In brief
Surgical penile lengthening consists of releasing (dividing) the suspensory ligament, which anchors the root of the penis to the pubic bone: a part of the shaft that is normally hidden becomes visible. In studies the mean gain is about 1–3 cm, mainly at rest; the corpora cavernosa do not lengthen. The European guidelines (EAU 2023) allow it with a weak recommendation and ask that penile dysmorphic disorder be excluded first.
What surgical penile lengthening is
In the literature it is also called lengthening phalloplasty or ligamentolysis. It is a male intimate surgery procedure that aims to increase the visible length of the penis, mainly at rest.
Real length and visible length
The penis does not end where we see it end. Part of the corpora cavernosa, the root, lies inside the body, under the pubic bone, and is held in position by a system of ligaments: the fundiform ligament, the suspensory ligament proper and the arcuate ligament. The real length is therefore that of the whole organ; the visible length is only the external portion.
The procedure does not lengthen the erectile tissue: by dividing the suspensory ligament, part of the root can slide forward and become external. It changes the visible length, not the real length.
The techniques described in the literature
1. Division of the suspensory ligament (ligamentolysis)
This is the basic technique, also recognised by the European guidelines: through an incision at the junction between penis and pubis, the fundiform ligament and the suspensory ligament are released. The most recent anatomical studies (Mariani, 2024) advise a targeted division that spares the deeper bundles and the posterior fibres linked to the arcuate ligament: these structures give the penis stability during erection.
2. Preventing retraction: fat flaps and spacers
The main limitation of simple division is that the ligament tends to reattach during healing, "pulling" the penis back inwards and reducing the gain. To avoid this, the literature describes two approaches:
- Autologous fat flap interposed between the root of the penis and the pubis, with a "T" closure of the wound (Shaeer, 2006): in the authors' series the gain had not decreased at six months.
- Custom-made silicone pubo-cavernous spacer (Rossi and Alei, 2022): in 245 patients operated on over more than twenty years, mean gain of 2.5 cm at rest and 1.9 cm on traction, stable for up to 48 months. It must be said clearly that a spacer is a foreign body: like any prosthetic material, it carries its own risks, including infection and the possible need to remove it.
3. Skin plasties (V-Y, Z-plasty)
When the penis moves forward, the skin at its base can "pull" and limit the result. Skin plasties, such as the V-Y or the Z-plasty, redistribute the skin of the pubis towards the shaft. The traditional V-Y can leave a bulge at the base of the penis and a more visible scar: the variants described in the literature aim precisely to reduce these drawbacks.
4. Associated procedures
If suprapubic fat hides part of the shaft, liposuction of the pubic region can improve the visible length even without touching the ligament. If the request concerns thickness and not length, the techniques are different: filler and fat grafting (lipofilling), described on the dedicated page on penile enhancement.
How much lengthening is realistically achieved
There is no standard result, and I distrust anyone who promises one. These are the figures reported in the literature, with their limitations:
| Source | Series | Reported gain |
|---|---|---|
| EAU guidelines 2023 | Summary of the literature | 1.1–4.3 cm on traction |
| Li, 2006 | 42 patients | 1.3 cm on average on traction (from −1 to +3 cm); only 35% satisfied |
| Rossi and Alei, 2022 | 245 patients, with spacer | 2.5 cm at rest, 1.9 cm on traction; more than 80% satisfied |
| Ramos, 2024 | 16 cadavers | 2.6 cm on average (from 0.4 to 6 cm) |
Two findings deserve attention. In Li's study some patients lost length instead of gaining it, because of scar retraction. And in Ramos's anatomical study the only factor that predicted the gain was the starting length: the shorter the penis was before division, the greater the lengthening. The width of the ligament did not prove to be predictive.
«Prima comprendere» ("Understand first"): psychological assessment and the EAU guidelines
The 2023 guidelines of the European Association of Urology on penile size abnormalities and dysmorphophobia put patient selection at the centre. They strongly recommend looking for a possible penile dysmorphic disorder, including with self-assessment questionnaires, and referring those who suffer from it to a course of psychological support before any procedure.
The finding that struck me most again comes from Li's study: 64% of the men operated on had penile dysmorphophobia, and in this group only 27% were satisfied after the procedure. The penis was not small; it was the perception that was, and surgery does not change that.
This is why at the first consultation, which lasts from half an hour to an hour, I ask you first of all why you want it, for how long, and what you expect to change. Then we measure. As a reference, the average measurements reported by the European guidelines are about 9 cm at rest and 13 cm in erection. If expectations are not realistic, or if the distress is not really about size, I prefer to tell you openly and advise against the procedure.
Non-surgical alternatives
- Penile extenders (traction therapy): the EAU guidelines report gains of about 1.7–2.3 cm at rest and 1.3–1.7 cm on traction, with few side effects but low-quality evidence. They require consistency, for many hours a day and for months.
- Psychological support: strongly recommended by the guidelines when dysmorphophobia or anxiety about size emerges.
Risks and complications
The European guidelines strongly recommend discussing the possible complications thoroughly before deciding. Surgery is not an exact science, and this procedure shows it well.
General risks, common to every operation
- Wound infection, haematoma, wound dehiscence (partial reopening of the wound)
- Complications related to anaesthesia
- Scar in the pubic region, with possible hypertrophic outcomes
Specific risks
- Scar retraction: the ligament reattaches and the penis is pulled back inwards, with partial or total loss of the gain. In some cases the result can be a shortening. Fat flaps and spacers were developed to reduce this risk.
- Instability and change in the angle of erection: the erect penis may be less anchored at the base and point lower. Targeted division, which spares the deep fibres, serves to limit this.
- Bulge or visible scar at the base of the penis, especially with traditional V-Y plasties.
- Changes in sensation, generally transient.
- Risks linked to the spacer, when used: infection, displacement, need for removal.
- Dissatisfaction: in the published series it is the most frequent complication, and it is prevented above all by honest patient selection.
In the literature reviews, true surgical complications are uncommon, below 5% in the studies considered by Danino (2024), and the large series by Rossi and Alei reports no erectile dysfunction or neurovascular injuries. The risk of a disappointing result, on the other hand, remains real.
Recovery
The timings I give my patients are approximate and are confirmed at the consultation:
- Daily activities and work: after about 7 days
- Sexual activity and sport: after about 6 weeks
Frequently asked questions
What does surgical penile lengthening involve?
Division of the suspensory ligament of the penis through an incision at the base of the penis: part of the root, normally internal, moves forward and becomes visible. Techniques to prevent the ligament from reattaching, such as a fat flap or a spacer, are often added.
How much lengthening can realistically be achieved?
In studies the mean gain is generally between 1 and 3 cm, measured at rest or on traction, with wide variability from person to person. In some cases scar retraction reduces or cancels the result.
Does the penis also lengthen in erection?
Little, or in a variable way. The procedure mainly changes the visible length at rest, because it does not change the size of the corpora cavernosa.
Does the procedure affect erection or sensation?
Dividing the ligament does not involve the corpora cavernosa or, if performed correctly, the neurovascular bundles, and no erectile dysfunction is reported in the large series. It can, however, change the angle and stability of the penis in erection, and changes in sensation are possible, generally transient.
Is the result permanent?
Not always. The main risk is scar retraction, which can cause part of the gain to be lost in the following months. Techniques with a fat flap or spacer were developed precisely to make it more stable: this is why I always combine a silicone spacer.
How long does recovery take?
As a guide, you return to normal daily activities after about 7 days. For sexual activity and sport about 6 weeks are needed. The timings are confirmed case by case during the consultation.
Who should not have the procedure?
Anyone suffering from penile dysmorphic disorder: in these cases the European guidelines recommend a psychological pathway, because surgery does not resolve the distress and dissatisfaction after the procedure is very frequent. Also anyone with unrealistic expectations, especially about erect length.
Are there non-surgical alternatives?
Penile extenders, according to the EAU guidelines, give gains of about 1.7–2.3 cm at rest with low-quality evidence and require constant use for months. When dysmorphophobia emerges, the first recommendation is psychological support.
Scientific bibliography
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Falcone M, Bettocchi C, Carvalho J, et al. – European Association of Urology guidelines on penile size abnormalities and dysmorphophobia: summary of the 2023 guidelines
Source: European Urology Focus, 2023 – European Urology Focus
What it covers: the summary of the European recommendations on penile size, dysmorphophobia and lengthening procedures: division of the suspensory ligament is allowed with a weak recommendation, with gains of 1.1–4.3 cm.
Why it matters: it is the official position of European urologists and the source of the recommendations on psychological screening, discussion of complications and traction therapy cited on this page.
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European Association of Urology – Penile size abnormalities and dysmorphophobia (EAU Guidelines on Sexual and Reproductive Health)
Source: Uroweb, current edition – Uroweb
What it covers: the full chapter of the guidelines, with average penile measurements, dysmorphophobia screening tools and assessment of the different techniques.
Why it matters: it allows the evidence behind the recommendations summarised above to be read in full.
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Li CY, Kayes O, Kell PD, et al. – Penile suspensory ligament division for penile augmentation: indications and results
Source: European Urology, 2006 – European Urology
What it covers: 42 men operated on over seven years: mean gain of 1.3 cm on traction, with cases of loss of length; only 35% satisfied, 27% among those with penile dysmorphophobia.
Why it matters: it is one of the most cited studies and honestly shows the limits of the procedure and the weight of patient selection.
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Shaeer O, Shaeer K, El-Sebaie A – Minimizing the losses in penile lengthening: "V-Y half-skin half-fat advancement flap" and "T-closure" combined with severing the suspensory ligament
Source: The Journal of Sexual Medicine, 2006 – PubMed
What it covers: describes a fat flap interposed between penis and pubis and a "T" closure to prevent retraction and the bulge at the base of the penis; at six months the gain was maintained.
Why it matters: it explains why division of the ligament alone is often not enough and how the technique has evolved.
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Rossi A, Alei G, Frisenda M, et al. – Penile lengthening original technique using a pubo-cavernous spacer. Long term results from a series of over 200 patients
Source: Archivio Italiano di Urologia e Andrologia, 2022 – PAGEPress
What it covers: 245 patients treated with ligament division and a silicone spacer: mean gain of 2.5 cm at rest, stable for up to 48 months, more than 80% satisfied.
Why it matters: it is the largest series with long follow-up, published by an Italian group.
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Mariani UM, Fayman M, Nkomozepi P, et al. – Topographic and structural anatomy of the suspensory ligament of the penis
Source: Aesthetic Surgery Journal, 2024 – Oxford Academic
What it covers: anatomical study of the three ligaments that support the penis; it indicates which fibres to preserve during lengthening so as not to lose stability in erection.
Why it matters: it is the basis of the "targeted" ligament division described on this page.
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Ramos M, Varanda Pereira A, Silva L, et al. – Morphometric predictors of penile length increase after division of its suspensory ligament
Source: Aesthetic Plastic Surgery, 2024 – Springer
What it covers: in 16 cadavers, division of the ligament gave a mean gain of 2.6 cm; the only predictive factor was the starting length.
Why it matters: it helps to understand why the result varies so much from person to person.
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Danino MA, Trouilloud P, Benkhadra M, et al. – Cosmetic male genital surgery: a narrative review
Source: Annals of Translational Medicine, 2024 – AME Publishing
What it covers: review of male cosmetic genital surgery; for lengthening it reports complications below 5% and stresses the difficulty of comparing studies that measure the penis in different ways.
Why it matters: it offers an up-to-date overview and recommends that these procedures be performed by dedicated surgeons, with fully informed consent.
For an overview of male intimate surgery as a whole:
Medically reviewed by Dr Giulio Maria Maggi, Plastic Surgeon — last review:
Article written by
Dr Giulio Maria Maggi
Aesthetic Plastic Surgeon — Turin, Asti and Alessandria
Medical Director — Aesthetic Clinic (Turin)
Registered with the Turin Medical Council (Ordine dei Medici di Torino) no. 20595
Full Member of AICPE — Italian Association of Aesthetic Plastic Surgery (verify)
Expertise and areas of interest
Dr Maggi trained specifically in intimate medicine and surgery by working for 12 years alongside Prof. Renato Marten Perolino, urologist and plastic surgeon, at Villa Maria Pia Hospital and, privately, at Clinica Fornaca and Clinica Cellini in Turin. From him he learned male-to-female gender-affirming surgery, and he was first operator in breast augmentation procedures on Prof. Perolino's patients in gender transition. He also trained internationally with Prof. José Guerrero Santos in Guadalajara and with Prof. Andrew A. Jacono in New York, for the Deep Plane facelift technique.
He focuses in particular on:
- Functional and aesthetic intimate surgery, male and female
- Deep Plane facelift
- Blepharoplasty
- Liposculpture and fat grafting (lipofilling)
- Breast surgery
- Body contouring
Clinical approach: «Prima comprendere» ("Understand first"). No promises of results: indications, risks and limits explained frankly, so that every patient can make a truly informed choice.
