What Is Scrotoplasty and Why Get It?
A man in his late 30s sustained an injury to his scrotum—the skin that contains the testicles—when he was younger. The scrotal skin was very thin on one side, and it caused constant pain. He went to several urologists who told him that there was nothing wrong.
Finally, the man traveled to Atlanta to see plastic surgeon Asaf Yalif, M.D. He discovered the man's injury had created a sort of internal hernia that caused the testicle to get "stuck."
"We were able to not only remove all of the abnormal skin, but we were also able to relocate the testicle in the appropriate location, create a more youthful look, and completely remove all symptoms of discomfort and abnormal feeling of herniation," Yalif said.
How was Yalif able to solve the man's problem? Scrotoplasty—aka scrotal reduction surgery or scrotal lift. It is sometimes erroneously referred to as testicular reduction surgery.
"We're not actually doing anything to the testicle," Yalif said.
What is scrotoplasty?
Scrotoplasty is typically used for one of two reasons: It can correct an issue with the scrotum or create a new scrotum.
A common indication for scrotoplasty is scrotal webbing, which is when the scrotal skin is attached too far up the shaft of the penis. Webbing can be present at birth or may result from too much skin being removed during circumcision. This may make the penis appear shorter in length.
Scrotoplasty is performed along with the placement of a penile prosthesis for erectile dysfunction (ED), improving a man's perception of his penile length. Scrotoplasty may also be used to manage scrotal lymphedema, a buildup of fluid caused by a blockage or damage to the lymphatic system.
The procedure can be performed as part of gender-affirming care, both in female-to-male transition (creation of a scrotum) and male-to-female transition (removal of the scrotum). In the context of gender affirmation, the complete removal of the scrotum is often referred to as a scrotectomy.
Some men have a very loose-hanging scrotum, and the sagging often increases with age. Recently, Laurence Levine, M.D., a professor of urology at Rush University Medical Center in Chicago, had a patient in his 60s come in with an excessively floppy scrotal sack that would touch the toilet water when he sat on the toilet.
"It was very, very elastic and very elongated," Levine said. "He just felt like the thing was always difficult to conceal within his underwear. He wanted it fixed, and so we did the surgery. It was a simple outpatient procedure. He did fine and seemed very appreciative."
What does a scrotoplasty entail?
The scrotoplasty procedure is tailored to the patient's specific complaint, Yalif said.
If the issue is that the scrotal skin has stretched to a point where it gets in the way or is painful when riding a bicycle, for example, the surgery will focus on reducing the overall volume of scrotal skin. Yalif said he does this while "allowing the testicles to continue to do their natural function."
If the reasons for the scrotoplasty are aesthetic—the man doesn't like his scrotum's appearance—it's the same concept.
"But we're going to change the incisions based on trying to create a shape that is more pleasing to the individual," Yalif said. "If the patient's super concerned about the asymmetry between the two testicles, we can try to correct some of the volume in the area, which is a fancy way of saying we try to even things out."
Scrotoplasties generally take between one and three hours—it depends on how much work is done internally and how much skin is removed. Patients can expect to have an incision and dissolvable stitches.
"We do leave a little space in between the stitches at the very bottom to allow for leakage to get out so that it can help the swelling to go down sooner," Yalif said.
Yalif recommends patients wear a pad for two or three weeks to absorb any leakage so it doesn't stay in their underwear. The final result is generally seen in eight to 12 weeks.
Scrotoplasty risks and potential complications
The main risk with scrotoplasty is bleeding because the scrotum is a highly vascular area.
"In the operating room, we control as much bleeding as we can," Yalif said. "There is always a risk of bleeding after surgery, depending on what internal work we're doing."
Injury to the testicle or the veins and arteries during the operation is another risk. Such injuries are uncommon, Yalif said, unless significant work for cremasteric dysfunction is being done. The cremaster is the involuntary muscle that contracts and pulls up the testicles.
Visible or abnormal scarring could result due to the incision.
Another potential complication is perceptual. Sometimes, the patient thinks the surgeon should have taken out more scrotal skin. Other times, the patient thinks they took out too much, causing it to be too tight.
"We need to be able to strike that balance between improving the overall symptoms and appearance while still enabling the testicles to do their job," Yalif said.
Recurrence is a possibility, Levine said, because the scrotal skin is naturally excessively elastic. It could stretch out again after the procedure, but Levine has not seen this in his experience with scrotal reductions.
Scrotoplasty for transgender care
Bobby Najari, M.D., a urologist and the director of the male infertility program at NYU Langone Health in New York City, primarily performs scrotoplasties for male-to-female gender affirmation. They are typically done at the time of the bilateral orchiectomy (the surgical removal of the testicles).
In the relatively rare situations in which a trans woman is certain she does not want a vaginoplasty (surgical construction of a vagina), Najari will do the orchiectomy and scrotoplasty at the same time.
"That involves removing a significant portion of the scrotal skin and tissue to essentially reduce the size of that scrotal tissue to be as minimal as possible," Najari said, adding that less than 5 percent of his orchiectomy patients elect to have a scrotoplasty.
Many of Najari's patients want to significantly reduce the size of the scrotum and are OK if there's minimal tissue left.
"If someone's goal is just a completely flat surface without any of that scrotal tissue visible, that's when I would get assistance from a plastic surgeon," he said.
Recovery from scrotoplasty
Following the scrotoplasty, patients will generally have swelling and discomfort for two to three weeks.
The most important thing during recovery is to stay off your feet as much as possible, especially the first week, Levine said. This will reduce the likelihood of bleeding and further swelling.
Using a towel to elevate the scrotum and icing the area can help reduce swelling. Antibiotics may be prescribed to help prevent infection.
Najari also recommends patients take it easy for the first few weeks: no heavy lifting, no exercise, no sexual activity.
"In those first couple of days, I send people home with a bandage that is applying pressure to the incision line to minimize that likelihood of bleeding," Najari said.
Tylenol can be used for pain control, although some patients may need something stronger in the first few days.
Benefits of scrotoplasty
When scrotoplasty is performed in concert with a penile implant, Levine said his patients feel as though they've recovered some length to their penis because it's more exposed.
"That can psychologically be beneficial for the patient," he said.
Scrotum-reduction surgery allows them to have a scrotum that appears closer to what they perceive as normal, which can improve their mental health.
"It's no longer dangling in the [toilet] water," Levine said. "It's not difficult to pull into their underwear. All that can be cosmetically beneficial to the patient."
In cases of gender-affirmation surgery, Najari said the benefits are largely tied to alleviating gender dysphoria from having the scrotum present, as well as simplifying their routine.
"It makes it easier for them to wear tighter outfits without needing to worry about tucking their scrotal tissue out of the way," Najari said. "It can make it easier for them to go about their daily habits."
Scrotoplasty—testicular reduction, according to many online searches—is a lot more common than men realize. It's a taboo subject, according to Yasif, who said it's a shame men don't feel more entitled to say, 'You know, I'm not happy with something about my body.' He has had patients come to his office from all over the world for a scrotoplasty.
"Uniformly, they're very happy to have found someone who can not only identify with what's going on and provide an explanation for why it's happening but also can address the problem in usually a single intervention," he said, adding that scrotoplasty is empowering for many men.