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V-Y Advancement Plasty — Male Cosmetic Application

The V-Y advancement plasty is the most commonly described skin-management technique used in conjunction with suspensory-ligament division (SLD) for cosmetic penile lengthening. The technique advances suprapubic skin distally to cover the newly exposed proximal penile shaft and prevents retraction of the penis back into the pubic fat pad.[1][2][3][4] It is also applied in the correction of buried / concealed penis and as a component of penoscrotal-web correction.

For the broader male cosmetic-genital-surgery decision framework see the Male Cosmetic Genital Surgery atlas page. For the foundational geometric flap principle see V-Y Advancement (Foundations). For SLD itself see Suspensory Ligament Division.

I. Definition and Principle​

The V-Y advancement plasty (also called inverted V-Y plasty or V-Y advancement flap) is a fundamental plastic-surgery technique in which a V-shaped incision is made in the suprapubic skin, the triangular flap is advanced distally toward the penile base, and the wound is closed in a Y configuration. This recruits suprapubic skin to cover the penile base, compensating for the skin deficit created when the internal (intracorporeal) portion of the penis is exteriorized after suspensory-ligament release.[2][3][5]

Key biomechanical principle. After SLD the corpora cavernosa can slide forward, but the overlying skin remains fixed to the pubis. Without skin advancement, the skin acts as a tether that pulls the penis back (retraction). The V-Y plasty breaks this tether by advancing the skin distally so the gained length is maintained.[2][4]

II. Indications​

A. Cosmetic penile lengthening (primary indication)​

V-Y plasty is most commonly performed as an adjunct to SLD for cosmetic penile lengthening in:[1][3][4][6]

  • Small-penis anxiety (SPA) / penile dysmorphophobia — men with objectively normal penile dimensions who perceive their penis as small.
  • True micropenis (stretched penile length below population norms).

B. Buried / concealed penis correction[7][8][9][10]​

  • Adult-acquired buried penis — from obesity, prior circumcision scarring, or lymphedema.
  • Congenital buried penis — in pediatric patients.
  • Trapped penis — from cicatricial scarring after circumcision.

C. Penile fibrosis with prosthesis implantation​

Knoll 1996 described a modified suprapubic V-Y advancement flap with tissue debulking in patients with extensive cavernous fibrosis undergoing penile-prosthesis implantation, achieving 3.5–6.5 cm of additional functional length in 11 patients.[11]

D. Penoscrotal-web correction​

V-Y plasty variants (including the V-I reconfiguration) are used to correct penoscrotal webbing, though Z-plasty is more commonly employed. See Penoscrotal-Web Correction.[12][13][14]

III. Surgical Technique — Standard V-Y Advancement Plasty​

Step-by-step (classic technique).[1][2][5]

  1. Patient positioning — supine, under general or regional anesthesia.
  2. Marking — an inverted V is drawn on the suprapubic skin with the apex pointing cephalad (toward the umbilicus) and the base at the penopubic junction. The V is typically 5–8 cm in height with the base spanning the width of the penile base.
  3. Incision — V-shaped incision through skin and subcutaneous tissue down to the rectus / Scarpa's fascia.
  4. Suspensory-ligament division — through the same incision the fundiform and suspensory ligaments are identified and divided. Fundiform first (superficial, from Scarpa's fascia) → suspensory ligament proper (deep, from the pubic-symphysis periosteum to Buck's fascia).
  5. Penile advancement — the penis is pulled distally, exteriorizing the previously intracorporeal portion of the shaft.
  6. Flap advancement — the V-shaped skin flap is advanced distally to cover the newly exposed proximal penile shaft.
  7. Closure — the V incision is closed as a Y — the limbs of the V are approximated, and the vertical limb of the Y extends distally along the dorsal penile shaft.
  8. Anti-retraction measures — various strategies prevent the penis from retracting back (see Section VI).

IV. Technical Modifications​

Several modifications have been developed to address the well-known complications of the standard V-Y plasty.

A. V-Y half-skin half-fat advancement flap with T-closure (Shaeer 2006)[2]​

  • The caudal half of the V flap is deskinned, leaving a cranial skin-covered V flap and a caudal rectangular fat flap.
  • The fat flap is advanced into the dead space between the penile base and pubis, preventing reattachment of the penis to the pubis.
  • The penopubic incision is closed as a T shape (rather than a Y) to avoid pulling the penis back during skin closure.
  • A stay suture from the glans to the thigh maintains the penis in the stretched position.
  • At 6 months — no loss of gained length, no hump formation, preserved erection angle, faint scar.

B. Inverted V-Y plasty with distally based fat flaps (Deskoulidi & Caminer 2023)[1]​

  • After inverted V-Y plasty and SLD, two distally based fat flaps are advanced into the dead space created by ligament division.
  • Combined with fat injections for girth enhancement.
  • n = 75 patients over 15 years of experience.
  • Length gain 2–4 cm (flaccid).
  • Girth gain ~ 1 cm (from fat injections).
  • Only 3 patients (4%) required revision of fat injections at 6–12 months.
  • Authors reported "very pleasing results with minimal complications."

C. Modified V-Y with scrotal-flap coverage (Shirong 2000)[15]​

  • After SLD, the exposed corpus cavernosum is covered with either a scrotal flap or skin graft.
  • V-Y suture technique used to prevent traction.
  • n = 52 patients (39 congenital short penis, 13 traumatic).
  • Satisfactory results in appearance and length.

D. Diamond-shaped penoplasty (Wang 2025)[16]​

  • A diamond-shaped incision at the penopubic junction (a geometric variant of the V-Y concept).
  • Combined with circumcision and suprapubic liposuction in selected patients.
  • n = 42 adult males with buried penis (mean BMI 35.56).
  • Flaccid length 1.94 → 5.55 cm (mean gain 3.61 cm).
  • Satisfaction 4.02/5.
  • Minor complications — wound disruption 7.1%, infection 4.8%.

V. Outcomes​

StudynTechniqueLength gainComplicationsSatisfactionFollow-up
Deskoulidi & Caminer 2023[1]75Inverted V-Y + SLD + fat flaps + fat injection2–4 cm flaccid3 revisions (4%)Improved sexual self-esteem15 yr experience
Mertziotis 2013 (V-Y group)[4]35V-Y plasty + SLDSimilar to circumcision groupHypertrophic scars 51%; retraction 11%Lower than circumcision group (p = 0.007)7 yr
Shaeer 2006[2]—V-Y half-skin half-fat + T-closure + SLDNo loss at 6 moNo hump, faint scarPreserved erection angle6 mo
Shirong 2000[15]52SLD + scrotal flap + V-Y sutureSatisfactoryNot detailedSatisfactory—
Knoll 1996[11]11Modified V-Y + prosthesis + tissue debulking3.5–6.5 cm functional0% infectionAll functional devices12 mo
Wang 2025[16]42Diamond-shaped (V-Y variant) ± liposuction3.61 cm flaccidWound disruption 7.1%, infection 4.8%4.02/56.7 mo

Systematic-review context — Vyas 2020 (16 studies, 1,192 patients across all augmentation techniques): length gain 8–83% (flaccid), 12–53% (erect); pooled complication rate 14.6%; combined length-and-girth augmentation had the highest complication rate; satisfaction 50–100%. Authors concluded that "enhancement procedures are controversial and investigational" with "inconsistent methodology" and "poor" study quality.[6]

VI. Complications​

The V-Y plasty has well-documented complications that have driven the development of alternative approaches.[2][4][17]

A. Hypertrophic / wide scarring — the most common complication​

  • 51% hypertrophic-scar rate in the Mertziotis comparative study (V-Y group).[4]
  • The suprapubic V-Y scar is in a high-tension area prone to hypertrophic healing.
  • Cosmetically unacceptable in many patients seeking aesthetic improvement.
  • Alter 1997 described patients presenting for reconstruction specifically due to "hypertrophic and / or wide scars" from prior V-Y plasty.[17]

B. Proximal penile "hump"​

  • A thick, hair-bearing mound at the base of the penis created by the advanced V-Y flap, which carries suprapubic subcutaneous fat and hair-bearing skin onto the proximal penile shaft.[17]
  • Alter described this as one of the most common complaints requiring reconstructive surgery after augmentation phalloplasty.
  • The Shaeer modification (deskinning the caudal half of the V) was specifically designed to eliminate this problem.[2]

C. Penile retraction​

  • 11% retraction rate in the V-Y group (vs 6% in the circumcision group) in the Mertziotis series — difference not statistically significant (p = 0.453).[4]
  • Retraction occurs when the penis retracts back into the pubic fat pad due to scar contracture, reattachment of the ligament, or inadequate skin advancement.

Prevention strategies.

  • Dead-space obliteration — fat flaps (Deskoulidi, Shaeer) to prevent penile reattachment to the pubis.[1][2]
  • Stay sutures — temporary traction suture from glans to thigh.[2]
  • Postoperative penile traction therapy (PTT) — penile-stretching devices worn for weeks to months after surgery.[3]
  • Anti-retraction sutures — tacking the caudal ligament remnant to Buck's fascia.[2]
  • T-closure instead of Y-closure — avoids pulling the penis back during skin closure.[2]

D. Altered erection angle​

  • Division of the suspensory ligament causes the erect penis to hang lower rather than pointing upward.
  • The Shaeer modification reported preserved erection angle at 6 months.[2]
  • Inherent to SLD rather than the V-Y plasty itself.

E. Hair-bearing skin on the penile shaft​

  • The V-Y flap advances pubic skin (which is hair-bearing) onto the proximal penile shaft.
  • Can result in hair growth on the penile shaft — cosmetically undesirable and may cause discomfort during intercourse.[17]

F. Low-hanging penis​

  • Alter described a "low-hanging penis" as a complaint after V-Y plasty + SLD, resulting from loss of the normal penopubic angle.[17]

VII. V-Y Plasty vs Alternative Approaches​

A. Circumcision ligamentolysis (Mertziotis 2013) — the only direct comparative study[4]​

ParameterV-Y plasty (n = 35)Circumcision approach (n = 47)p value
Operative time150.7 min125.2 min0.005
Length gainSimilarSimilarNS
Girth gainSimilarSimilarNS
Hypertrophic scars51%0%—
Penile retraction11%6%0.453
Satisfaction scoreLowerHigher0.007
SEAR improvementLowerHigher0.001

The authors concluded the circumcision-ligamentolysis procedure "demonstrated improved results in terms of safety, operation time, retraction rate and cosmetic appearance without any compromise in the gained penile size."[4]

B. Trans-scrotal approach (Karimian 2026)[18]​

  • Novel approach performing SLD through a scrotal incision, avoiding any suprapubic scar.
  • n = 21 patients (14 BDD, 2 hypospadias, 5 micropenis).
  • Flaccid length gain 2.6 ± 1.66 cm; stretched-length gain 2.4 ± 0.57 cm.
  • No major complications; all discharged within 24 hours.
  • Significant improvement in Male Genital Self-Image Scale (MGSIS).
  • No change in IIEF-5 (erectile function preserved).

VIII. V-Y Plasty for Buried / Concealed Penis​

In the context of adult-acquired buried penis, V-Y plasty variants serve a different purpose — not cosmetic lengthening, but functional exteriorization of a penis that has become trapped within surrounding tissue.[7][8][10]

Classification and approach (Tausch 2016, n = 56).[8]

  • All procedures begin with ventral penile release.
  • If penile skin is viable → phalloplasty with scrotal flaps and penoscrotal-skin anchoring.
  • If penile skin is nonviable → complete skin excision + split-thickness skin graft (STSG).
  • Severe abdominal lipodystrophy → adjacent tissue transfer (including V-Y advancement).
  • Overall success rate 88% (49/56).

Key principles (Alter & Ehrlich 1999).[10]

  • Ventral tacking sutures from the subdermis of the penoscrotal junction to the tunica albuginea are critical to prevent recurrence.
  • Without these tacking sutures, the corporeal bodies "telescope proximally inside the scrotum and pubis," leading to surgical failure.

For the operative deep-dive on buried-penis repair see Buried Penis Repair (04e).

IX. Reconstruction of V-Y Plasty Complications​

Alter 1997 published the seminal series on reconstruction of deformities resulting from penile-enlargement surgery, including V-Y plasty complications.[17]

  • 19 men underwent 24 reconstructive operations from 1994–1996.
  • Procedures included:
    • Scar revisions for hypertrophic / wide V-Y scars.
    • V-Y advancement-flap reversal — converting the Y back to a V to remove the hair-bearing hump.
    • Fat-nodule removal for complications of concurrent fat injection.
  • Penile appearance and function improved in all patients.
  • Complications of reconstruction — 1 hematoma, minor wound complications, 1 inadequately reversed V-Y flap.
  • Author emphasized that "significant improvement can be achieved with proper reconstruction" but noted reconstructive limitations — not all deformities can be fully corrected.

X. Evidence Quality and Limitations​

The evidence base for V-Y plasty in penile cosmetics is limited and of low quality.[3][6][19]

  • No randomized controlled trials exist comparing V-Y plasty with other approaches or sham surgery.
  • The only comparative study (Mertziotis) was non-randomized and sequential (V-Y performed first, then circumcision approach), introducing selection and learning-curve bias.[4]
  • Most series are single-surgeon, single-center with short follow-up.
  • Inconsistent outcome measurement — no standardized method for measuring penile-length gain across studies.[6][19]
  • The García Gómez 2022 narrative review concluded that "the low scientific quality of the analyzed papers makes it difficult to establish recommendations to choose one technique over any other" and suggested that "non-invasive techniques should be proposed as a first-line treatment."[3]
  • The Vyas 2020 SR found "poor" study quality regarding methodology for patient selection and outcomes reporting.[6]

XI. Clinical Summary​

The V-Y advancement plasty is the historically dominant skin-management technique for penile lengthening when combined with suspensory-ligament division, achieving 2–4 cm of flaccid length gain.[1][2][4] It carries a high rate of cosmetically significant complications, most notably hypertrophic scarring (51%), a proximal hair-bearing hump, and penile retraction (11%).[4][17]

These complications have driven the development of multiple modifications — the half-skin half-fat flap with T-closure (Shaeer), distally based fat flaps (Deskoulidi), and diamond-shaped penoplasty (Wang) — as well as alternative approaches that avoid the suprapubic V-Y incision entirely, including the circumcision ligamentolysis (Mertziotis) and trans-scrotal approach (Karimian).[1][2][4][16][18]

The only direct comparison (Mertziotis n = 82) found that the circumcision approach achieved equivalent length and girth gains with significantly better satisfaction (p = 0.007) and SEAR scores (p < 0.001), leading some authors to question whether V-Y plasty remains necessary for penile lengthening at all.[4]

For buried-penis correction V-Y plasty variants remain a useful component of the reconstructive armamentarium, particularly when combined with ventral tacking sutures, suprapubic lipectomy, and scrotal-flap reconstruction, with overall success rates of 88% in comprehensive classification-based approaches.[8][10]

See Also​

References​

1. 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

2. 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

3. García Gómez B, Alonso Isa M, García Rojo E, Fiorillo A, Romero Otero J. Penile-length-augmentation surgical and non-surgical approaches for aesthetic purposes. Int J Impot Res. 2022;34(4):332–336. doi:10.1038/s41443-021-00488-7

4. 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

5. Alter GJ. Augmentation phalloplasty. Urol Clin North Am. 1995;22(4):887–902.

6. 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

7. Pestana IA, Greenfield JM, Walsh M, Donatucci CF, Erdmann D. Management of "buried" penis in adulthood: an overview. Plast Reconstr Surg. 2009;124(4):1186–1195. doi:10.1097/PRS.0b013e3181b5a37f

8. Tausch TJ, Tachibana I, Siegel JA, et al. Classification system for individualized treatment of adult buried-penis syndrome. Plast Reconstr Surg. 2016;138(3):703–711. doi:10.1097/PRS.0000000000002519

9. Borsellino A, Spagnoli A, Vallasciani S, Martini L, Ferro F. Surgical approach to concealed penis: technical refinements and outcome. Urology. 2007;69(6):1195–1198. doi:10.1016/j.urology.2007.01.065

10. Alter GJ, Ehrlich RM. A new technique for correction of the hidden penis in children and adults. J Urol. 1999;161(2):455–459.

11. Knoll LD, Fisher J, Benson RC, et al. Treatment of penile fibrosis with prosthetic implantation and flap advancement with tissue debulking. J Urol. 1996;156(2 Pt 1):394–397. doi:10.1097/00005392-199608000-00015

12. Bagnara V, Donà A, Berrettini A, et al. The "V-I penoscrotal reconfiguration": a simple technique for the surgical treatment of congenital webbed penis. Int J Urol. 2024;31(8):886–890. doi:10.1111/iju.15476

13. Schifano N, Castiglione F, Cakir OO, Montorsi F, Garaffa G. Reconstructive surgery of the scrotum: a systematic review. Int J Impot Res. 2022;34(4):359–368. doi:10.1038/s41443-021-00468-x

14. Thomas C, Navia A. Aesthetic scrotoplasty: systematic review and a proposed treatment algorithm for the management of bothersome scrotum in adults. Aesthet Plast Surg. 2021;45(2):769–776. doi:10.1007/s00266-020-01998-3

15. Shirong L, Xuan Z, Zhengxiang W, et al. Modified penis-lengthening surgery: review of 52 cases. Plast Reconstr Surg. 2000;105(2):596–599. doi:10.1097/00006534-200002000-00018

16. Wang J, Ni J, Xu Y, et al. "A diamond-shaped" penoplasty technique with or without concurrent suprapubic liposuction for adult-acquired buried penis: clinical outcomes and patient-satisfaction rates. Asian J Androl. 2025;27(1):72–75. doi:10.4103/aja202476

17. Alter GJ. Reconstruction of deformities resulting from penile-enlargement surgery. J Urol. 1997;158(6):2153–2157. doi:10.1016/s0022-5347(01)68185-0

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

19. Abu-Ghname A, Banuelos J, Davis MJ, et al. Augmentation phalloplasty for acquired penile shortening: a systematic review of techniques, outcomes, patient satisfaction, and limitations. J Sex Med. 2020;17(2):331–341. doi:10.1016/j.jsxm.2019.11.260