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Secrets of a Beverly Hills Cosmetic Surgeon

with Robert Kotler, MD, FACS

Dr. Kotler's blog has now been retired. We appreciate all the wisdom and support he has brought to the WebMD community throughout the years.

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Tuesday, June 7, 2011

A Subject Rarely Discussed: Hidden or Buried Penis

In the world of educating the public about skin care, beauty and surgical and non-surgical cosmetic procedures, often, some conditions — usually less glamorous — can be overlooked. Yet, these conditions can cause as much distress and concern to those afflicted as teenage acne, congenitally asymmetrical or deformed breasts or super-enlarged noses.

One of those “orphan subjects”, if you will, is the hidden or buried penis deformity. In the operating room, I have seen the malformed anatomy and can understand the great anguish, not generally shared with friends or family, that accompanies the condition.

I have invited Gary Alter, MD, of Beverly Hills, to discuss the hidden or buried penis and explain how he deals with it. Dr. Alter, a world’s authority on plastic surgery of the external genitalia, is a UCLA Assistant Professor, board certified in both urology and plastic surgery, and thus uniquely qualified.

Dr. Alter, as was I, was a featured on E! Channel’s DR 90210. One of his most-enlightening segments was devoted to the surgical correction of the condition.

- Robert Kotler, MD, FACS

A “hidden” or “buried” penis refers to a penile shaft that is buried below the surface of the penile skin and also to a partially or totally obscured penis. There are numerous causes of a hidden or a buried penis including congenital, obesity, aging with an overlying fold of abdominal fat and skin, a shortage of penile skin from chronic inflammation, or an overly aggressive circumcision.

A congenital buried penis is rare.  It includes an abnormally large pubic fat pad and firm tissue that pulls the penis inward.  In addition, there is a congenital lack of attachments of shaft skin to the penile shaft. In a normal infant or child with congenital buried penis, inadvertent removal of excess normal shaft skin during circumcision can leave a variable amount of foreskin and a shortage of shaft skin.  If the circumcision line is placed too far from the head of the penis, normal shaft skin is removed and foreskin is left to cover the shaft. Since foreskin does not have normal attachments to the deeper shaft, the buried penis is created or made worse. In addition, the incision line can narrow upon healing, further burying the penis by pushing it downward into the pubic fat.

Adults also have either inadequate skin or a lack of attachments of the penile skin to the deeper penile erection chambers.  In the latter case, the penis thus goes inside the body while the skin stays on the outside, sometimes giving the appearance of an uncircumcised or absent penis. The skin of the lower abdomen and pubis sags with age, causing the penis of some men to hide under the excess skin and fat.  Obesity makes the concealment of the penis worse.  There is a wide variation from the very mild to the very severe deformity. The penis may look normal when standing but bury with sitting or bending over.

As with the child, circumcision on an unrecognized buried penis can remove normal shaft skin instead of foreskin, thereby worsening the situation. If a second circumcision is performed on a boy or man with concealment, it may complicate reconstruction by removing the remaining skin, thus, necessitating a skin graft.

If the patient has a severe buried or hidden penis, the penile skin and head of the penis can become chronically irritated by chronic dampness, causing discomfort. This irritation can cause progressive destruction of the penile skin with further burying and constriction of the penile skin, thus preventing the head from being visible..

A hidden penis can cause severe self-esteem issues. These boys or men may not have a visible penis while standing and may have to sit to urinate. A boy or young adult can be ridiculed and made to feel inadequate by siblings or friends.  It is not uncommon for concerned parents of a young boy to go to the pediatrician or pediatric urologist. Unfortunately, there is tremendous misinformation and lack of education even amongst these physicians. The parents are usually told that their son will outgrow the deformity if he loses weight or when he reaches puberty. Unfortunately, this is untrue in most instances especially if the boy has a moderate or severe buried penis. The boy is then lives with this psychologically traumatic deformity that could be corrected with a relatively non-invasive procedure.

Adult males are also told that nothing can be done or that weight loss will correct the situation.  Unfortunately, these men and boys often avoid social interactions that may require undressing, thus, severely affecting their lives. They may not participate in team sports or even date in order to avoid embarrassment and rejection. Social isolation can occur.

The surgical correction of a buried penis depends on the abnormality. However, marked improvement can be achieved in almost all patients. The correction is based on re-establishing the connection of the erectile chambers of the penis to the penile skin along with the removal of excess pubic fat and/or skin.

In severe cases of buried penis in which the patient has inadequate penis skin resulting from an overly aggressive circumcision or chronic inflammation, then the penis must be freed and covered with a skin graft.

The surgery is usually performed as an outpatient unless a skin graft is needed. The improvement in penile and pubic appearance can be dramatic. Equally impressive is the patient’s positive personality and self-esteem improvement leading to more self-confidence and social interaction.

For more information and photos see www.garyalterplasticsurgeon.com.

- Gary Alter, MD

Posted by: Robert Kotler, MD, FACS at 12:24 pm

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