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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.
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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 ller 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 ller (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 bettersticks 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 satised 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, parafn, uid silicone, and polyacrylamide.
9e11
Autologous fat injections are widely used,
12
although the key
for a predictable takehas 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 ap, uses the supercial
circumex iliac artery and vein from the groin implanted
between the penile skin and corpora.
16
Some widely used dermal llers, 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 llers 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 llers 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 llers have been used as volumizing
agentsin 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 efcacy 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 dissatised with the average penile dimensions
found in the literature (accid length ¼9.2 cm, erect length ¼
13.1 cm, accid 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; Pzer, 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 ller 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 inltration 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
bers 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
orice 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 identied,
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 supercial 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 difcult and the clinical results
were similar with the two variations.
As the PMMA injection was being performed, massage with
rm 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 missilepenis, hourglasspenis, 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 xed 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
fth. Third and fourth sessions were mostly touch-upsessions
to correct minor decits 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
patientsexpectations. The average total volume used in the rst
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-ofce 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
accid penis (Table 1), and patientsself-assessment showed an
average girth increase of 2.5 cm (P<.001) during relaxation and
2.3 cm (P<.001) in full erection.
In-ofce measurements showed an average increase in accid
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 accid 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 accid girth increase after several polymethylmethacrylate injections*
n Minimum Maximum Mean SD Signicance
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 ller
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 decits 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 brosis after extraction; one had lost at least 2 inches
in length with a severe accordioneffect.
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
virtuallengthening should be used as a last resort and
stretching devices should be used instead.
27
Inatable Penile Prosthesis
For one reason or another, a penis with an internal pros-
thesis, rigid or inatable, loses some length by internal scar
tissue and loses girth over time.
28
Three patients with internal
prostheses were fully satised 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 rmer, 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
rmer, facilitating the implantation of PMMA.
Complications
Postoperative swelling and internal inammation resolved
within a few days. None of the patientssexual partners expressed
any concern or discomfort with this initial softstep. 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
camouage 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 llers 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 nd any obvious dissatisfaction in our notes of
the remaining non-responders. Patient satisfaction was measured
on a scale of 1 (very dissatised) to 10 (extremely satised;
Figures 8e10).
Overall satisfaction with the procedure was 8.7 on a scale of
1 to 10. Of the 203 patients, 168 were satised (83%;
score ¼8e10), 25 were not satised (12%; score ¼6 and 7),
and 10 were dissatised (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 patients 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 gratication
and self-esteem. In addition to different hyaluronic acid
llers 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 llers.
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 (Bellall 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 efcient. 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 specically for penile girth
enhancement.
TAKE HOME MESSAGE
The retrospective evaluation of 729 patients who underwent
girth augmentation with a permanent dermal ller (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
Conict of Interest: The authors report no conicts 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
REFERENCES
1. Ghanem H, Glina S, Assalian P, et al. Position paper: man-
agement of men complaining of a small penis despite an
actually normal size. J Sex Med 2013;10:294-303.
2. Shaeer O, Shaeer K. Impact of penile size on male sexual
function and role of penile augmentation surgery. Curr Urol
Rep 2012;13:285-289.
3. Veale D, Miles S, Bramley S, et al. Am I normal? A systematic
review and construction of nomograms for accid and erect
penis length and circumference in up to 15,521 men. BJU Int
2015;115:978-986.
4. Eisenman R. Penis size: survey of female perceptions of sexual
satisfaction. BMC Womens Health 2001;1:1-4.
5. Villeda Sandoval CI, Calao-Pérez M, Enríquez González AB,
et al. Orgasmic dysfunction: prevalence and risk factors from
a cohort of young females in Mexico. J Sex Med 2014;
11:1505-1511.
6. Hilliges M, Falconer C, Ekman-Ordeberg G, et al. Innervation of
the human vaginal mucosa as revealed by PGP 9.5 immuno-
histochemistry. Acta Anat (Basel) 1995;153:119-126.
7. Pauls R, Mutema G, Segal J, et al. A prospective study
examining the anatomic distribution of nerve density in the
human vagina. J Sex Med 2006;3:979-987.
8. Song YB, Hwang K, Kim DJ, et al. Innervation of the vagina:
microdissection and immunohistochemical study. J Sex
Marital Ther 2009;35:144-153.
9. De Siati M, Selvaggio O, Di Fino G, et al. An unusual delayed
complication of parafn self-injection for penile girth
augmentation. BMC Urol 2013;13:66.
10. Sasidaran R, Zain MA, Basiron NH. Low-grade liquid silicone
injections as a penile enhancement procedure: is bigger better?
Urol Ann 2012;4:181-186.
11. Francis J, Poh Choo Choo A, Wansaicheong Khin-Lin G.
Ultrasound and MRI features of penile augmentation by
Jamaica Oilinjection. A case series. Med Ultrason 2014;
16:372-376.
J Sex Med 2016;13:1414e1422
Penile Girth Enhancement With PMMA-Based Soft Tissue Fillers 1421
12. Kang DH, Chung JH, Kim YJ, et al. Efcacy and safety of penile
girth enhancement by autologous fat injection for patients with
thin penises. Aesth Plast Surg 2012;36:813-818.
13. Alei G, Letizia P, Ricottilli F, et al. Original technique for penile
girth augmentation through porcine dermal acellular grafts:
results in a 69-patient series. J Sex Med 2012;9:1945-1953.
14. Solomon MP, Komlo C, Defrain M. Allograft materials in
phalloplasty: a comparative analysis. Ann Plast Surg 2013;
71:297-299.
15. Elist JJ, Shirvanian V, Lemperle G. Surgical treatment of penile
deformity due to curvature using a subcutaneous soft silicone
implant: case report. Open J Urol 2014;4:91-97.
16. Shaeer O. Shaeers augmentation phalloplasty: the super-
cial circumex iliac ap. J Sex Med 2014;11:1856-1862.
17. Kwak TI, Oh M, Kim JJ, et al. The effect of penile girth
enhancement using injectable hyaluronic acid gel, a ller. J Sex
Med 2011;8:3407-3413.
18. Yang DY, Lee WK, Kim SC. Tolerability and efcacy of newly
developed penile injection of cross-linked dextran and poly-
methylmethacrylate mixture on penile enhancement:
6 months follow-up. Int J Impot Res 2013;25:99-103.
19. Sito G, Marlino S, Santorelli A. Use of Macrolane VRF 30 in
hemicircumferential penis enlargement. Aesthet Surg J 2013;
33:258-264.
20. Siebert T, Chaput B, Vaysse C, et al. The latest information on
Macrolane
TM
: its indications and restrictions. Ann Chir Plast
Esthet 2014;59:e1-e11.
21. Lemperle G, Knapp TR, Sadick NS, et al. ArteFill®permanent
injectable for soft tissue augmentation: 1. Mechanism of action
and injection techniques. Aesth Plast Surg 2010;34:267-272.
22. Carvalho I, Salaro C, Carvalho M. Polymethylmethacrylate
facial implant: a successful personal experience in Brazil for
more than 9 years. Dermatol Surg 2009;35:1221-1227.
23. Rosa SC, Macedo JL, Magalhães AV. An experimental study of
tissue reaction to hyaluronic acid (Restylane) and poly-
methylmethacrylate (Metacrill) in the mouse. Am J Derma-
topathol 2012;34:716-722.
24. Serra MS, Gonçalves LZ, Ramos-E-Silva M. Soft tissue
augmentation with PMMA-microspheres for the treatment of
HIV-associated buttock lipodystrophy. Int J STD AIDS 2015;
26:279-284.
25. Malkoc E, Ates F, Uguz S, et al. Effective penile block for
circumcision in adults. Wien Klin Wochenschr 2012;
124:434-438.
26. Chung E, Brock G. Penile traction therapy and Peyronies
disease. A state of art review of the current literature.
Ther Adv Urol 2013;5:59-65.
27. Chi-Ying L, Kayes O, Kell P, et al. Penile suspensory ligament
division for penile augmentation: Indications and results.
Eur Urol 2006;49:729-733.
28. Deveci S, Martin D, Parker M, Mulhall JP. Penile length alter-
ations following penile prosthesis surgery. Eur Urol 2007;
51:1128-1131.
29. Medeiros CC, Cherubini K, Salum FG, et al. Complications after
polymethylmethacrylate (PMMA) injections in the face: a
literature review. Gerodontology 2014;31:245-250.
30. Kadouch JA, van Rozelaar L, Kanhai RJ, et al. Complications
of penis or scrotum enlargement due to injections with
permanent lling substances. Dermatol Surg 2012;
38(7):1244-1250.
J Sex Med 2016;13:1414e1422
1422 Casavantes et al
... PMMA microspheres are relatively large, and therefore not susceptible to phagocytosis once injected into the penis [29]. It has been shown to be a biocompatible substance, with minimal complications, and has been termed to be a "living tissue" as the microspheres become embedded in collagen fibers and capillaries over time [30]. In a prospective study of 15 subjects who underwent PMMA injection by Kim et al., the average flaccid penile length increased 3 cm, and this enhancement was maintained over 18 months [29]. ...
... Further, there were no reports of filler degradation or migration. In a larger retrospective study by Casavantes et al., 729 men underwent penile augmentation with PMMA filler and demonstrated an average girth increase of 2.4 cm and high patient satisfaction rates [30]. The study also reported a 0.4% complication rate and concluded that PMMA is safe and effective for long term penile augmentation [30]. ...
... In a larger retrospective study by Casavantes et al., 729 men underwent penile augmentation with PMMA filler and demonstrated an average girth increase of 2.4 cm and high patient satisfaction rates [30]. The study also reported a 0.4% complication rate and concluded that PMMA is safe and effective for long term penile augmentation [30]. ...
Article
Full-text available
Purpose of Review Some men experience small penis syndrome (SPS), a body dysmorphic disorder in which a patient believes their penis to be small even when it is clinically average. As cosmetic surgery becomes more widely accepted, management of SPS may present a challenge for urologists. We aim to provide an updated review of aesthetic penile augmentation procedures. Recent Findings Augmentation procedures range from invasive to noninvasive. Surgical solutions include grafts and flaps, suspensory ligament release, and suprapubic lipectomy. Minimally invasive solutions include injections of fillers (hyaluronic acid, polylactic acid, and polymethyl methacrylate). Noninvasive solutions include external devices such as vacuum pumps and traction devices. Summary In the current climate, aesthetic penile augmentation is becoming a desirable option for many patients but remains clinically controversial. Our review summarizes recent and relevant studies and demonstrates the need for further research and consensus on penile augmentation procedures.
... A total of 29 studies were included in the review (3 concerning non-invasive approaches [10][11][12], 11 regarding injection therapies [13][14][15][16][17][18][19][20][21][22][23], and 15 reporting surgical procedures [24][25][26][27][28][29][30][31][32][33][34][35][36][37][38]). Overall, 3,327 patients were evaluated, but only 5 (17.2%) articles [13,15,18,26,29] included more than 100 subjects. ...
... A total of 29 studies were included in the review (3 concerning non-invasive approaches [10][11][12], 11 regarding injection therapies [13][14][15][16][17][18][19][20][21][22][23], and 15 reporting surgical procedures [24][25][26][27][28][29][30][31][32][33][34][35][36][37][38]). Overall, 3,327 patients were evaluated, but only 5 (17.2%) articles [13,15,18,26,29] included more than 100 subjects. The mean age of patients ranged from 23 [37] to 55.5 [19] years. ...
... Injection of hyaluronic acid, polylactic acid, polymethylmethacrylate, autologous fat, and liquid silicone for PGE were reported in six [14,15,[20][21][22][23], four [19,[21][22][23], two [17,18], one [16], and one [13] studies, respectively. Eight articles [14,[16][17][18][19][21][22][23] showed a significant increase in penile girth (p < 0.05). ...
Article
The present study aimed to describe and critically discuss the current evidence regarding the penile girth enhancement procedures for aesthetic purposes. We designed a narrative review of the literature. A comprehensive search in the MEDLINE database was performed. Original articles in English-language, published until March 2021, were selected. A total of 29 studies were included (3 reporting non-invasive approaches, 11 injection therapies, and 15 surgical procedures). The vast majority of articles (26, 89.7%) were not randomized controlled trials, with overall low quality and limited level of evidence. Only 1 (33.3%) paper regarding non-invasive approaches reported a minimal (+0.03 cm) but a significant increase of penile girth (p = 0.034). A low rate (11.2–14.4%) of mild, temporary adverse events and poor-to-moderate patient satisfaction were found. Eight (72.7%) articles concerning injection therapies showed a significant increase in penile girth (p < 0.05). A low rate of mild complications, generally at the injection site, and a high patient satisfaction rate (75–100%) were highlighted. Nine (60%) papers on surgical treatments found a significant increase in penile girth (p < 0.05), while the other 6 (40%) studies reported a generic improvement in penile circumference. Skin necrosis or ulcers, wound infections, or need for reoperation were reported in 8 (53.3%) studies. A high patient satisfaction rate (60–100%) was reported. Our review highlighted the overall positive results of injection procedures, the poor outcomes associated with non-invasive techniques, and the good efficacy and satisfaction with a non-negligible risk of complications in patients undergoing surgical treatments. However, the adverse events are probably largely under-reported and these procedures should still be considered under investigation due to the limited evidence available and the lack of guidelines.
... Two lines parallel to the spongy body of the urethra are drawn as limiters of the area to be preserved. An automatic gun is used to inject precise volumes of filler, generally equal to 0.1 ml, between Buck's fascia and the deepest part of the Dartos [77]. ...
... Casavantes et al. subjected 729 men to 2-3 sessions of injections, achieving not only an increase in average girth of 2.21 (SD 1.16) cm, but also an increase in average flaccid penis length of 0.7 cm, likely due to PMMA's ability to create a stiffer shaft at rest. Eighty-three percent of patients were satisfied with the postoperative results [77]. Unfortunately, 52% of patients directly witnessed shaft deformities secondary to the formation of nodularities, single or multiple, and indentations due to areas of void. ...
Article
Full-text available
The reason behind the spread of penis enlargement practices over time is rooted in the virility that the appearance of the genitals can give a man, as well as an altered perception of his own body. The approach should be to modulate the interventions on the real needs of patients, carefully evaluating the history, the psychological picture, and possible surgical advantages. The aim of this study was to shed light on cosmetic surgery of male genitalia through minimally invasive and more radical techniques, with the purpose of laying the foundation for possible indications and recommendations for the future. A non-systematic literature review using the PubMed and Scopus databases was conducted to retrieve papers written in English on cosmetic surgery of the penis published over the past 15 years. Papers discussing cosmetic surgery in patients with concomitant pathologies associated with sexual dysfunction were excluded. The main outcomes recorded were change in penile dimensions in term of length and girth and surgical complications.
... Casavantes та ін. [49] повідомили про 8-річний досвід застосування ін'єкцій поліметилметакрилату для збільшення обхвату СЧ, виконавши 1500 ін'єкцій 729 чоловікам, включаючи велику кількість пацієнтів, які раніше проходили інші процедури потовщення СЧ. В результаті лікування товщина СЧ в середньому збільшилась на 2,4 см, що спостерігалося в спокійному, розтягнутому та ерегованому станах (за повідомленнями пацієнтів) [49]. ...
... [49] повідомили про 8-річний досвід застосування ін'єкцій поліметилметакрилату для збільшення обхвату СЧ, виконавши 1500 ін'єкцій 729 чоловікам, включаючи велику кількість пацієнтів, які раніше проходили інші процедури потовщення СЧ. В результаті лікування товщина СЧ в середньому збільшилась на 2,4 см, що спостерігалося в спокійному, розтягнутому та ерегованому станах (за повідомленнями пацієнтів) [49]. ...
Article
Full-text available
Review objective: to evaluate the current scientific evidence of all available injectable methods of penis enlargement, to evaluate their effectiveness. Materials and methods. A systematic search of scientific medical information include databases MEDLINE, Embase, AMED and HMIC. A manual web search of relevant links in the found texts was performed. Results. Conditions in which phallus thickening is used: concern with penis size or small penis syndrome, penile dysmorphophobia, penis reduction (radical prostatectomy for prostate cancer, Peyronie's disease, congenital anomalies, erectile dysfunction). Injectable thickening of penis started using in the in the early XX century, paraffin and mineral oils were introduced. In the 1940s, safer liquid silicone and polymethyl methacrylate were used. Gel-like biodegradable materials are currently popular because they lack most of the disadvantages of permanent substances: hyaluronic acid, polylactic acid, dextran gel and mixtures of these substances. Thickening of the penis depends on the volume inserted filler and averages + 2–4 cm in circumference. In 2003, Moon et al. for the first time proposed a method of enlarging the penis head with hyaluronic acid. Other drugs were also used: hydrogel, polyacrylamide and dextran gel. Hyaluronic acid is the most commonly used drug. Promising filler is polylactic acid, which stimulates the fibroblasts development at the injection site and is relatively safe to use. The circumference length of the penis head can be increased by an average of 1.5 cm. Conclusion. Penis enlargement procedures are gaining popularity among men. However, there are a limited number of scientific papers that would describe the results and complications of these procedures. Further research is needed to study the impact of penis enlargement techniques on men's sex life and well-being, because it is the key motivating factor in turning to experts on this issue.
... Penile injection therapy with several materials has been described. The most common of which are autologous fat injection, liquid injectable silicone, and cosmetic soft tissue filler such as hyaluronic acid, calcium hydroxylapatite, collagen, polymethyl-methacrylate microspheres (PMMA) (38)(39)(40). Generally, these types of injections offer mixed satisfaction results, with some reported serious adverse effects such fat and silicone embolism and diffuse penile fibrosis. ...
Article
Nowadays, aesthetic concerns have gained attention, especially by patients looking for a less invasive alternative to minor facial corrections. Polymethylmethacrylate (PMMA) is widely used as a soft tissue filler; the demand for this polymer has increased, and along with it, there are some reports of adverse reactions. Such adverse reactions stem from consequences of immune and inflammatory reactions to PMMA. Some animal models have been used to unravel the causes of these reactions, among other factors involving the management of PMMA. The aim of this study was to determine the immunogenic profile of PMMA implantation in different anatomical planes of mice, over up to 360 experimental days. In this study, BALB/c mice were divided into 30 groups for immune evaluation of the interaction between the organism and the polymer; 2% PMMA was implanted subcutaneously, 10% intramuscularly and 30% in periosteal juxtaposition and followed during five experimental days (7, 30, 90, 180 and 360 days after implantation-DAI). Pro- and anti-inflammatory cytokines (IL-2, IL-4, IL-6, IFN-gamma, TNF, IL-17A, IL-10 and TGF-beta) were quantified in all experimental days. There was no statistical difference between the groups analyzed considering the evaluated parameters. Therefore, at all implanted depths, PMMA behaved inertly in a murine model.No Level Assigned This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Article
Polymethylmethacrylate (PMMA) is a filler used for aesthetic and/or repair purposes. The response to the implantation of biomaterials varies according to factors related to the patient, the professional responsible for the application and the material used. In vitro and in vivo experimental models have been used to study aspects such as the organism/biomaterial interface and the role of macrophages, dendritic cells and neutrophils. This study aimed to characterize the inflammatory reactions related to polymer concentration, implantation depth and exposure time. Different concentrations of PMMA were implanted in different anatomical planes in mice. The consequences of contact with PMMA, from structural changes to the inflammatory characteristic of tissue damage, were histologically evaluated. The implantation interfered in the morphological structure of the region where it was implanted, expanding it and due to the inflammatory reaction generated, by the presence of the vehicle in the initial phase and by the collagen produced in the chronic phase. The 30% concentration of PMMA induced a greater presence of foreign body giant cells both subcutaneously, at 7, 30 and 90 days after implantation (DAI), and intramuscular at 30DAI. Tissue remodeling was more expressive in the subcutaneous region with significant density of the extracellular matrix at 90DAI. In conclusion, the foreign body reaction resulting from the implantation process acquires different characteristics depending on the anatomical plane and the concentration of implanted product, where the more superficial the implantation plane, the greater the inflammatory reaction. Moreover, PMMA concentration and the depth of implantation did not influence the collagen production.No Level Assigned This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266.
Article
Background: Augmentative phalloplasty is a controversial issue. A safe, stable, and efficient surgical method for penile girth enlargement (PGE) was not avaliable. This paper introduces a novel autologous scrotal flap-turning procedure "scrotal dartos flap method" for males with small penis syndrome (SPS) and addresses its efficacy and safety. Methods: A single-centered, prospective study was conducted at the Zhongnan Hospital of Wuhan University, where 29 patients were treated with "scrotal dartos flap method". The key procedure for this technique is fully turning the scrotal dartos flap to the loose plane just between the superficial penile fascia and Buck's fascia to increase the circumference of the penis. Penile girth improvement and adverse events (AEs) were recorded. Results: Complete follow-up data were collected for 27/29 (93.1%) of the patients. It yielded a 3.59 ± 0.80 cm (50.8%) girth improvement. This enlargement surpassed that of most previous published surgical procedures. Additionally, there were no serious AEs (such as penile fibrosis, flap infection, sclerosis, or removal) during the 6-month follow-up. Wound infection (n = 1), hematoma (n = 2), and folding (n = 1) were all slight. Conclusions: This novel autologous flap-turning procedure performed better than the majority of previously published PGE methods and was accompanied by only slight and acceptable AEs. "Scrotal dartos flap method" appears to be a viable method for the PGE treatment of SPS.
Article
The aim of this review is to describe reported techniques and to provide available scientific data on the success of penis length procedures for cosmetic purposes. Penis lengthening methods remain a controversial issue. Penis size is a matter of great interest among men who are affected by ‘small penis anxiety’’ or just believe themselves to have a small penis, even though the dimensions of the organ fall within the normal range. We performed a narrative review of the literature based on a comprehensive search in the MEDLINE database for original articles published until March 2021, referring to lengthening approaches exclusively for aesthetical reasons. Abstracts, opinion papers and case series ≤10 patients were not considered. We included the results of 14 papers in the review that gathered the experience obtained in a total of 1661 patients. Four of the studies referred to non-surgical procedures for penile length augmentation (PLA) and the remaining 10 analyzed the results of invasive (surgical) procedures. Both invasive and non-invasive techniques achieve similar improvements in penis length. These procedures vary in complexity and require specialized training and experience. However, the low scientific quality of the analyzed papers makes it difficult to establish recommendations to choose one technique over any other. However, it seems reasonable that, if possible, non-invasive techniques should be proposed as a first-line treatment. Before deciding the procedure, we must carry out a correct psychological evaluation of our patients, discuss with them the technique of choice, and adjust their expectations.
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The aging skin is a challenge for medical science. Plastic surgeons and dermatologists are called every day to solve problems like filling wrinkles or folds. The material used must be biocompatible because abnormal reactions may cause catastrophic results. This study analyzes the biological behavior of polymethylmethacrylate (Metacrill) and hyaluronic acid (Restylane), using a histopathologic study in mice. A prospective study was performed using 40 mice for each substance: polymethylmethacrylate or hyaluronic acid was injected into the right ear, the left ear been used as a control. Histopathologic analyses of the right ear, liver, and kidney were performed at intervals during the study and revealed the development of a granulomatous reaction with fibrosis and absorption of spheres and signs of liver and kidney sistematization for polymethylmethacrylate. A discrete cellular reaction, with less formation of fibrosis, and no giant cells were seen in the mice injected with hyaluronic acid.
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Progression of lipodystrophy syndrome is a big challenge in HIV treatment. Nowadays, fat loss at the lower part of buttocks has become another problem as patients have started to complain that it is painful to be seated for a long time and/or on hard surfaces. We developed a method for buttock lipoatrophy treatment with PMMA-microspheres, as silicone prostheses and autologous fat transplant were not completely efficient. The treatment consisted of net-crossed injections, in the subcutaneous layer, of a 30% PMMA-microspheres solution on the atrophic areas of the buttock. One hundred and fifty-four patients were included. The amount of PMMA-microspheres used to treat buttock lipoatrophy depended on the degree of atrophy and size of the area to be treated. Patients were satisfied with this treatment and reported to be more comfortable to be seated for longer period of time. We demonstrated that soft tissue augmentation with PMMA-microspheres is safe and efficient for the treatment of buttock lipoatrophy associated with HIV lipodystrophy.
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Penile self-injection of various oils is still carried out among Eastern Europe people for penile girth augmentation despite the potential destructive complications of this practice are well known. Penile reactions to such foreign bodies include scarring, abscess formation, ulceration, and even Fournier's gangrene; voiding problems due to mineral oil self-injection have been reported only once. To our knowledge, we describe the first case of paraffin self-injection for penile girth augmentation presenting with acute urinary retention. A 27-year-old Romanian man presented with severe penile pain and acute urinary retention five years after having practiced repeated penile self-injections of paraffin for penile girth augmentation. The penile shaft was massively enlarged, fibrotic and phymotic; urethral catheterization failed due to severe stricture of the proximal pendulum urethra. The patients refused placement of a suprapubic catheter and underwent immediate penile surgical exploration. The scarred tissue between dartos and Buck's fascia and a fibrotic ring occluding the urethra were removed and the penile skin reconstructed. Pathology confirmed the diagnosis of paraffinoma. The patient resumed normal voiding immediately after catheter removal on second postoperative day; he was very pleased with cosmetic, sexual and voiding results at six weeks, six months and 1 year follow-up. The present report describes a novel complication of penile self-injection for penile girth augmentation. Because of the increasing number of patients seeking penile augmentation, physicians dealing with sexual medicine should pay more attention to such request to prevent the use of non medical treatments that can turn into medical disasters.
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In recent years, penile traction therapy (PTT) has gained considerable interest as a novel nonsurgical treatment option for men with Peyronie’s disease (PD) and short penises. The current published literature suggests that selected cases of PD may benefit from a conservative approach with PTT, resulting in increased penile length and reduction of penile deformity. It appears to be safe and well tolerated but requires a great deal of patient compliance and determination. This article reviews the current literature pertaining to the use of PTT in men with PD, short penises and in the setting of pre- and postprosthesis corporal fibrosis.
Article
Objectives To systematically review and create nomograms on flaccid and erect penile size measurements.Methods Study key eligibility criteria: measurement of penis size by a health professional using a standard procedure; a minimum of 50 participants per sampleExclusion criteria were samples with a congenital or acquired penile abnormality. previous surgery, complaint of small penis size or erectile dysfunctionSynthesis methods: Calculation of a weighted mean and pooled standard deviation and simulation of 20,000 observations from the normal distribution to generate nomograms of penis size.ResultsNomograms for flaccid pendulous (n = 10,704, mean 9.16cm, sd 1.57) and stretched length (n=14,160, mean 13.24cm, sd 1.89), erect length (n = 692, mean 13.12cm, sd 1.66), flaccid circumference (n = 9,407, mean 9.31cm, sd 0.90); and erect circumference (n = 381, mean 11.66cm, sd 1.10) were constructed.Consistent and strongest significant correlation was between flaccid stretched or erect length and height, which ranged from r = 0.2 to 0.6.Conclusionspenis size nomograms may be useful in clinical and therapeutic settings to counsel men and for academic research.Limitations: a relatively small number of erect measurements were conducted in a clinical setting and the greatest variability between studies was with flaccid stretched length.
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Penile paraffinoma is a rare but well-known entity. There have been few studies describing the ultrasound and MRI features of penile paraffinoma. In this case series we describe the imaging findings of 4 patients who self-injected "Jamaica oil" into their penises for the purpose of penile augmentation and discuss the utility of US and MRI in the management of these patients.
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Introduction: Orgasmic dysfunction (OD) is defined as the inability to achieve an orgasm, markedly diminished intensity of orgasmic sensations, or marked delay of orgasm during any kind of sexual stimulation. OD definition and method of diagnosis vary widely across studies. Aim: The aim of this study was to identify the prevalence and risk factors that predispose Mexican women to OD. Methods: A representative sample of women from Mexico City was surveyed using an online website. Women between 18 to 40 years old were selected, and the orgasm domain from the Female Sexual Function Index was used to identify OD. A cutoff point was calculated using a construct with a histogram and calculated median. A univariate and multivariate analysis was conducted to examine the relationship between potential risk factors and sexual function. Main outcome measures: OD prevalence; significant risk factors on multivariate analysis. Results: OD prevalence was 18.3%. Univariate analysis showed younger age (P = 0.01), lower degree of education (P = 0.02), single marital status (P = 0.038), and dissatisfaction with the thickness and/or size of partner's penis (P = 0.01) as significant variables related to OD. In multivariate analysis, younger age (P = 0.01) and dissatisfaction with the thickness/size of partner's penis (hazard ratio 3.04, P = 0.01) remained significant. Conclusion: OD is a prevalent alteration in young women. Marital status, education, and dissatisfaction with thickness/size of partner's penis are definitely related variables.
Article
Penile girth augmentation can be achieved by various techniques, among which are liposuction injection, synthetic grafts, and autologous grafts, with variable outcome, mostly related to viability and receptivity of the tissue used for augmentation. Flaps are considered superior to grafts considering their uninterrupted blood supply. The current work describes long-term experience with penile girth augmentation using the superficial circumflex iliac artery and vein (SCIAV) flap. SCIAV flap was used for penile girth augmentation in 40 candidates who followed up for a minimum of 18 months. The flap was mobilized from the groin region. The penis was pulled out of a peno-pubic incision. The flap was tunneled under the pubic region to emerge at the base of the penis and was sutured to the subcoronal area and on either sides of the spongiosum. Another session was required for either de-bulking of the oversized flap (four overweight candidates), flap pedicle (n = 6), or for donor site scar revision (n = 11). Gain in girth in centimeters was evaluated. Excluding dropouts (n = 8) and participants who had encountered de-bulking of the flap body (n = 4), 40 participants had a preoperative average flaccid girth (AFG) of 9.3 ± 1.1 cm. Immediately postoperative AFG was 14.9 ± 1.1 cm (P < 0.001). Postoperative AFG at the final follow-up visit (a minimum of 18 months) was 14.5 ± 1.1 cm (55.6% gain compared with baseline, P < 0.001). SCIAV flap is a reliable option for long-lasting and sizable penile girth augmentation. One-stage augmentation is more suited for non-obese candidates. A second session may be indicated in overweight candidates or for scar revision. Shaeer O. Girth augmentation of the penis using flaps "Shaeer's augmentation phalloplasty": The superficial circumflex iliac flap. J Sex Med **;**:**-**.
Article
Introduction: Hyaluronic acid has come to represent the most widely used injectable cosmetic product in the world. Brought into being by the Swedish company Q-Med, in 2007 Macrolane™ was authorized for use in France, and the year after, it received official European approval as a means of breast augmentation. Since then, however, numerous controversies pertaining to its side effects have led to its withdrawal from the worldwide breast augmentation market. The objective of this article is to carry out a review of the literature providing updated information on Macrolane™ and its recent indications. Materials and methods: We carried out a review of the literature on the PubMed and PubMed Central data bases through use of the keywords "Macrolane™", "NASHA", "hyaluronic acid" and "soft filler", and subsequently analyzed the levels of evidence and possible biases of the different publications. The official sites of the French, English, Spanish and American scholarly organizations of plastic surgery were likewise consulted. Perusal of the notifications and recommendations for use brought out by the Q-Med company completed our study. Results: A large majority of the available clinical series on Macrolane™ with regard to not only breast augmentation, but also its other indications, offer an insufficient level of evidence and present a number of conflicts of interest. Since April 2012 Macrolane™ has been temporarily withdrawn by its distributors from the worldwide breast augmentation market. In point of fact, Macrolane™ injections have been found to interfere with breast imaging and screening for breast cancer. As regards the latest indications for this controversial product, it is not yet possible to step back and take stock. Conclusions: Present-day scientific data fail to justify the market reappearance of Macrolane™ breast augmentation products. Q-Med has shown full awareness of the problem by imposing worldwide restrictions on products aimed at penis as well as breast enlargement. Larger cohorts of female patients are more necessary than ever, as is an approach based on stepping back and taking stock.