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Plast Aesthet Res || Vol 2 || Issue 1 || Jan 15, 2015 27
INTRODUCTION
One of the traditional benefits that aesthetic surgery
offers to patients is the improvement in self‑esteem.
The appearance of the external genitalia, both male and
female, can have similar degrees of influence on social
relationships and may cause a concern similar to that
generated by a lipodystrophy or a nose with inadequate
proportions. Given the unrealistic expectations (sometimes
fanciful) that these patients tend to assume about
the anticipated results, it is essential to properly and
thoroughly inform patients about treatment characteristics,
limitations, and what results they can expect. Although
a large number of patients who are interested in genital
aesthetic surgery request a consult for purely aesthetic
motivation, as in other domains of aesthetic surgery, there
are many in which a functional defect coexists with the
aesthetic burden that can worsen patient experience in
sexual or social relationships.
Generally speaking, aesthetic surgery of male genitalia is
focused on increasing penis measures in both length and
girth. There are, however, ancillary techniques that work
to improve the “visual” size of the penis and scrotum. At
the present time, there is only one technique capable of
increasing girth in erection but none (at least known to
the author) capable of increasing dynamically the length in
erection. Therefore, currently, existing techniques are able
to increase the girth in erection or flaccidity but not both.
There are surgical techniques that increase the length in
the flaccid state, but no reports known to the author that
describe increasing the length of the penis in erection.
For these reasons the enhancement of the penis size is
better achieved by performing several surgical techniques
Composite augmentation phalloplasty:
personal experience after 275 patients
Juan Monreal
Consultant Plastic Surgeon, Hospital Moncloa, Avenida de Valladolid, 83, 28008 Madrid, Spain.
Address for correspondence: Dr. Juan Monreal, Londres, 54-1ºD, Torrejon de Ardoz, 28850 Madrid, Spain. E-mail: juanmonreal@gmail.com
ABSTRACT
Aim: To report the author’s experience in augmentation phalloplasty by studying a retrospective
series of patients who underwent fat grafting for girth enhancement or a composite technique based
on suspensory ligament release plus fat grafting performed simultaneously. Methods: The author
analyzed retrospectively the outcomes of 275 augmentation phalloplasty procedures performed in
259 patients until November 2013. Of these, 127 correspond to girth augmentation with fat grafting
and 148 to composite augmentation phalloplasty (girth augmentation with fat grafting and length
improvement by suspensory ligament release). In 16 patients girth and length enhancement were
performed in two separate procedures. Results: Of this 259 patients, 87 underwent postoperative
follow-up for at least 12 months and 160 patients underwent follow-up for at least 6 months. The
average increase in circumference at 6 months was 1.7 cm (1.57 cm at 12 months) and the average
increase in length of 3.2 cm (3.1 cm at 12 months). Twenty-two patients showed minor complications
that were treated without sequelae and without inuencing the nal result. Conclusion: By judicious
use of currently available techniques, it is possible to achieve stable increases in penis size. The use
of composite techniques provides better nal results than the use of individual techniques performed
alone due to the increase of the actual volume of the penis. An adequate informed consent is essential
in all patients due to the unrealistic expectations expressed by the majority of them.
Key words:
Adipose tissue, fat grafting, lipolling, penis augmentation
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DOI:
10.4103/2347-9264.149374
Original Article
Plast Aesthet Res || Vol 2 || Issue 1 || Jan 15, 201528
simultaneously or in stages. If it is assumed that the penis
is a cylindrical body, a more successful outcome should
seek to increase the entire volume (diameter and length)
than only one of the dimensions [Figure 1]. There is only
one exception to this approach which is the treatment of
a buried or partially buried penis. In this case, given the
importance of adequate pubic skin redraping and marking
the new peneopubic angle, the author recommends girth
enhancement in a second staged step.
An important factor that is difficult to standardize is the
measurement of penile length and girth in flaccidity and
erection. Several ways to do this are postulated, with the
main objective of obtaining an accurate estimate of the
increase in these measures in postoperative follow‑up for
comparative purposes. As a general rule the established
mean normal values of flaccid length are between 7.2 cm
and 11.0 cm measured from the peneopubic angle to the
tip of the glans, with an average of 9.5 cm. A normal girth
will vary between 7.7 cm and 12.0 cm, with an average
of 9.56 cm.[1] It is extremely important that the surgeon
standardize the method for taking these measurements to
maintain consistency in daily practice.
The author presents his experience in a retrospective
study of 275 augmentation phalloplasty procedures.
The final analysis focuses on the main increase in penis
measurements (girth and length) in the flaccid state and
the stability of improvement over time.
METHODS
The author analyzed retrospectively the outcomes of
275 augmentation phalloplasty procedures performed in
259 patients. The main motivation for all patients was to
achieve greater penis size without the development of any
form of impotence or sexual dysfunction. Mean preoperative
penis dimensions in the flaccid state were 8.9 cm in
girth (range, 6.5-10.2 cm) and 9.2 cm in length (range,
7.4-12.2 cm). Of the 275 procedures, 127 underwent girth
enhancements with fat grafting and 148 were undertaken
for composite phalloplasties (girth enhancement with fat
grafting and length improvement by suspensory ligament
release). In 16 patients, these procedures were performed
in two surgical stages, not < 6 months apart. All patients
signed the corresponding informed consent. The age of
patients ranged from 23 to 57 years with a mean age of
38 years. All cases of girth enhancement with fat grafts
were performed under local anesthesia with sedation on an
ambulatory basis; composite phalloplasty were performed
under spinal anesthesia on an ambulatory basis as well. All
pre and postoperative measures and pictures were taken in
forced flaccidity (applying a light traction on the penis for
about 3 s). Postoperative measurements were scheduled on
the day after the operative procedure and again at 1, 4, 6,
and 12 months postoperatively.
Girth enhancement with fat grafting
The technique of fat grafting used in this series has been
published previously.[2,3] Briefly, lipoaspirate is harvested
with a 20‑hole 3 mm cannula (Quirumat, Spain). The
lipoaspirate is washed with Ringer’s lactate, and layer
separation is obtained by decanting for about 30 min. Once
processed, the washed fat is injected under the dartos and
Buck’s fascia. The engrafting process must be performed
with extreme caution, placing fat fragments of no
> 3 mm in diameter to ensure a proper take and prevent
necrosis and cyst formation. Whether girth enhancement
is performed alone or in combination with suspensory
ligament release, the infiltration cannula is advanced
from the peneo‑pubic angle towards the preputial skin or
circumcision scar. The fat is injected in a retrograde fashion
and distributed all around the girth; this is tailored to the
needs of each patient, from the peneo‑pubic angle to the
coronal sulcus scar (if the patient is circumcised) or to the
foreskin proper (if he is not circumcised). The distribution of
fat is particularly important in the penis foreskin to prevent
unaesthetic nodules or bulges or the presence of an offset
devoid of fat when the patient removes the foreskin. This
technique can be performed alone (127 + 16 cases in our
series) or preferably at the same time as the suspensory
ligament release (148 patients in our series).
The behavior of fat grafted to the penis is mostly the
same as when performed in other body areas. Although
postoperative swelling usually takes about 6 weeks to
disappear, the volume loss in the grafts should stabilize
by 3-4 months; at this timepoint the improvement in girth
must be stable.
Composite augmentation phalloplasty
Figures 2 and 3 summarize the sequence of steps
performed during suspensory ligament release as done in
Figure 1: The penis can be approximated to a cylinder, and thus,
enhancement of girth and length at the same time improves real volume.
From left to right: original size, length improvement, girth improvement,
both simultaneously
Figure 2: (a) Anatomy of the suspensory ligament: (A) deep neurovascular
bundle; (B) suspensory ligament; (C) surgical approach. (b) Pick‑ups are
shown grasping the most caudal and superficial aspect of the ligament
b
a
Plast Aesthet Res || Vol 2 || Issue 1 || Jan 15, 2015 29
the current series. Although composite phalloplasty can
be performed under local anesthesia and sedation, the
author prefers spinal anesthesia that adds little morbidity
and enhances patient comfort. The procedure begins with
a 3.5 cm incision located about 2.5-3.0 cm cranial to
the peneo‑pubic angle. The first step is to perform the
dissection and release of the fascial and fasciocutaneous
attachments. The dissection then proceeds down to the
front edge of the suspensory ligament. Thus, the release
must be performed directly from the attachments to the
symphyseal ligament to avoid accidental damage to deep
penile neurovascular structures. The release is then carried
further down, stopping at the start of the pelvic floor. The
author usually does not release bone attachments except in
cases of micropenis. After the ligament release is complete,
corpora cavernosa will move easily forward and downward,
creating a dead space between these structures and the
pubic bone; This dead space must be filled with local
tissues; the availability of these tissues can be extremely
variable depending on the body mass index of the patient.
In slim patients it is usually necessary to take the fat that
surrounds the spermatic cords. When there is enough
pubic fat, adipofascial flaps can be tailored and turned
down as described by Hinderer and Espinosa.[4] Available
tissues are interposed inside the dead space created by the
ligament release while simultaneously pulling on the penis
and checking on the stability of the repair.
Upon completion of these steps, a skin gap can be observed
and that is caused by penis advancement. Although a variety
of skin plasties can be planned in advance and performed
at the beginning of the procedure, the author prefers to do
this once the penis advancement has been completed, to
modify for each situation. Treatment of the skin gap begins
by closing the defect in a horizontal fashion [Figure 4]. This
closure produces two dog ears that will provide the final
measure of skin advancement. The distal dog ear is tailored
to provide a Y or T advancement. The proximal dog ear is
usually smaller and can be managed by defatting and direct
closure; in about 2-3 months it will flat tenon on its own.
Performed correctly, closure of the skin by an advancement
plasty stabilizes and maintains the improvement in
length [Figure 5]. It must be kept in mind that an overly
ambitious cutaneous advancement usually results in
the incorporation of hairy skin and some scrotalization
of the penis shaft which worsens the aesthetic result.
Before epidermal closure, the author inserts a vacuum
drain and then proceeds to girth augmentation with fat
grafting as previously described. All sutures used including
epidermal closure can be performed with 4/0 absorbable
monofilament.
As a rule composite augmentation phalloplasty can be
performed on an outpatient basis. The drain is removed
after 24 h and antibiotics are continued for 3 days. After
Figure 5: Intraoperative views (a) before and (b) after completion
of composite augmentation phalloplasty. Green arrows depict initial
incision location. Red arrows mark peneopubic angle
Figure 6: Original model of traction system (JES extender). Today all
brands look the same as the original
Figure 3: Sequence of suspensory ligament release as performed by the
author. (a) Transverse incision; (b) symphysis approach and complete
release; (c) transverse closure, advancement and dog ears; (d) dog ear
treatment
d
c
b
a
Figure 4: Sequence of suspensory ligament release as performed by
the author. (a) Transverse incision; (b) symphysis approach; (c) complete
release (green arrow: pubis, blue arrow: urogenital diaphragm);
(d) transverse initial closure
a
b
cd
ab
Plast Aesthet Res || Vol 2 || Issue 1 || Jan 15, 201530
15 days, patients can start using the traction system if
previously circumcised. In noncircumcised patients traction
must be delayed until foreskin swelling has disappeared.
The author recommends the use of an extender [Figure 6]
because it ensures control over initial scar maturation and
helps to prevent ligament reattachment. In addition, when
used correctly, additional length is added to that offered
by the surgical procedure. All patients are encouraged
to maintain sexual abstinence during the 1st month
postoperatively.
RESULTS
Of the 259 patients who underwent surgery, 160 provided
a 6 months follow‑up and 87 completed 12 months of
follow‑up. In 99 patients follow‑up was < 6 months. The
average increase in girth was 1.7 cm at 6 months and
1.6 cm at 12 months and the mean increase in length
was 3.1 cm and 3.2 cm at 6 and 12 months, respectively.
In 22 patients (8% of the series) the author detected minor
complications that were treated without sequelae and
without influencing the final result. No patient reported
functional problems or difficulty in sexual activity after the
second postoperative month. Postoperative length gain did
not change during the first 6 months of follow‑up. Patients
who used the extender for at least 3 months after surgery
achieved modest additional increases in length, which did
not exceed 1.3 cm. The author was not able to properly
analyze the increase in erection measurements due to lack
of data. Figures 7‑9 represent average results of composite
augmentation phalloplasty. Figures 10 and 11 represent
average results of penis girth enhancement with fat grafting.
Minor complications encountered after phalloplasty
were combined infection: marginal wound dehiscence (3
cases, 2%), the development of small seromas that required
aspiration (5 cases, 3.4%, especially when performing the
suprapubic adipofascial flap), liponecrotic cysts that were
resectable secondarily (4 cases, 2.7% in the first 4 years
of experience). There were no incidents of keloid scar
formation, however, in 5 cases the final scar was considered
hypertrophic. The author currently recommends placement
of silicone sheets or gels as part of the postoperative
care. The use of a postoperative traction system is not
mandatory but helps to minimize the chances of abnormal
scarring and to gain extra length. Lack of compliance with
the extender device or the presence of erosion caused by
the pulling ring is a common cause for abandoning the use
of postoperative traction. The author did not encounter
any cases of postoperative paradoxical shortening.
Regarding girth enhancement performed as a stand‑alone
procedure, the complications were liponecrotic cysts in
7% of patients (9 cases in the first 5 years of experience),
1 case of postoperative infection that needed a complete
antibiotic course (0.8%), and 1 case of fat overgrowth
due to extreme weight gain (0.8%) [Figure 12]. Lack
of abstinence, especially during the first 2 weeks, can
certainly cause the loss of grafted fat to some degree, so
the patient should be warned about this.
Figure 7: Case 1. preoperative and 11 months postoperative views
of composite augmentation phalloplasty (40 mL of fat). (a and c)
Preoperative; (b and d) 11 months postoperative
Figure 8: Case 2. preoperative and 16 months postoperative views
of composite augmentation phalloplasty (55 mL of fat). (a and c)
Preoperative; (b and d) 16 months postoperative
Figure 9: Case 3. preoperative and 12 months postoperative views
of composite augmentation phalloplasty (65 mL of fat). (a and c)
Preoperative; (b and d) 12 months postoperative
DISCUSSION
Standard measurement of the penis has been a
controversial issue and a subject of discussion
d
c
b
a
d
c
b
a
d
c
b
a
Plast Aesthet Res || Vol 2 || Issue 1 || Jan 15, 2015 31
for a long time. The racial controversy introduces
more variables, which can influence decisions
about justifying augmentation phalloplasty.[5,6] The
enhancement of penis size can be achieved using
surgical or nonsurgical procedures. Unfortunately the
uses of unproven techniques or synthetic fillers have
made these treatments notorious for their sequelae or
bad results.[7] Nonsurgical techniques that use traction
by weights have been employed by many cultures
over the centuries and are based on cultural, religious
or aesthetic purposes.[8,9] The modern age of these
treatments began at the end of the 1990’s with the JES
Extender device. These techniques exploit the ability
of tissues to respond to physical stimuli as traction
or expansion with hyperplasia and cell division,
a well‑known behavior used by plastic surgeons
worldwide.
As in any medical or surgical procedure using expansion
or distraction, while using a penis extender a pulling
force of a certain intensity must be applied and must be
as continuous as possible and for a minimum time period
and hence that the biological phenomena responsible for
tissue modification are started. The use of these devices
often requires a great deal of diligences on the part of
patients to get results that are minimally satisfactory.
Erosions are sometimes produced by traction ring or
by irregular use of the device and are some of the
factors that negatively affect the results, which may be
minimal. In any case, an adequate knowledge about the
management of these devices must be present in the
armamentarium of the surgeon performing phalloplasties,
since it can be an extremely useful complement to the
surgical procedure to secure, maintain and/or improve
the outcome. The author always uses traction as an
adjunct to surgical treatment and never as a stand‑alone
treatment.
As in the case of surgical lengthening, there is not a
single surgical solution to increase the thickness or
perimeter of the penis.[10,11] Pericavernous techniques
provide girth augmentation in flaccid penises but little
or no improvement in erection. These techniques try to
obtain an increase in girth by implanting some of the
available grafts (fat or dermofat grafts) or biological
implants (acellullar dermis) around the penis shaft
outside the albuginea and under the dartos fascia. More
advanced techniques using resorbable matrices together
with autologous fibroblasts have also been described
with good results.[12,13] Albugineal techniques get good
results in erection but none in flaccidity.[14] The injection
of synthetic fillers is probably one of the options
that are frequently performed, but may cause many
deformities and complications. All of these techniques
are more invasive and thus can yield a greater number
and severity of complications. Fat grafting is probably
the least aggressive technique but requires fine control
and technique to avoid complications and poor results.
It was introduced as a technique for girth enhancement
Figure 10: Case 4. preoperative and 3 years postoperative view of girth enhancement with fat grafting in two sessions (30 + 40 mL). (a) Preoperative;
(b) 3 years postoperative; (c) pinch of implanted fat
Figure 11: Case 5. preoperative and 9 months postoperative view of
girth enhancement with fat grafting (35 mL of fat). (a) Preoperative;
(b) 9 months postoperative
Figure 12: (a) Preoperative view of fat graft overgrowth due to 26 kg of
weight gain 4 years after girth augmentation; (b) intraoperative view of
complete lipectomy
c
b
a
b
a
ab
Plast Aesthet Res || Vol 2 || Issue 1 || Jan 15, 201532
in the mid‑1980’s and continues to be used due of its
versatility.
Traction treatments are the only ones able to achieve
effective length improvements of the penis, producing
an increase in actual tissue mass and at the same time
“softening” the corpora cavernosa fascial and osseous
attachments. The combined use of both types of
treatments (suspensory ligament release and extender
use) can produce the best outcome by extending the
“hidden” part of the penis with generation of additional
tissue. All penis lengthening techniques are based
on the release of natural physiologic anchors that
bind the corpora cavernosa to the pubic symphysis,
isquiopubic bone branches, and abdominal aponeurotic
expansions. Although this lengthening can be performed
through a simple transverse incision or even using an
endoscope (not published), a number of ancillary skin
advancements can be performed to ease ligament release
and to procure advancement and stabilization, and thus
prevent length loss due to scar contracture. In this
regard several techniques have been published such as
M‑plasty (popularized in China and reported by Reed[15]),
VY advancement (Roos and Lissoos[16]), Z‑plasty (Horton[17]),
double Z‑plasty (Alter[18,19]) and personal techniques of
Abecassis[20] and Panfilov.[21] Although the author supports
the use of local tissues to fill the advancement gap to
additionally maintain advancement, some authors have
published their experience inserting small testicular
prostheses as spacers with no better results.[22]
In our practice performing suspensory ligament release,
skin flap advancement together with simultaneous girth
enlargement using fat grafts is the most satisfactory
approach to increase penis size. This composite technique
generates real volume increase which results in a better
perceptual outcome for the patient. Additionally, the
increase in shaft convexity and downward position creates
the illusion of a longer penis as well. The incidence of
complications or side effects is relatively low and easy to
solve without affecting final results. A thorough knowledge
of regional anatomy helps to prevent serious or minor
complications. There are two good safety rules: perform
the ligament release as close to the bone as possible and
do not perform any grafting that may exceed the capacity
of the tissue. Although liponecrotic cyst occurrence can
be solved easily, damage to the deep penile neurovascular
structures usually has disastrous consequences. Patient
satisfaction after augmentation phalloplasty is lower
when compared with other popular aesthetic surgical
procedures. In our series, only 32% perceived the result
as very good and an additional 43% as good, in spite
of being clearly informed about the limitations and
outcomes for other patients and follow‑up demonstration
of improved average measurements. As with any other
aesthetic surgery procedure, informing the patient is
extremely important in achieving an adequate degree of
satisfaction. Two relatively distinct patient groups exists:
those who present with a real hypoplasia and those cases
of body dismorphic disorder. The former tend to show
higher degrees of satisfaction and understand easily the
limitations of the techniques. Patients with unrealistic
expectations that do not understand this information
must be discouraged from the procedure because the level
of disappointment will likely be very high. It is extremely
important not to assure the patient that any type of result
will be an improvement; patients should understand that
it is possible to see no improvement, an event caused
usually by an inadequate scar contraction.
Composite augmentation phalloplasty techniques are safe
and reproducible and yield satisfactory results if properly
performed. Although apparently easy to perform, a
thorough knowledge of anatomy and grafting techniques
is needed to get good results and avoid complications.
Volumetric enhancement by ligament release and
cutaneous advancement together with an increase in
girth with fat grafting is probably a safer option, with
better results and lower morbidity. The future of penis
enlargement will be enhanced with techniques that
provide dynamic improvements in size, possibly through
the use of tissue engineering.
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Plast Aesthet Res || Vol 2 || Issue 1 || Jan 15, 2015 33
How to cite this article: Monreal J. Composite augmentation
phalloplasty: personal experience after 275 patients. Plast Aesthet Res
2015;2:27-33.
Source of Support: Nil, Conict of Interest: None declared.
Received: 19-09-2014; Accepted: 23-10-2014
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