Trouser Talk Part 4: Augmentation Phalloplasties – The ‘Rise’ of Cosmetic Penile Surgery, Dr. Niro Sivathasan | Aesthetic Surgeon

Trouser Talk Part 4: Augmentation Phalloplasties – The ‘Rise’ of Cosmetic Penile Surgery

The ‘Rise’ of Cosmetic Penile Surgery

An increasing number of millennial females are pining for ‘bigger booties’ or ‘BBLs’ (Brazilian Butt Lifts), when in the not-so-distant past, small but perky was en-vogue; and similarly, men are seeking larger penises, perhaps contributed to by the Internet-assisted proliferation of pornographic material. It is interesting to note that especially in Greco-Roman periods and during other subsequent periods, smaller penises were seen as better and preferable.

Penile lengthening requires invasive surgery. In contrast, widening of the penile shaft (as distinct to the penile head or glans), may be effected using non-surgical or surgical means. It is important for prospective patients to note that the gain in length is determined by how much tissue is available (hidden under the skin), and that the increase in length is primarily in the flaccid state; ‘erect gains’ are typically 0.5 cM at best, in my opinion. Patients must recognize that there is a risk of significant scar-tissue-formation after lengthening, with the penis becoming ‘reattached’ to the pelvic bone and leading to loss of gained length. Patients must also appreciate that the formation of scar tissue has a large genetic component, and that post-operative stretching protocols are very important. I personally recommend the use of a penile traction device AND the use of exercises, to help combat the degree of ‘potential’ loss.

There are different methods to increase the width of the penis. Non-surgical modalities are nearly always temporary in nature, and whilst cheaper than surgery, require multiple ‘lifetime top-ups.

They involve allogenic fillers, just like those which are popular amongst women wanting bigger lips, being injected under the deep fascia of the penis. It is important to note that if the fillers are wrongly injected (into corpora cavernosa = the erectile cylinders of the penis), it is possible to damage the erectile mechanism.

There are two key surgical techniques to increase the girth: lipotransfer (i.e. minimally invasive, autologous filling) and dermal fat grafts. Lipotransfer to the penis is a relatively elementary approach, and involves undertaking liposuction in a small area, and then injecting the suctioned fat into the penis. Disappointingly, it is very typical for over 50% of the transferred fat to be lost after just 6-12 months! Surgeons try to compensate for this inevitable loss by overfilling the penis with fat in a ‘single’ sitting – which is usually to fulfil over-zealous claims; however, this outcome is short-lived and in these overfilled cases, >75% of the fat is lost around one year after the operation (due to the extra fat not receiving the nourishment required to survive).

‘Free dermal fat grafts’ (DFGs), which were traditionally used to fill contour defects, such as after trauma, are the gold standard. They are physically comprised of the dermis of the skin (= the deeper white part) and an in-tact layer of subcutaneous fat (= the fat immediately beneath the skin), so they are entirely natural. This results with this approach are not just natural in feel, but also last forever.

Relative proportions are very important; so, just like making the head larger to match the shaft, it is certainly a good idea to debulk fat from the groin and lower tummy (i.e. suprapubic and lower abdominal area) to make the penis generally look larger. The suprapubic area is considered to be a ‘privileged fat zone’ because it has a propensity to experience fat-accumulation and this fat may be rather fibrous; so, surgical debulking of this (mons pubis lipectomy) improves the general appearance of the region. Much akin to ‘mummy makeovers’, during augmentation phalloplasties, it is also possible to have complementary procedures, such as reduction of man boobs (gynaecomastia surgery) with local liposuction, or production of a flatter tummy (e.g. subtotal panniculectomy or even a radical abdominoplasty); this effectively gives a new lease of life to many men wanting to start a new chapter.

As for any surgical procedure, phalloplasties (also known as penoplasties) are not without risk, and in addition to seeking a surgeon who has been fellowship-trained in this endeavour, it is important for patients to know that post-operative performance in the bedroom has a large psychological component – meaning, such performance cannot be predicted during the pre-operative consultation. Patients must also recognize that as with nearly everything in life, there is always a trade-off; and in the case of penile lengthening, there shall be a decrease in the reduction of the angle of erection.

Due to misunderstandings, particularly amongst the bulk of the medical community, penile augmentations have wrongly been labelled as ineffective; the art is in choosing the suitable approach for an appropriate patient – the right procedure for the right patient! It goes without saying that healing responses are unpredictable and significantly vary between individuals, but in my experience, the results have been overwhelmingly successful and have changed the lives of ‘patient’ men. Why the emphasis on patience being a temperamental requirement? Well, breast augmentations typically take 3-6 months for the final result to be evident, whilst penile augmentations take 12 months for the end result and require discipline during the process of healing.

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