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Suspensory Ligament Division (SLD)

Suspensory Ligament Division (SLD) is the most established surgical technique for penile lengthening. It releases the ligamentous attachments anchoring the penile root to the pubic symphysis, allowing the intracorporeal (hidden) portion of the penis to advance anteriorly. Mean flaccid length gain 1.3–2.6 cm in clinical series — but satisfaction is highly variable (27–83%) and the procedure remains investigational per the SMSNA 2024 Position Statement.[1][2][3][4] For positioning vs other male cosmetic options see Cosmetic Genital Surgery — Male.

SMSNA 2024 — investigational

The SMSNA 2024 Position Statement characterizes SLD and other cosmetic penile-enhancement procedures as investigational with limited data. Multidisciplinary approach with psychiatric / psychological evaluation is recommended to identify patients with penile dysmorphic disorder (PDD) who should not be offered surgical intervention.[4]

Anatomy of the penile suspensory ligamentous system​

A cadaveric study of 49 specimens identified three distinct ligaments[5][6][7]:

  1. Fundiform ligament — the most superficial; arises from Scarpa's fascia (superficial bundles) and the linea alba (deep median bundles); inserts into superficial penile fascia and continues to the scrotal septum. Loose, fibro-fatty tissue not adherent to the tunica albuginea.[5][7]
  2. Suspensory ligament proper — deeper, dense fibrous connective tissue arising from the pubic symphysis and inserting into Buck's fascia of the corpora cavernosa. Two lateral circumferential bundles + one median bundle circumscribing the deep dorsal vein. Primary target of SLD.[5][6]
  3. Arcuate (pubic) ligament — the deepest component; arises from the body of the pubis and pubic symphysis and inserts into Buck's fascia, with lateral attachments to the inferior pubic rami.[5][7]

The suspensory ligament maintains the base of the penis in front of the pubis and is a major support point during erection — stabilizing the upward erection angle during coitus.[6][8]

Mechanism of penile lengthening​

SLD does not actually make the penis longer — it exteriorizes more of the existing intracorporeal shaft that normally resides behind the pubic symphysis, by releasing the tethering effect of the suspensory ligament.[9][10]

Ramos 2024 cadaveric morphometric study (16 specimens) — complete ligamentolysis produced uniform length increase averaging +26.4 mm (SD 14.8; range 4–60 mm).[9]

Key finding: a significant negative correlation between pre-ligamentolysis length and gain (r = −0.601, p = 0.014) — men with shorter baseline lengths achieved proportionally greater gains. Age, ligament width, pubic-arch depth, and ethnicity did not correlate with gain.

Surgical techniques​

1. Classic infrapubic approach with V-Y plasty​

The most commonly described technique[11][12][13]:

  • Penopubic incision with an inverted V-shaped skin flap.
  • Division of the suspensory ligament down to the pubic symphysis.
  • V-Y skin advancement to cover the newly exposed shaft and prevent retraction.
  • Optional silicone spacer or fat flap in the dead space between the corpora and pubis.

Deskoulidi & Caminer 2023 — refined V-Y with distally based fat flaps advanced into the dead space + fat injections for simultaneous girth enhancement. Over 15 yr / 75 patients: +2–4 cm flaccid length gain, minimal complications, 4% revision for fat injections.[11]

Drawbacks of V-Y plasty: hypertrophic scarring 51% in one comparative study, plus visible "hump" at the penile base and potential for retraction.[14]

2. V-Y half-skin half-fat advancement flap with T-closure (Shaeer technique)​

Designed to address the drawbacks of standard V-Y plasty[12]:

  • The caudal half of the V-flap is deskinned, creating a rectangular fat flap.
  • The fat flap is pulled into the gap between the penis base and pubis to prevent reattachment.
  • T-shaped closure to avoid pulling the penis back.
  • Stay suture from glans to thigh maintains the penis in a stretched position postoperatively.
  • 6-mo outcome: no length loss, no hump, faint scar.

3. Circumcision (subcoronal) ligamentolysis​

Avoids the penopubic incision entirely.[14]

  • Ligamentolysis through a subcoronal circumcision incision; penile skin degloved to access the suspensory ligament.
  • No V-Y plasty required.

Mertziotis 2013 comparative study (n = 82, V-Y vs circumcision):

OutcomeV-Y plastyCircumcision approachp
Length / girth gainsimilarsimilar—
OR time151 min125 min0.005
Retraction11%6%0.453
Hypertrophic scar51%0%—
Satisfactionlowerhigher0.007
SEAR (Self-Esteem and Relationship)lowerhigher< 0.001

4. Trans-scrotal approach (Karimian 2026)​

n = 21 (14 BDD, 5 micropenis, 2 hypospadias)[1]:

  • Flaccid penile length +2.6 ± 1.66 cm (p < 0.001).
  • Stretched penile length +2.4 ± 0.57 cm (p < 0.001).
  • MGSIS significantly improved.

5. Combined with adjuncts to prevent reattachment​

  • Acellular dermal matrix (ADM) — Zhang 2019 in 15 patients with buried penis (mean BMI 28.9): SLD + ADM filler + suprapubic liposuction → +4.3 cm on-table and +2.4 cm at 3 mo (p < 0.05).[15]
  • Distally based fat flaps — Deskoulidi 2023.[11]
  • Silicone spacer — Li 2006 series.[2]

Efficacy​

StudynTechniqueFlaccid ΔErect ΔSatisfactionFollow-up
Li 2006 Eur Urol[2]42SLD ± silicone spacer+1.3 ± 0.9 cmNR35% overall; 27% in PDD6–78 mo
Deskoulidi-Caminer 2023 PRS[11]75SLD + V-Y + fat flaps+2–4 cmNRimproved sexual self-esteemup to 15 yr
Karimian 2026 Aesthetic Plast Surg[1]21Trans-scrotal SLD+2.6 ± 1.66 cm flaccid; +2.4 ± 0.57 cm SPLNRMGSIS significantly improvednot specified
Mertziotis 2013 Asian J Androl[14]82V-Y (35) vs circumcision (47)similarNRhigher in circumcision (p = 0.007)not specified
Zhang 2019 Andrologia[15]15SLD + ADM + liposuction+2.4 ± 0.8 cm at 3 moNR100% satisfied3 mo
Panfilov 2006 Aesthet Plast Surg[13]88SLD + fat transfer+1.5–4.8 cm (avg 2.42)NRNRnot specified
Ramos 2024 cadaveric[9]16Complete ligamentolysis+26.4 mm avg (range 4–60)N/AN/AN/A

Key efficacy patterns​

  • Flaccid > erect length gain — the ligament plays a less significant role in erect length (corpora are already fully distended).[3]
  • Vyas 2020 SR of 1,192 patients across aesthetic augmentation phalloplasty — flaccid 8–83% gain; erect 12–53%.[3]
  • On-table gain partially lost during healing due to scar contracture and retraction — 3-mo gain typically 50–60% of intraoperative gain.[15]
  • Spacer / filler in the infrapubic dead space significantly improves outcomes by preventing ligament reattachment.[2][15]

SLD combined with penile prosthesis implantation​

Aboul Fotouh 2022 J Sex Med prospective RCT (n = 61) — SLD + pubic lipectomy via Z-plasty during malleable penile prosthesis implantation vs conventional penoscrotal placement[16]:

  • SLD group: +1.5 cm functional penile length (IQR 0–2) and +2.5 cm visible length (IQR 1–3.5) vs 0 cm in controls (p < 0.001).
  • Sexual satisfaction, frequency, and self-confidence improved more in SLD group.
  • 2-yr length gains preserved.
  • Complications were higher in SLD (28.6% vs 9.7%) — primarily wound complications and edema.

Hardrock Sandwich Technique (HST)​

Sertkaya 2025 Int J Impot Res retrospective n = 456 — bovine pericardial graft + autologous plasma gel "sandwich" + SLD + testicular prosthesis composite (see the dedicated HST page for the full evidence base)[17]:

  • Mean girth +43.1% (+4.51 cm) at POD 1; length +20.8% (+2.17 cm).
  • Satisfaction 83.4%, self-confidence 71.1%, self-esteem 75.3%.
  • Complications: seroma 6.1%, wound dehiscence 2.3%, infection 2.7%, hematoma 1.4%, skin necrosis 0.2%; 0% sexual dysfunction.

Complications​

SLD carries a notable complication profile distinguishing it from non-surgical approaches.[18][3][16]

Reported complications​

  • Penile retraction / loss of gained length — most common functional complication; due to scar contracture and ligament reattachment. 6–11%.[14]
  • Erection instability — loss of upward erection angle resulting in a "floppy" or downward-pointing erection. 9.7% in the prosthesis RCT. Inherent consequence of removing the stabilizing ligament.[16][8]
  • Altered erection angle — downward / horizontal pointing rather than upward, can impair function.[12]
  • Poor cosmetic appearance — irregular fat nodules (58%), skin deformity / scarring (33%), scrotalization (33%) in the Wessells 1996 referral series.[18]
  • Scrotalization — scrotal skin advances onto the penile shaft, creating an unsightly appearance and shortening visible penis.[18]
  • Wound complications — 50% in the Wessells 1996 series.[18]
  • Sexual dysfunction — 33% in the same series.[18]
  • Hypertrophic scarring — 51% with V-Y plasty (Mertziotis 2013).[14]
  • Glans numbness — 9.7% in the prosthesis RCT.[16]
  • De novo erectile dysfunction — 3–5% per the PSL-repair literature (Liu 2025).[8]
  • Penile edema — common postoperatively (77.4% in one series); typically transient.[16]
  • Reoperation — necessary in 50% of patients in the Wessells 1996 referral complication series.[18]

Pooled complication rate​

Vyas 2020 SR — pooled complication rate 14.6%, with combined length + girth procedures having the highest complication rate.[3]

Satisfaction — the central challenge​

Patient satisfaction after SLD is highly variable and often disappointing, particularly in PDD patients.[2][18][3]

SourceSatisfaction
Li 2006 overall (n=42)35%
Li 2006 PDD subgroup27%
Wessells 1996 referral complication series (n=12)8% reported subjective length increase
Refined-technique series (fat flaps, spacers, combined approaches)75–83% (selection / reporting bias likely)
Vyas 2020 SR50–100% (inconsistent methodology)

The disconnect between objective length gains and subjective satisfaction is recurring. Li et al. concluded SLD "may increase penile length but usually not to a degree that satisfies the patient" and that men with PDD "should be encouraged to seek psychological help primarily, with surgery reserved as the last resort."[2]

Postoperative protocols to prevent retraction​

Preventing scar contracture and retraction is critical to maintaining length gains.

  • Penile traction therapy (PTT) — postoperative use of penile extenders to maintain elongation during healing. Recommended after SLD though not specifically RCT-validated in this setting. See Penile Traction Therapy.[12][13]
  • Stay sutures — temporary glans-to-thigh sutures during early postoperative period.[12]
  • Spacer placement — silicone spacer, ADM, or fat flap in the infrapubic dead space to physically prevent reattachment.[2][15][11]

SLD vs non-surgical penile lengthening​

FeatureSLDPenile Traction TherapyVED
Flaccid length gain+1.3–2.6 cm (clinical); up to 4.8 cm with combined techniques+1.5–2.5 cmMinimal (~ 0.3 cm, NS)
Erect length gain12–53% (variable)+0.5–1.5 cmNot demonstrated
OnsetImmediate (surgical)Gradual (3–6 mo)N/A
PermanencePermanent (retraction possible)Maintained with continued useTemporary
InvasivenessSurgical (general / regional)Non-invasiveNon-invasive
Complication rate14.6% pooledMinimal (transient discomfort)Minimal
Satisfaction27–83% (highly variable)60–93%30%
Effect on erectionMay impair (instability, altered angle)No adverse effectNo adverse effect
ReversibilityIrreversibleReversible (stop use)Reversible

Limitations of evidence​

  • No RCTs comparing SLD to sham surgery or non-surgical alternatives for cosmetic penile lengthening.[3][4]
  • Overall low quality of evidence — 89.7% of penile-augmentation studies are not RCTs.[19]
  • Inconsistent outcome reporting — different measurement techniques, time points, satisfaction instruments.[3]
  • Publication bias — complications likely under-reported; the Wessells 1996 referral series remains one of the few studies specifically documenting them.[18]
  • Limited long-term data — most studies report 3–12 mo; very long-term functional outcomes (erection stability, sexual function) poorly characterized.[3]
  • No standardized surgical technique — approaches vary widely.[3][10]
  • Patient-selection criteria are not standardized — proportion of PDD vs true micropenis vs other indications varies across studies.[20]

Where SLD fits​

SLD remains the most commonly performed surgical procedure for penile lengthening and can produce meaningful flaccid length gains, particularly when combined with adjuncts (spacers, fat flaps, skin plasty). However, the procedure carries significant risks — erection instability, retraction, poor cosmetic outcomes, and notably low satisfaction in PDD. The SMSNA 2024 considers these procedures investigational; a multidisciplinary approach with psychological screening is strongly recommended before any surgical intervention.[2][18][3][8][4][20]

See also​

Cosmetic Genital Surgery — Male · Small Penis Syndrome / PDD · Penile Traction Therapy · HA Filler — Penile Girth · PLA Filler — Penile Girth

References​

1. Karimian B, Shamshirgaran A, Farsani RM, Mohammadi A, Aghamir SMK. Trans-scrotal suspensory ligament release: a novel technique for penile length augmentation. Aesthetic Plast Surg. 2026;50(3):1431-1438. doi:10.1007/s00266-025-05053-x

2. Li CY, Kayes O, Kell PD, et al. Penile suspensory ligament division for penile augmentation: indications and results. Eur Urol. 2006;49(4):729-733. doi:10.1016/j.eururo.2006.01.020

3. Vyas KS, Abu-Ghname A, Banuelos J, Morrison SD, Manrique O. Aesthetic augmentation phalloplasty: a systematic review of techniques and outcomes. Plast Reconstr Surg. 2020;146(5):995-1006. doi:10.1097/PRS.0000000000007249

4. Trost L, Watter DN, Carrier S, et al. Cosmetic penile enhancement procedures: an SMSNA position statement. J Sex Med. 2024;21(6):573-578. doi:10.1093/jsxmed/qdae045

5. Mariani UM, Fayman M, Nkomozepi P, Ihunwo AO, Mazengenya P. Topographic and structural anatomy of the suspensory ligament of the penis: implications for phalloplasty. Aesthet Surg J. 2024;44(5):516-526. doi:10.1093/asj/sjad376

6. Hoznek A, Rahmouni A, Abbou C, Delmas V, Colombel M. The suspensory ligament of the penis: an anatomic and radiologic description. Surg Radiol Anat. 1998;20(6):413-417. doi:10.1007/BF01653133

7. Chen X, Wu Y, Tao L, et al. Visualization of penile suspensory ligamentous system based on visible human data sets. Med Sci Monit. 2017;23:2436-2444. doi:10.12659/msm.901926

8. Liu W, Calopedos R, Blecher G, Love C. Penile suspensory ligament: anatomy, function, and clinical perspectives of its repair. J Sex Med. 2025;22(1):175-183. doi:10.1093/jsxmed/qdae166

9. Ramos M, Varanda Pereira A, Silva L, Inácio AR, Álvares Furtado I. Morphometric predictors of penile length increase after division of its suspensory ligament. Aesthetic Plast Surg. 2024;48(8):1635-1643. doi:10.1007/s00266-023-03837-7

10. Zaccaro C, Subirà D, López-Diez I, et al. History and future perspectives of male aesthetic genital surgery. Int J Impot Res. 2022;34(4):327-331. doi:10.1038/s41443-022-00580-6

11. Deskoulidi PI, Caminer D. Lengthening phalloplasty with division of the suspensory ligament and distally based fat flaps in penis enlargement operations. Plast Reconstr Surg. 2023;152(3):434e-437e. doi:10.1097/PRS.0000000000010313

12. 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. J Sex Med. 2006;3(1):155-160. doi:10.1111/j.1743-6109.2005.00105.x

13. Panfilov DE. Augmentative phalloplasty. Aesthetic Plast Surg. 2006;30(2):183-197. doi:10.1007/s00266-004-0153-y

14. Mertziotis N, Kozyrakis D, Bogris E. Is V-Y plasty necessary for penile lengthening? Girth enhancement and increased length solely through circumcision: description of a novel technique. Asian J Androl. 2013;15(6):819-823. doi:10.1038/aja.2013.58

15. Zhang X, Huang Z, Xiao Y, et al. Suspensory ligament release combined with acellular dermal matrix filler in infrapubic space: a new method for penile length augmentation. Andrologia. 2019;51(9):e13351. doi:10.1111/and.13351

16. Aboul Fotouh El Gharably M, Ghoneima W, Lotfi MA, et al. The efficacy of suspensory ligament release and pubic lipectomy via penopubic Z plasty during penile prosthesis implantation in improving sexual satisfaction: a prospective randomized controlled trial. J Sex Med. 2022;19(5):852-863. doi:10.1016/j.jsxm.2022.02.024

17. Sertkaya Z, Albayrak AT, Başağa Y, Sökmen D. A retrospective evaluation of the safety and effectiveness of an innovative penile enlargement approach: the Hardrock Sandwich Technique. Int J Impot Res. 2025. doi:10.1038/s41443-025-01172-w

18. Wessells H, Lue TF, McAninch JW. Complications of penile lengthening and augmentation seen at 1 referral center. J Urol. 1996;155(5):1617-1620.

19. Manfredi C, Romero Otero J, Djinovic R. Penile girth enhancement procedures for aesthetic purposes. Int J Impot Res. 2022;34(4):337-342. doi:10.1038/s41443-021-00459-y

20. Schifano N, Cakir OO, Castiglione F, Montorsi F, Garaffa G. Multidisciplinary approach and management of patients who seek medical advice for penile size concerns: a narrative review. Int J Impot Res. 2022;34(5):434-451. doi:10.1038/s41443-021-00444-5