrated penile shortening in the stretched
condition in 71% of patients; 23% of patients were
found to have o1.0 cm decrease in length whereas
48% were seen to have a41.0 cm decrease in
stretched penile length.15
A second study published in 2003 by Savoie
et al.,16 similarly examined post-RRP flaccid and
flaccid stretched penile lengths. Penile lengths and
girth of 63 men undergoing RRP were measured pre-
and postoperatively. Measurements were recorded
from the pubopenile skin to the meatus, in the
flaccid and stretched flaccid conditions. Penile
circumference was also measured midshaft. Mea-
surements were taken preoperatively in the holding
area and then 3 months postoperatively. About 68%
of patients demonstrated a statistically significant
reduction in penile length in both the flaccid and
flaccid stretched conditions, but interestingly, an
increase in penile girth was also seen.16 Etiology of
penile shortening is unclear at the present time.
Theories include early penile shortening related to
urethral shortening due to RRP, or secondary
corporal fibrosis from chronic hypoxia and fibrosis.
There is increasing evidence, however, that penile
shortening is not limited to surgical treatments of
prostate cancer. This was demonstrated by Haliloglu
et al.17 in 2006, when they looked at penile length in
men treated with a combination of androgen
suppression and radiation therapy. All subjects
received hormone deprivation therapy in the form
of a luteinizing hormone releasing hormone (LH-
RH) agonist, (either leuprolide or goserelin) every 3
months for a total of nine injections. Twenty days of
bicalutamide (50 mg per day) was given ten days
prior to the LHRH agonist. External beam radiation
(70 Gy) was administered in a two-phase four-field
approach. Penile measurements were recorded in
the stretched flaccid condition from the pubopenile
skin to the tip of the glans. They found that there
was a statistically significant decrease in penile
length in men treated with hormonal suppression
plus radiation. More specifically the men who had a
pretreatment stretched length of o14 cm had a
lower percentage of penile shortening compared to
men with pretreatment lengths 414 cm.17 Although
the literature is limited, there is some evidence that
external beam radiation can cause penile fibrosis
International Journal of Impotence Research
and ultimately penile shortening.18 The effects of
hormone deprivation alone on penile length is not
known.
Awwad et al.14 examined penile size on normal
adult Jordanian men and in men with erectile
dysfunction. Their data on ‘normal’ subjects have
already been outlined earlier. Awwad found that
when comparing normal men to men with erectile
dysfunction, there was a statistically significant
reduction in both flaccid and stretched penile
length. More specifically, the average flaccid penile
length was 7.7 cm (potent patients 9.3 cm), whereas the
average stretched penile length was 11.6 cm (potent
patients 13.5 cm). Penile girth of the impotent men was
not assessed. The authors cited loss of elasticity and
lack of intermittent stretching of tunica albuginea as
one explanation for the disparity in penile length
between potent men and impotent men.14
Probably the most common etiology of penile
shortening is seen in patients with Peyronie’s
disease. It is important to note that both the natural
history of disease and the scarring process after
surgical repair with incision/excision of plaque with
graft or a penile plication procedure for surgical
correction may cause a reduction in penile length.19
When the disease is circumferential or bilateral, it
prevents the tunica albuginea from expanding thereby
causing penile shortening.20 Surgical procedures for
correction can result in fibrosis that can result in
further reduction in length when compared to
preoperative measurements. Typically, 60–100% of
patients undergoing penile plication procedures will
have some degree of penile shortening. In addition,
0–50% of patients undergoing incision of plaque with
graft may have penile shortening.21 This is likely the
result of graft contraction. There is some early data
suggesting that a penile extension device may increase
length, prevent graft contraction and minimize post-
operative penile shortening.22,23
Lastly, congenital micropenis results from a
number of biochemical etiologies, and it is lifelong.
By definition, micropenis is ‘a normally formed
penis that is at least 2.5 s.d. below the mean in
size’.24,25 The biological causes stem largely from
defects in the hypothalamus, specifically when an
inadequate amount of gonadotropin-releasing hor-
mone is released. This may be a primary hypotha-
lamic or an anterior pituitary problem. Lastly, the
micropenis can result from embryonic testis failure
causing insufficient masculinization.22 Bladder ex-
strophy and epispadias also can result in penile
shortening, thought to be related to a congenitally
shortened anterior corporal length.26
Penile augmentation procedures
When speaking of penile enhancement surgery, one
must distinguish between those procedures that

increase penile circumference, penile length and
plastics procedures to change skin surrounding the
penis.
The Sexual Medicine Society of North America
has drafted a position statement on penile lengthen-
ing and girth enhancement surgery. It reads as
follows:
‘The Society for the Study of Impotence has found
no peer reviewed, objective or independently-mon-
itored studies, or other data, which prove the safety
or efficacy of penile lengthening and girth enhance-
ment surgery.
Therefore, penile lengthening and girth enhance-
ment surgery can only be regarded as experimental
surgery.
The Society is aware of complications and adverse
outcomes that should be clearly disclosed to
patients considering such surgery.
The Society believes that those government
agencies charged with the regulation of medical
practice and the enforcement of laws prohibiting
false or unsubstantiated advertising claims should
give careful attention to claims made with regard to
these surgical procedures.’ (www.smsna.org)
Penile girth enhancements
One of the earlier papers aimed at penile girth
enhancement was reported in 2002, by Austoni et al.
Thirty-nine patients underwent elective enhance-
ment surgery for hypoplasia of the penis or func-
tional penile dysmorphophobia. Penile
dysmorphophobia is defined as a condition in those
men whose penis are normal, but request an
augmentation procedure as a result of an altered
perception of the organ. Penile dysmorphophobia
can be both a functional issue and an aesthetic
issue.27,28 The procedure was carried out by using a
saphenous vein graft. Incisions were made in the
tunica albuginea from apex of the corpora to the
crura and saphenous vein patches were placed.27 At
9 months postoperatively, there was no statistically
significant increase in flaccid penile circumference,
but there was a statistically significant increase in
erect circumference. Erect diameter (location on
shaft not specified) preoperatively was 2.85 cm,
whereas the average erect diameter postoperatively
Table 2 Penile circumference enhancement studies
Authors Year Number of Age range
subjects
Austoni 2002 39 24–47
Perovic 2006 204 19–54
Panfilov 2006 60 24–34
Abbreviation: NA, not available.
Penile size and penile enlargement surgery
BE Dillon et al
523
was 4.21 cm. The authors indicated that there were
no ‘major complications’.27
Fat injection into the penis is the mainstay of girth
enhancement procedures. The goal of fat injection
into the dartos layer of the penis is uniform
enhancement of penile circumference. In 2006,
Panfilov29 described his method of injecting the
penis with autologous fat. In his protocol, 200–
250 cm3 of a physiologic solution containing adre-
nalin (1:800 000) and 0.02 xylocaine (50 ml xylo-
caine 1% per 1 l solution) was instilled into two
2–3 mm incisions on the upper inner thigh. After
approximately 50 min, the fat was harvested. Fat
was injected in four 1 mm incisions around the
penis at the 1, 5, 7 and 11 o’clock positions. For each
incision anywhere from 10 cm3 to 16 cm3 of fat is
injected. After injections, the penis is ‘kneaded’ to
even out the injections. At 1 year of follow up, 77
patients were highly satisfied, 8 patients were fairly
satisfied and 3 patients were not satisfied. One
patient had too much fat injected into his foreskin,
and 2 patients had excessive loss of fat.29 Table 2
summarizes these studies.
Alter has written extensively regarding his
experience with penile enhancement surgery.29–31
In particular he has described the use of dermal fat
grafts for penile girth enhancement. According to
the author, dermal fat grafts are superior to auto-
logous fat injections because less than 50% of fat
survives in autologous fat injections whereas,
dermal fat grafts had been used with success in
plastic surgery.30 Dermal fat grafts are taken from the
groin area below the swimsuit line, or from the
gluteal creases. Alter states that circumferential
placement of a dermal fat graft is the preferred
technique, with the size of the dermal fat graft based
on the measurement of the penis on full stretch from
the pubopenile junction to the distal corona. The
urethra is usually left uncovered. Penile weights are
used after approximately 1 month, postoperatively,
to prevent shrinkage and graft contraction.30
It is reported that circumference is increased
between 1 and 2 inches, using the aforementioned
procedure. The procedure is rather lengthy (several
hours), but results in a uniform increase in girth,
without nodularity. Edema resolves with 6 weeks,
whereas normal texture is regained in 4–6 months. It
should be noted, however, that there can be severe
Average gain in Average gain in erect
flaccid circumference (cm) circumference (cm)
0.15 1.36
3.15 2.47
2.65 NA
International Journal of Impotence Research
 Penile size and penile enlargement surgery
BE Dillon et al
524
complications that include, but are not limited
penile shortening, asymmetry and curvature due to
fibrosis if the graft does not take uniformly.30,31
With the advent of tissue engineering, there are a
number of new mechanisms to perform circumfer-
ential enhancement. In 2006, Perovic et al.32
reported their series of 84 patients who had penile
circumferential enhancement using a biodegradable
scaffold. Age ranges of their subjects were 19–54
years, and indications for augmentation were penile
dysmorphic disorder or failed penile enhancement
surgery. After fibroblast cells were harvested from
scrotal biopsies, they were grown to a volume of
2  107, and then seeded on a tube-shaped polylacti-
co-glycolic-acid scaffold. After 24 h of incubation,
the penis was degloved and scaffold was trans-
planted between dartos and Buck’s fascia.32 At 24
months median follow up, mean increase in girth
was 3.15 cm (1.9–4.1 cm) in the flaccid state and
2.47 cm (1.8–3.0 cm) in the erect state. Complica-
tions included infection in three patients, penile
skin necrosis in two patients and seroma in five
patients. All patients were able to be treated
conservatively.32
A more novel technique used in penile girth
enhancement has been the use of AlloDerm. Allo-
Derm is ‘an acellular dermal matrix derived from
donated human skin’, which is available in sheets.
Although most of the data for AlloDerm are
anecdotal, recently, they have been widely used in
penile girth enhancement. The AlloDerm sheets are
placed above Buck’s fascia. The reported minimal
scar is one advantage of this technique for penile
girth enhancement.33
Figure 2 (a) Location of incision. (b) Post operative schematic showing cut ligament and skin realignment. Inverted V–Y skin plasty at
penile base with release of suspensory ligament. Reprinted with permission from British Journal of Urology.
International Journal of Impotence Research
Penile lengthening
The mainstay of penile lengthening procedures are a
combination of release of the suspensory ligament of
the penis with an inverted V–Y penopubic skin
advancement (Figure 2).34 Most surgeons recom-
mend cutting the suspensory and fundiform liga-
ment in combination with the use of postoperative
penile weights. There is minimal evidence-based
data in the literature documenting pre- and post-
operative lengths.
Shirong et al.35 performed penile elongation
surgeries in patients who had congenital micro-
phallus. They defined microphallus as an erect
length of less than 8 cm, or in men with traumatic
injuries. They performed 52 procedures over a
7-year period, in men aged 23–52 years. The
procedure consisted of cutting the suspensory
ligaments, beginning with the superficial ligaments
and if more length was needed, the deep suspensory
ligaments were partially cut. A scrotal flap was used
to cover the exposed corpora, and in some cases a
V–Y suture was used on the ventral side to
avoid traction and allow better cosmesis.35 Only 20
patients were followed postoperatively, and increase
in length was seen from 3.5–6.5 cm. There was an
average decrease in length of 0.5–1.5 cm within the
first 6 months of the procedure.
It is often standard protocol that after transection
of the fundiform and suspensory ligaments, penile
weights (at least 10 pounds) are used. Penile weights
are hung from the corporal ridge, once the patient
has recovered from the initial procedure. The
weights prevent reattachment of the suspensory
ligament and should be worn intermittently

throughout the day. Some men opt to use progres-
sively heavier weights for anywhere from months to
years, which act as tissue expanders.30,31 In addition,
Alter has suggested the placement of fat (dissected off
the spermatic cord) between the suspensory ligaments
and bone to prevent adherence to the pubic bone
resulting in penile shortening.29,30
Recently, Shaeer et al.36 reported a variation on
the skin reconstruction and fat placement to prevent
postoperation shortening. They recommend placing
a pubic fat flap between the penis and the pubic
bone after the suspensory ligament is released. In
addition, they report a combination of a ‘T closure’
in addition to the V–Y advancement.36
In 2000, Perovic described his technique for
penile elongation. Nineteen patients, aged 18–52
years were included in the study. Inclusion criteria
were limited to patients who ‘thought their penis
was too short for sexual satisfaction’. All patients
had anatomically normal penis, but short erect
lengths between 6 and 10 cm. Patients who had a
penile length greater than 10 cm, were excluded.
Perovic’s procedure involved completely disassem-
bling the penis into two components: the glans cap
with the urethra attached on the ventral aspect and
the neurovascular bundle on the dorsal aspect, and
the corpora. An autologous piece of rib cartilage was
then shaped and sutured in a place inserted between
the corpora and the glans. Thirteen patients noted
an increase in length between 2 and 3 cm, whereas
the remaining six had an increase between 3 and
4 cm. No infections or erosions were noted, and the
cartilage remained roughly the same size as at the
time of implantation. Fifteen patients reported
painless intercourse at 3 months. Five patients
noted a dorsal curvature that was corrected with a
vacuum device.37
Paniflov29 described his technique for penile
elongation in 2006. He described incomplete cutting
of the fundiform ligament of the penis. This allowed
for the elongation of the extracorporeal part of the
penis. Then, a ‘V–Y plasty’ was used to elongate the
penile skin at the base.29 The average penile length
preoperatively was 8.75 cm (6.5–10 cm), which was
increased to a mean of 11.14 cm at 12 months
postoperatively. Few objective outcome data were
reported and no complications were reported.
Complications of penile lengthening procedures
may be significant. There is minimal short- and
long-term patient satisfaction data. Penile short-
ening is the major complication, usually resulting
from the freely hanging penis reattaching to the
pubic bone higher on the corporal bodies. This
complication may be minimized by the placement of
fat as described previously. Other complications
include loss of sensation, angling of the penis
downward (due to lack of support) and hypertropic
scarring of wounds.
A discussion of penile lengthening would be
incomplete without the mention of penile recon-
Penile size and penile enlargement surgery
BE Dillon et al
525
struction for bladder exstrophy epispadias. After the
exstrophy is repaired these patients are often left
with deformities of their penis, mainly a shortened
penis or an upward-tethered penis. This is thought
to be a result of a congenitally shortened anterior
corpus cavernosum.26 These deformities can lead to
significant psychological and social issues in adult-
hood. A number of techniques have been described
on how to reconstruct the epispadic penis. Cantwell
was one of the first to describe the repair of
epispadias in his 1895 article in the Annals of
Surgery.38 Since then many others have developed
their own novel techniques as well as modified
Cantwell’s procedure. In 1971, Kelley and Eraklis2
separated the corpora from the ischiopubic ramus in
a patient with exstrophy of the bladder to gain
length. One of the more common techniques used to
correct exstrophy epispadias is the modified Cant-
well–Ransley repair, a staged repair. This repair
emphasizes penile chordee correction, urethral
reconstruction, glandular reconstruction and penile
skin closure. In 2000, Surer et al.39 reported their 10-
year experience using this technique in 93 patients.
Of the subjects, 79 had classic exstrophy and 14 had
complete epispadias. A primary repair was per-
formed in 65 of the patients who had classic bladder
exstropy and 12 who had epispadias. A secondary
repair was done in 14 patients who had classic
bladder exstrophy and 2 who had complete epispa-
dias. The authors found that more than 90% of the
patients had a functionally usable penis (at 68 months
of followup). Complications from the procedure
included urethrocutaneous fistula in 19–23%, urethral
strictures in 9% and minor skin separation in 6%.
They ultimately concluded that the modified Cant-
well–Ramsley procedure yields excellent results both
cosmetically and functionally.39
Penile skin reconstruction (hidden penis and
penoscrotal web)
A ‘hidden’ penis usually occurs secondary to over-
lying skin or abdominal fat. As described by Alter,
this may result from ‘aging, obesity, overly aggres-
sive circumcision, abdominoplasty with aggressive
release of dartos fascia attachments to Scarpa’s
fascia or penile lengthening using an ill-advised
large pubic V–Y advancement flap’.40 This is
compared to a ‘buried’ penis where the penile shaft
is underneath the surface of the prepubic skin.
Buried penis often results from obesity and/or
radical circumcision. In 1999, Alter and Ehrlich
described a novel technique for correction of the
hidden penis in adults. The authors stressed, that
prior to embarking on the procedure, the etiology of
the concealment must be identified correctly to fix
the condition properly.
The amount of penile skin must be assessed to
assure that there is sufficient amount to perform the
International Journal of Impotence Research
 Penile size and penile enlargement surgery
BE Dillon et al
526
procedure. When concealment is due to overhan-
ging suprapubic skin, the skin is excised in an
elliptical fashion, which will allow for visibility of
the penis. It is important to taper the fat cephalad
and laterally, which will prevent an unsightly
appearance. The subdermal tissue of the suprapubic
skin is then tacked to the rectus fascia which
maintains the upward position of the resected skin
(Figure 3).40
Sometimes a suprapubic lipectomy or liposuction
is performed if a large suprapubic fat pad is present.
On occasion, release of the penile suspensory
ligaments may be performed to allow for additional
penile length. Even after the suprapubic fat issues
are addressed, there is still a tendency of the corpora
to retract into the scrotum. In order to prevent the
retraction, a midline incision is made at the
penoscrotal junction, and dissection carried down
to the spongiosum and tunica albuginea. Two
tacking sutures are placed on either side of the
urethra from the tunica albuginea to the ventral
penoscrotal subdermal tissue (Figure 4). These
sutures prevent retraction of the penis into the
scrotum.40
As implantation of a penile prosthesis has been
perceived by some as resulting in penile short-
ening,41,42 Miranda-Sousa et al.43 developed a novel
technique of releasing the penoscrotal web to give
the appearance of a longer penis. The procedure was
done in patients undergoing penile prosthesis
implant for erectile dysfunction. Ninety patients,
Figure 3 Technique of tacking subdermal penopubic junction to
rectus fascia with multiple rows of polyester sutures. Reprinted
with permission from Journal of Urology.
International Journal of Impotence Research
with a mean age of 62 years, underwent placement
of a penile prosthesis. Group 1 consisted of 43
patients who had penile prosthesis placement (39
received Coloplast inflatable penile prosthesis and 4
received semi-rigid penile prosthesis) along with
ventral phalloplasty with takedown of penoscrotal
web. Group 2 contained 37 men who had Mentor
Titan inflatable prosthesis placed through a stan-
dard penoscrotal incision. After the degree of
penoscrotal webbing is determined by placing the
penis on traction and distracting the scrotum in the
midline, an asymmetric ‘V’ incision is made on each
side of the web. A diamond shaped piece of scrotal
skin is removed and closed in a modified Heineke–
Michulz type fashion. In Group 1, 42 of 43 (98%)
men reported good overall satisfaction; 84% re-
ported an overall increase in their perception of
penile length, whereas 12% reported no change and
4% reported decrease in penile length. The authors
reported that the difference in patients reporting an
increase in length vs those reporting a decrease in
length reached statistical significance. In group 2, 31
of 37 (84%) patients reported penile shortening,
which also reached statistical significance. Compli-
cations associated with the procedure were uncom-
mon and minor (two wound hematomas and three
superficial infections in group 1, and one wound
separation in group 2). Operative time in group 1
was roughly 12 min longer than that in group 2.
Most importantly, there were no prosthetic infec-
tions in either group.43
Figure 4 Technique of bilateral tacking of subdermal penoscrotal
junction to periuretheral tunica albuginea. Reprinted with
permission from Journal of Urology.

In 2007, Alter44 published his surgical technique
for the correction of penoscrotal web, in which he
defines the penoscrotal web as ‘an obtuse attach-
ment of scrotal skin onto the ventral shaft, which
shortens the functional and visual ventral penile
length.’ He attributes most penoscrotal webs to
aggressive circumcision in which too much ventral
penile skin is excised, however the penoscrotal web
can also be congenital. Alter uses the ‘Z-plasty’
technique to correct penoscrotal web. Using this
technique, the midline raphe is used for the central
limb of the Z plasty, and then a 601 angle Z-plasty is
performed. According to Alter, 601 allows for a
theoretical gain in length of 75%. Skin incisions are
made along the Z-plasty through skin and super-
ficial dartos fascia, and skin closed with a 4–0 or 5–0
moncryl. He does caution that closing the Z-Plasty
can cause circumferential narrowing of the penis.44
More recently Chang and Liu published their
technique for the correction of the penoscrotal
web. Chang and Liu45 reported that despite being
effective, Z-plasty can be technically difficult. The
authors offer a V–Y advancement flap technique for
the correction of penoscrotal web. They described
making a V incision at the penoscrotal junction, and
this flap is then mobilized, using caution to preserve
blood supply so as to not devascularize the flap.
This flap was then advanced upwards and closed in
a Y configuration using 4–0 chromic suture. This
same technique was repeated 1.5 cm below the
previous suture line to completely correct the web.
The authors added that the ideal angle of ‘V’ should
be approximately 601 with a length of 1 cm to gain
maximum length. Using an angle greater than 601
can restrict length, however, an angle too small can
compromise blood supply.45
Complications
Many of the previously quoted studies do not
discuss complications. Penile enhancement surgery
is a highly risky procedure. There is no standard
surgical technique, and much of the performed
procedures are experimental with minimal objective
pre- and postoperative data. In patients who have
autologous fat transfer for girth enhancement,
complications include loss of injected fat and
irregularity at the injection site, scar thickening
with keloid formation and scrotalization.46,47 These
complications are usually seen when the V–Y flap
techniques is employed.46,47 Sexual dysfunction
and further penile shortening are also reported
complications of these penile enhancement
procedures.
In 1997, Alter46 nicely reviewed the complica-
tions from penile enhancement surgery. Alter
reoperated on 19 men over a 2-year interval, all of
whom had penile enlargement surgeries by other
physicians. In all 19 men, cutting the suspensory
ligaments and advancing the skin in the V–Y
Penile size and penile enlargement surgery
BE Dillon et al
527
advancement flap was performed in an attempt to
achieve penile lengthening. Penile girth enhance-
ment was accomplished by autologous fat injec-
tions. Patients presented various complaints such as
hypertrophic scars, low hanging penis and penile
lumps. In 12 of 19 patients, either complete or total
reversal of the V–Y advancement flap was per-
formed. In addition, 12 of the men had removal of
subcutaneous fat nodules. Alter attributed most of
the poor results to flap viability secondary to
vascular supply, or to a thick V–Y flap. Often a
complete reversal of the V–Y flap was either
impossible, or undesirable. Elevation of the V flap
was performed, aligning hair-bearing skin on the
flap to the scrotum to maintain blood supply and
scrotal dog ears were excised.46
Discussion
This review gives an overview of studies that
examine the average length of the penis, conditions
that result in penile shortening and penile enhance-
ment procedures.
Variability arises between standardization of
penile measurements. Objective standardization is
required to make comparison of data more accurate.
Penile length should be measured from the base of
the penis, or the pubopenile junction at the most
proximal point to the tip of the glans as the most
distant point of measurement. Penile length should
be evaluated in three states: flaccid, flaccid
stretched and erect, whereas penile girth or circum-
ference should be measured as flaccid and erect. In
order to accurately reflect penile size, both length
and girth measurements should be taken in all
states. These measurements should be made by a
single health professional, not with self-reported
questionnaire data. With the exception of Wessells’
data,5 no study performed measurements under all
conditions. Rather, measurements were recorded in
either the flaccid state or the erect state, but never in
both. Given the tremendous variability in penile size
and the unpredictable penile extensibility, it would
appear that penile measurement should be per-
formed in all states in order to arrive at a consensus
statement regarding penile size.
Why perform penile enlargement surgery? Is the
motivation of the patient purely for cosmetic and
psychological reasons or is there a bona fide medical
need/condition to warrant or justify penile enlarge-
ment? With respect to those patients seeking
enlargement for the former reason, there is no
medical necessity to perform the surgery. This is
usually true with cosmetic plastic surgery for
women for breast augmentation when not associated
with breast cancer. Is this type of surgery reasonable
in men with respect to penis length? Should the
surgeon consider psychiatric clearance prior to
International Journal of Impotence Research
 Penile size and penile enlargement surgery
BE Dillon et al
528
consideration of penile augmentation surgery?
Should this be the standard of care?
There are medical conditions that result in
legitimate penile shortening. There is evidence that
some of the current treatments for prostate cancer,
can lead to penile shortening. Specifically, men who
undergo radical prostatectomy and possibly radiation
therapy and hormonal treatment are susceptible to
penile shortening.15–17 Although penile shortening
has been documented, there is no quality of life data to
support or refute the overall importance of this effect
on male sexuality. Along similar lines, patients who
have peyronie’s disease are also subject to penile
shortening, but much like those treated for prostate
cancer, penile shortening is not usually significant
enough to warrant enlargement surgery.
Surgeons who consider performing this type of
surgery must be able to justify why enlargement
surgery should be performed. This discussion
should first include the distinction between those
procedures that increase penile girth and those that
are aimed at increasing penile length. Regardless of
which type of procedure is being sought, the patient
should be aware that there is no universally
accepted protocol for either type of surgery. Most
of the reported case studies have been in a small
experimental population with short followups.
They should also be informed of the numerous
complications that can result from such procedures,
which included but are not limited to poor cosm-
esis, further shortening and sexual dysfunction.
Plastic surgical procedures on the skin of the
penis holds more optimism. It appears that the
overall risks of these procedures are minimal.
Quality of life data collection will be necessary to
determine if the value of these procedures approach
that of breast augmentation for women.
Conclusions
The issue of penile size is one that will forever be an
area of controversy for most men. This review sheds
some light on the objective data regarding penile
size. To reach a true consensus of penile size, a
study comparing men from different races and
nationalities would need to be performed. Standard
measuring techniques are necessary to determine
the results of penile lengthening procedures. We
have sufficiently demonstrated medical and surgical
conditions in which penile shortening occurs. In
addition, we have highlighted the procedures that
are currently being performed for penile lengthen-
ing, girth enhancement and plastics skin reconstruc-
tion, and their associated complications.
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