Penile Girth Enhancement With Polymethylmethacrylate-Based Soft Tissue Fillers

Abstract

Introduction:
An unknown percentage of men will take every risk to develop a larger penis. Thus far, most injectables have caused serious problems. Polymethylmethacrylate (PMMA) microspheres have been injected as a wrinkle filler and volumizer with increasing safety since 1989.

Aim:
To report on a safe and permanently effective method to enhance penile girth and length with an approved dermal filler (ie, PMMA).

Methods:
Since 2007, the senior author has performed penile augmentation in 752 men mainly with Metacrill, a suspension of PMMA microspheres in carboxymethyl-cellulose.

Main outcome measures:
The data of 729 patients and 203 completed questionnaires were evaluated statistically.

Results:
The overall satisfaction rate was 8.7 on a scale of 1 to 10. After one to three injection sessions, average girth increased by 3.5 cm, or 134% (10.2 to 13.7 cm = 134.31%). Penile length also increased by weight and stretching force of the implant from an average of 9.8 to 10.5 cm. Approximately half the patients perceived some irregularities of the implant, which caused no problems. Complications occurred in 0.4%, when PMMA nodules had to be surgically removed in three of the 24% of patients who had a non-circumcised penis.

Conclusion:
After 5 years of development, penile augmentation with PMMA microspheres appears to be a natural, safe, and permanently effective method. The only complication of nodule formation and other irregularities can be overcome by an improved injection technique and better postimplantation care.

Full text

SURGERY
Penile Girth Enhancement With Polymethylmethacrylate-Based
Soft Tissue Fillers
Luis Casavantes, MD,
1
Gottfried Lemperle, MD, PhD,
2
and Palmira Morales, MD
1
ABSTRACT
Introduction: An unknown percentage of men will take every risk to develop a larger penis. Thus far, most
injectables have caused serious problems. Polymethylmethacrylate (PMMA) microspheres have been injected as a
wrinkle filler and volumizer with increasing safety since 1989.
Aim: To report on a safe and permanently effective method to enhance penile girth and length with an approved
dermal filler (ie, PMMA).
Methods: Since 2007, the senior author has performed penile augmentation in 752 men mainly with Metacrill,
a suspension of PMMA microspheres in carboxymethyl-cellulose.
Main Outcome Measures: The data of 729 patients and 203 completed questionnaires were evaluated
statistically.
Results: The overall satisfaction rate was 8.7 on a scale of 1 to 10. After one to three injection sessions, average
girth increased by 3.5 cm, or 134% (10.2 to 13.7 cm ¼134.31%). Penile length also increased by weight and
stretching force of the implant from an average of 9.8 to 10.5 cm. Approximately half the patients perceived some
irregularities of the implant, which caused no problems. Complications occurred in 0.4%, when PMMA nodules
had to be surgically removed in three of the 24% of patients who had a non-circumcised penis.
Conclusion: After 5 years of development, penile augmentation with PMMA microspheres appears to be a
natural, safe, and permanently effective method. The only complication of nodule formation and other
irregularities can be overcome by an improved injection technique and better postimplantation care.
J Sex Med 2016;13:1414e1422. Copyright !2016, International Society for Sexual Medicine. Published by Elsevier
Inc. All rights reserved.
Key Words: Polymethylmethacrylate Injections; Girth Enhancement; Penile Enlargement; Penile Injection
Technique; Dermal Filler for Penile Injection
INTRODUCTION
“Bigger is better”sticks in the heads of many men
worldwide,
1e3
although women feel more excitement if their
vagina is optimally stretched.
4,5
Because the main nerve supply of
the vagina is found in its lower third,
6e8
the length of a penis
appears to matter less than girth during intercourse.
Because a large percentage of men are not satisfied with the
size of their penis,
1e3
the demand to increase it is high and has
led to many attempts using all kinds of injectables, including
mineral oils, paraffin, fluid silicone, and polyacrylamide.
9e11
Autologous fat injections are widely used,
12
although the key
for a predictable “take”has not been established. Absorption, oily
cysts, irregularities, and non-predictable results continue to be
common side effects. In addition, commercial products of slowly
absorbable dermal acellular grafts (AlloDerm, Acelity, San
Antonio, TX, USA)
13
often have to be removed because of
infection and folding,
14
and the manufacturer does not recom-
mend them for girth enhancement. Similar problems have
occurred after implantation of a solid silicone 3/4 tube.
15
Few methods are successful with long-term effectiveness. One
method, a vascularized dermis-fat flap, uses the superficial
circumflex iliac artery and vein from the groin implanted
between the penile skin and corpora.
16
Some widely used dermal fillers, such as cross-linked hyal-
uronic acids, have been successfully injected to increase girth for
up to 1 year 6 months.
17e20
Non-absorbable soft tissue fillers have become more and more
popular,
18
and more body areas are being altered as patients
Received August 19, 2015. Accepted June 24, 2016.
1
Avanti Derma, Tijuana, BC, Mexico;
2
Division of Plastic Surgery, University of CaliforniaeSan Diego, San Diego,
CA, USA
Copyright ª2016, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jsxm.2016.06.008
1414 J Sex Med 2016;13:1414e1422

widen the requests for trendier looks and attributes. One of the
safest non-absorbable soft tissue fillers is comprised of micro-
spheres of polymethylmethacrylate (PMMA) suspended in
vehicles such as bovine collagen or cellulose.
21
After injection into the body, individual microspheres become
encapsulated with granulation tissue, which is followed by the
ingrowth of blood vessels, eventually creating a “living tissue”
(Figures 1 and 2). Similar fillers have been used as “volumizing
agents”in Europe and the United States for facial augmenta-
tion
21,22
and in Brazil for muscle augmentation since 1998.
23,24
The purpose of this study is to report the safety and efficacy of
PMMA microspheres suspended in carboxymethyl-cellulose
(Metacrill, Nutricel, Guapimirim, Rio de Janeiro, Brazil) for
cosmetic or corrective girth enhancement of the penile shaft.
METHODS
Patients
The study included 729 men treated with an estimated 1,500
sessions of penile girth enhancement with PMMA microsphere
injections from September 1, 2007 to February 15, 2015. Patients
were healthy men with an average age of 37 years
(range ¼19e68). Seventy-six percent were circumcised, 94%
were looking for cosmetic enhancement, and 6% were seeking
correction after other surgical procedures or trauma. Patients came
from all over the world with a strong desire to change the
diameter of their penis; 64% were Caucasian, 16% were Latino,
9% were African American, 4% were Asian, and 7% were of other
races. They were dissatisfied with the average penile dimensions
found in the literature (flaccid length ¼9.2 cm, erect length ¼
13.1 cm, flaccid girth ¼9.3 cm, erect girth ¼11.7 cm).
3
Statistics
Questionnaires with 20 questions about sensitivity, sexual
function, adverse events, and satisfaction were sent to all 729
patients; the answers of 203 patients could be evaluated (return
rate ¼27.8%). Pre- and post-treatment girth measurements
of the 203 patients were compared using a paired t-test in SPSS
(SPSS, Inc, Chicago, IL, USA) and descriptive statistics (eg, mean
and SD) were calculated. Comparisons were performed for
each session. The mean difference between the pre- and post-
treatment groups was calculated as "2.2192 (SD ¼1.1615)
with a Pvalue less than .001 for all measurements.
Product
The injected product was Metacrill, which is comprised of
PMMA microspheres suspended in a carboxy-methylcellulose gel.
The approximate number of PMMA microspheres per milliliter is
3 million for Metacrill 10% and 9 million for Metacrill 30%.
Technique
Preparation
Girth enhancement with PMMA is an outpatient procedure
performed under regional anesthesia. Patients were premedicated
with lorazepam (Ativan; Pfizer, Mexico City, Mexico) 1 mg
sublingually; all uncircumcised and selected circumcised patients
received betamethasone (Diprospan; Schering-Plough, Xomchilco,
Mexico) 1 mL by intramuscular injection to control swelling.
Markings
First, two ventral longitudinal lines were drawn immediately on
both sides of the urethra to avoid injecting filler in this area
(Figure 3). Second, two dorsal longitudinal lines were drawn on the
sides of the shaft, from the base to the corona, followed by two to
three transversal lines to demarcate 9 to 12 sections (Figure 4).
Local Anesthesia
After asepsis, local anesthesia was performed using circular
plus ventral upward infiltration with lidocaine 2% without
epinephrine at the penile root.
25
Figure 1. Polymethylmethacrylate microspheres after 3 months
are surrounded by granulation tissue. Figure 2. At 10 years, the microspheres are embedded in collagen
fibers and capillaries, which converted the polymethylmethacrylate
implant to “living tissue.”
J Sex Med 2016;13:1414e1422
Penile Girth Enhancement With PMMA-Based Soft Tissue Fillers 1415

Injection Technique
In the typical patient, nine sections and six entry points were
used for a full treatment. Entry points were made with a sharp
16-gauge needle (Figure 5), which was used only to open the skin
and allow the 22-gauge microcannula to travel into the gliding
space. The entry points were located alongside the longitudinal
lines, with one next to the proximal transversal line and the other
two on each side of the distal transversal line.
PMMA microspheres were injected using disposable micro-
cannulas (22-gauge #50 mm or 22-gauge #70 mm) with the
orifice on the side of the tip facing down. A commercially
available mechanically precise injection pistol (BioMedical, Porto
Alegre, Brazil) ensured standard volume deposits of 0.1 mL
(Figure 6). The senior author has presented this technique in
medical meetings under the name Exact Implantation Tech-
nology (EIT). Using the EIT, the Buck fascia is easily identified,
and the PMMA suspension is deposited overlying the Buck fascia
at the level of the deep Dartos fascia.
The PMMA suspension injected overlying the Buck fascia
leaves the superficial Dartos fascia untouched, and the alveolar
gliding space is preserved, maintaining the gliding of the skin
over the implant or of the implant over the Buck fascia. The
implants were positioned in direction of the base and the corona,
in individual drops, slightly overlapping but avoiding ridges.
Most treatments were performed using manual traction with
the penis in relaxation; induced erection was tried but manipu-
lating a tumescent penis was more difficult and the clinical results
were similar with the two variations.
As the PMMA injection was being performed, massage with
firm pressure was applied to distribute the product to the desired
areas. Patients were carefully instructed to continue the massage
on their own and were seen 24 hours later to make sure they were
following the instructions as indicated. Patients continued the
massage and manipulation for as long as 72 hours. In addition,
some patients used a metal or hard rubber roller to even out the
implanted PMMA.
17
All patients were prescribed with antibi-
otics and a penile extensor (ESL-40) was prescribed for patients
with severe retraction.
Figure 3. The corpus spongiosum is marked with two lines. Figure
3 is available in color online at www.jsx.jsexmed.org.
Figure 4. Two longitudinal lines are drawn at the sides of the shaft
followed by two transversal lines that demarcate nine sections for
polymethylmethacrylate injection. Figure 4 is available in color
online at www.jsx.jsexmed.org.
Figure 5. Entry points are marked alongside the longitudinal lines
to reach all nine segments. Figure 5 is available in color online at
www.jsx.jsexmed.org.
J Sex Med 2016;13:1414e1422
1416 Casavantes et al

Micropenis
A common criterion for a micropenis is a dorsal erect length
shorter than 7 cm for an adult compared with an average erection
length of 12.5 cm. In the sample of 729 patients, 13 patients
(1.8%) had a micropenis. To maintain a normal girth-length
ratio, these patients are treated with less product, a lower
concentration, smaller microcannulas, and fewer sessions using
only two to four entry points.
Peyronie Disease
PMMA implants can be individualized to partly or fully
balance the shaft of the penis in the presence of curvatures.
Minor deformities or curvatures associated with Peyronie disease
can be corrected by volume compensation on the concave side.
Good results were obtained in two patients (0.3%) with mild
Peyronie disease.
26
The same principle is used to correct unusual
shapes, such as “missile”penis, “hourglass”penis, thin base, etc,
by injecting PMMA in areas that lack volume.
All treatments were performed as outpatient procedures under
local anesthesia at Avanti Derma (Tijuana, Mexico).
RESULTS
Clinical Outcome
Once implanted, the water-based carrier (70e90% of the
volume) is absorbed and metabolized by the body, causing
partial loss of the initial volume. The lost volume will be regained
slowly but steadily as the connective tissue surrounds each
PMMA microsphere within 2 to 3 months. In all patients, the
PMMA implant was fixed to the Buck fascia and the penile skin
was moved over the implant or the implant was in the deep
Dartos fascia and moved over the Buck fascia. The surface was
absolutely smooth in approximately 50% of patients. In the
other half, one could sense or observe irregularities of the surface,
which typically was no problem for most patients. Otherwise,
they came for a touch-up session to smoothen the surface with
PMMA 10%.
Injected Volumes
Patients were required to have a minimum of two sessions and
a maximum of three performed approximately every 6 weeks.
Thirty-three percent of patients returned for the second follow-
up sessions, 16% for a third, 6% for a fourth, and 3% for a
fifth. Third and fourth sessions were mostly “touch-up”sessions
to correct minor deficits using small volumes of PMMA.
Most patients received PMMA 10% in the three distal (neck)
segments and PMMA 30% in the mid-shaft and base. Injected
volumes varied among individuals for anatomic reasons and
patients’expectations. The average total volume used in the first
session was 20 mL, of which half consisted of a 30% concen-
tration and the other half consisted of 10% and 20% concen-
trations. The 20% PMMA suspension was produced in sterile
fashion in a 2-mL syringe using a female-to-female connector
between a 10% and a 30% PMMA syringe. The average total
volume was 40 mL (range ¼140 mL in one patient to 5 mL in
another patient).
Penile Measurements
In-office measurements showed a mean increase in girth of 2.4
cm (P<.001) from 10.4 to 12.8 cm for the mid-shaft of the
flaccid penis (Table 1), and patients’self-assessment showed an
average girth increase of 2.5 cm (P<.001) during relaxation and
2.3 cm (P<.001) in full erection.
In-office measurements showed an average increase in flaccid
penile length of 0.7 cm from 9.8 to 10.5 cm, which could be
attributed to the rather stiff implant that surrounds the corpora
and prevents total shrinking in a flaccid stage, even under stress,
cold weather, or cold water.
Figure 6. Injection pistol ensured standard volume deposits of
0.1 mL. Figure 6 is available in color online at www.jsx.jsexmed.org.
Table 1. Penile flaccid girth increase after several polymethylmethacrylate injections*
n Minimum Maximum Mean SD Significance
Mid-shaft before 203 6.5 16.0 10.542 1.4907
Mid-shaft after 203 8.5 17.0 12.761 1.4145 P<.001
Penile base before 203 7.0 16.5 10.719 1.4700
Penile base after 203 9.0 18.0 13.007 1.4679 P<.001
Penile neck before 203 7.0 15.0 10.207 1.3703
Penile neck after 203 8.0 24.5 12.254 1.5916 P<.001
*Two examples of the smallest and largest treated penises and the mean in 203 evaluated patients.
J Sex Med 2016;13:1414e1422
Penile Girth Enhancement With PMMA-Based Soft Tissue Fillers 1417

Patients With Previous Procedures
Circumcision
Irregularities are more common in uncircumcised patients
who need a more conservative approach (smaller volume of filler
and fewer sessions); their skin is loose and the foreskin has to be
preserved intact. The neck has to be approached with the fore-
skin under full retraction and the mid-shaft and base with the
foreskin fully extended; the continuation between the two areas
often results in an overlap that leads to nodules owing to excess
or to deficits owing to lack of product. In contrast, circumcised
patients are better candidates because they have tighter skin that
helps keep the suspension in place during the initial phase, and
the entire shaft is one single area of implant. A common
complication in circumcised patients is the development of a
tight ring at the circumcision scar, leaving an initial crease that
needs to be corrected in a future session, once the implant is
settled.
Soft Silicone Penile Implants
Seventeen of the 729 patients (2.3%) had a permanent
implant
15
removed before their treatment with PMMA. All had
developed fibrosis after extraction; one had lost at least 2 inches
in length with a severe “accordion”effect.
Suspensory Ligament Release
Girth enhancement with PMMA is compatible with surgical
penile lengthening through suspensory ligament release whether
the injections are performed before surgery or after the area is
fully healed. The PMMA implant in these patients has the same
effect as in non-operated patients, but based on statistical data,
27
we do not recommend this surgery to our patients, because some
have no results or develop paradoxical shortening. Furthermore,
the satisfaction rate of 35% led to the conclusion that this
“virtual”lengthening should be used as a last resort and
stretching devices should be used instead.
27
Inflatable Penile Prosthesis
For one reason or another, a penis with an internal pros-
thesis, rigid or inflatable, loses some length by internal scar
tissue and loses girth over time.
28
Three patients with internal
prostheses were fully satisfied with their girth enhancement
with PMMA.
Autologous Fat Transfer
Nine of the 729 patients (1.2%) underwent fat transfer that
left irregularities
12
but also made the tissues firmer, facilitating
the implantation of PMMA.
Regenerative Tissue Matrix (AlloDerm)
Ten patients (1.4%) previously received regenerative tissue
matrix implants
14
that were totally or partly dissolved at the time
of the PMMA implantation. This implant made the tissues
firmer, facilitating the implantation of PMMA.
Complications
Postoperative swelling and internal inflammation resolved
within a few days. None of the patients’sexual partners expressed
any concern or discomfort with this initial “soft”step. Because
the PMMA implant does not cover the urethral part of the
corpus spongiosum, no lower urinary symptoms were seen.
Irregularities
The penis is the only area of the human body that does not
have a layer of subcutaneous adipose tissue that could help
camouflage the implant, and irregularities such as nodules and
voids are easily detectable even with the use of a small volume.
More half the patients (52%) reported minimum to severe
irregularities such as single nodules (Figure 7), multiple nodules,
hard ridges at the circumcision scar or at the base, micro-nodules
at the entry points, indentations, or voids. The incidence of
irregularities was higher owing to the inclusion of numerous
(22%) non-circumcised patients whose penile skin is longer and
looser. Three patients (0.4%) had one PMMA nodule surgically
removed with no further complications.
Granulomas
Inactive nodules were often confused with granulomas by
patients and some physicians, but no true granulomas were
documented. Granulomas can occur after injections of fillers into
Figure 7. Common irregularities of nodules and voids.
J Sex Med 2016;13:1414e1422
1418 Casavantes et al

the dermis but not into deeper spaces (epi-periosteal) or the
areolar space between the Buck and Dartos fasciae with lesser
immunologic activity.
21
Migration
No instances of PMMA translocation or migrating of PMMA
microspheres to neighboring areas were seen.
Exudate Through the Entry Points
Sterile exudate through the entry points is a common occur-
rence that resolves in approximately 24 hours. Two patients
(0.3%) presented exudate that lasted longer than 72 hours but
resolved with no further complications.
Removal of PMMA Penile Implants
Total surgical removal of a PMMA implant might require
aggressive degloving of the penis, which is associated with painful
recovery and permanent irregularities. Removal should be the last
option, and meticulous smoothening of irregularities with cross-
linked hyaluronic acid,
17
Silikon 1000, silicone micro-droplets,
or PMMA is more advisable.
Patient Satisfaction
All 729 patients included in this study received a questionnaire
to assess long-term safety and satisfaction for up to 7 years;
however, only 203 patients (28%) returned this questionnaire.
We could not find any obvious dissatisfaction in our notes of
the remaining non-responders. Patient satisfaction was measured
on a scale of 1 (very dissatisfied) to 10 (extremely satisfied;
Figures 8e10).
Overall satisfaction with the procedure was 8.7 on a scale of
1 to 10. Of the 203 patients, 168 were satisfied (83%;
score ¼8e10), 25 were not satisfied (12%; score ¼6 and 7),
and 10 were dissatisfied (5%; score <5).
Sexual Function
Because the PMMA implant is independent of the corpora
cavernosa and the corpus spongiosum, erectile function is not
affected. The survey of 203 patients showed that erectile function
was unaltered in 83%, enhanced in 15%, and decreased in 1.5%.
The sensitivity of the penis was unaltered in 83%, enhanced in
15%, and decreased in 2%.
Because the pudendal dorsal nerve endings running in the
Buck fascia are covered with the PMMA implant, we expected
some changes, such as delayed orgasms, but such an effect was
not reported by any patient.
DISCUSSION
Although penile augmentation is under-reported in the liter-
ature, public interest in such procedures is increasing. The
growing demand for such procedures requires an honest and
meticulous long-term evaluation of the injected materials and
clear documentation of a patient’s satisfaction and complaints.
The most common reason for girth enhancement is,
whether subjective or not, a small penis; some expect an
enhancement of their sexual life with their partners and a
small percentage recognize that it is for their own gratification
and self-esteem. In addition to different hyaluronic acid
fillers with a limited longevity of 6 to 18 months,
17e20
Figure 8. Circumcised patient before and 3 months after one session with polymethylmethacrylate 20 mL.
J Sex Med 2016;13:1414e1422
Penile Girth Enhancement With PMMA-Based Soft Tissue Fillers 1419

modern PMMA microspheres are as safe, with the immense
advantage of a lifetime effect. Increasing expertise and injec-
tion skills have decreased serious implant irregularities to an
acceptable level.
PMMA microsphere injections for facial wrinkles have been
used since 1989,
21
with varying success and some complications
typical for all dermal fillers.
29,30
Foreign body granulomas have
been largely prevented by injecting deep to the bone and
Figure 10. Corrective treatments. Left panel shows deformity. Middle panel shows retraction after removal of the solid silicone implant.
Right panel shows a penis after several sessions of polymethylmethacrylate injections.
Figure 9. Uncircumcised patient before and 11 months after one session with polymethylmethacrylate 22 mL.
J Sex Med 2016;13:1414e1422
1420 Casavantes et al

beneath the fatty layer of the skin, where immunologic sensi-
tization is much less pronounced than in the dermis.
21
In the
total series of 729 patients, we found no late foreign body
granulomas.
Metacrill is approved in Brazil, Mexico, and Europe, and
ArteFill (Bellafill since 2015; Suneva Medical, Santa Barbara,
CA, USA) is approved by the U.S. Food and Drug Adminis-
tration in the United States and South Korea, but the latter
product is too expensive when considering an average volume of
PMMA 40 mL per patient. The same is true for Artecoll (Artes
Medical, San Diego, CA, USA), which is approved in Europe by
the Conformité Européenne and in China by the Chinese Food
and Drug Administration; PMMA microspheres in these prod-
ucts are suspended in rather expensive bovine collagen. There-
fore, for larger volumes, we rely on the two affordable PMMA
products (Metacrill and Linnea Safe [formerly New Plastic;
BioMedical, Sao Paulo, Brazil]) approved by ANVISA, the
Brazilian Health Ministry.
CONCLUSION
There is no perfect penile implant, but PMMA microspheres
seem to be safe, stable, and efficient. The level of patient satis-
faction is very high. Because penile PMMA implants are fairly
new, most patients worry about possible future complications,
but based on the wide experience of facial PMMA microsphere
injections,
21
the future of penile implantations is promising, with
the expectation of a life-long effect that will be stable and safe.
What we are witnessing is a shift to a wider use of injectable
implants and techniques designed specifically for penile girth
enhancement.
TAKE HOME MESSAGE
The retrospective evaluation of 729 patients who underwent
girth augmentation with a permanent dermal filler (PMMA
microspheres) showed an average increase in girth of 2.4 cm and
an overall satisfaction rate of 8.7 on a scale of 1 to 10.
ACKNOWLEDGMENT
The authors would like to thank Nicole Gaid HS BSc, MSc,
MB BCh BAO, MMI, for her invaluable contribution in the
analysis and interpretation of data.
Corresponding Author: Luis Casavantes, MD, Avanti Derma,
Boulevard Agua Caliente 4558-1107, 22420 Tijuana, BC,
Mexico. Tel: þ52-664-687-4848; E-mail: drc@avantiderma.
com
Conflict of Interest: The authors report no conflicts of interest.
Funding: None.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Luis Casavantes; Gottfried Lemperle
(b) Acquisition of Data
Luis Casavantes; Palmira Morales
(c) Analysis and Interpretation of Data
Palmira Morales
Category 2
(a) Drafting the Article
Luis Casavantes; Gottfried Lemperle
(b) Revising It for Intellectual Content
Luis Casavantes; Gottfried Lemperle
Category 3
(a) Final Approval of the Completed Article
Luis Casavantes; Gottfried Lemperle; Palmira Morales
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