ANSWERS FROM DR. VICTOR LIU
Penis Enlargement – Girth
Girth (circumference of the shaft) enlargement can be done either non-surgically by injection of filler or the patient’s own fat. Or, it can be done surgically by insertion of a sleeve of collagen via the same incision used for the penis elongation, so that no additional incision is needed. The best option for you can only be determined by you and your treating doctor in a person-to- person consultation. Select a physician who does both non-surgical and surgical procedures, so that the doctor can offer you both options.
The non-surgical procedure uses filler injection or fat injection to enlarge the shaft. There are different types of fillers. Some are made of hyaluronic acid. They are temporary and what most doctors use. Some are permanent; the most common of which is Bellafill.
There are different types of hyaluronic acid, depending on the amount of cross linkage of the molecules. Some last between 3 to 6 months and some last as long as 1½ years, and in some cases, up to 2 years. They are generally disintegrated and absorbed by the body. It does not make sense to me to do a penile enlargement which has to be repeated every 1½ to 2 years. Therefore, I prefer to use a permanent filler, in this case, Bellafill. Occasionally, a mixture of Bellafill and Voluma is used. Although Bellafill is considered permanent, part of it dissolves with time. The filler is made of little micro-spheres and there is a carrier which carries the micro-spheres to be injected. The carrier occupies more than 50% of the volume of the Bellafill injected. This is absorbed with time by the body. However, at the same time, the micro spheres stimulate the body to produce collagen so that the eventual volume injected will remain the same. Sometimes, after several years, there is a decrease in the size and additional injections are necessary. However, this decrease is very small compared to the decrease experienced with the temporary filler, which is completely absorbed with time. In the shaft of the penis, much more filler can be injected because of the space underneath the skin superficial to the
Buck’s fascia, a very strong layer that protects the functioning parts of the penis, such as the corpus cavernosum, which is responsible for erection and the corpus spongiosum, which houses the urethra for urination. The nerves and the blood vessels that are important for the functioning of the penis are also enclosed underneath the Buck’s fascia. The space between the Buck’s fascia and the skin is where the filler is injected and quite a lot can be injected into this area. Penile size can, therefore, be increased substantially. However, if too much filler is injected into this area, the penis is enlarged, but when touched, feels very soft and unnatural.
The other type of injection is with the patient’s own fat. Its major advantage is that it is safe because it comes from the patient himself and there is no risk of allergic reaction. However, as with the fillers mentioned above, fat injection for augmentation can leave the penis feeling too soft and “mooshy” compared to the normal penis when touched. Additionally, more than 50 of the injected fat will disappear. The fat is that not absorbed stays permanently. One way to decrease the amount of fat absorbed is by adding PRP or nano fat to the fat that is injected. When done well, about 80%, as opposed to 50%, of the fat will remain.
For enlargement of the glans, the only way is injection of filler, or sometimes, fat. Several sessions are required. The reason is that there is no space between the skin and the deeper layer of the functioning glans, which is the corpus spongiosum, a meshwork of blood vessels. Filler or fat cannot be injected into this area because it may migrate, causing blockage in other parts of the penis and beyond. Therefore, injection of the glans with filler has to be done only intradermally and immediately subdermally. Because only a small amount can be put into this area, to enlarge the glans, multiple injections at different times are required.
Another way to increase the girth of the penis is by a minor surgery in which a sleeve of collagen (such as Alloderm or Surgimend) is inserted and wrapped around the penis just above the Buck’s fascia and underneath the skin. This, by itself, will increase the volume and, therefore, the girth of the penis. In addition, the presence of this layer of collagen stimulates the body to form more collagen and, therefore, further increases the girth. Injection of fat or filler on top of the sleeve at the same time as surgery further increases the girth of the penis and can also even out any unevenness, especially at the edge of the sleeve. This insertion of the sleeve and injection of filler can increase the girth by a great amount and the penis will feel natural without the “mooshiness” associated with injection of filler alone. If the patient wishes to have a greater increase in girth, the treatment of choice is insertion of the sleeve plus injection of filler. The insertion of the sleeve can be done via a small incision just above the base of the penis within the pubic hair and is thus camouflaged by the hair and becomes virtually invisible
As explained earlier, the penis will be elongated in the flaccid state when augmentation of the girth is done. However, if the patient wishes to have the penis longer when there is an erection, minor surgery is required.
The base of the penis is attached to the bone in the pubic area by suspensory ligaments. To increase the length of the penis, the suspensory ligament has to be divided, and the penis pushed forward beyond the edge of the bone. Thus, the functioning and visible part of the penis is lengthened, both when flaccid and erect. When done properly, an average of 1 inch of increase in penile length can be achieved. This is variable, depending on the anatomy of the patient. I have seen as much as 2½ inches of increase and as little as no increase in the length of the penis. However, the average is a 1 inch increase. This whole procedure can be done through the same incision used for girth augmentation; no additional scar will result.
One of the problems with detachment of the suspensory ligament is the tendency for it to be reattached. This is very common in the older methods of detachment. However, with the newer techniques, both the superficial and deep suspensory ligaments are detached and the space that is formed by this detachment is filled with tissue from the surrounding area. This tissue prevents the re-attachment of the suspensory ligament and also gives stability to the base of the penis. Suspensory ligament detachment is a procedure that has to be done by a physician who is very familiar with this area and is well-trained. I have taught other surgeons to do this procedure and when I asked them to videotape the procedure when they perform it in their own offices, I see that most of them detach the suspensory ligaments insufficiently. It is true that the suspensory ligament should not be totally detached at the proximal end so that there is no instability. However, the attachment is very wide, with both superficial and deep ligaments and one has to be extremely diligent in ensuring that all attachments in the superficial and deep areas are detached. The post-operative care is very important for maintaining the elongation of the penis by the detachment. This consists of manual extension by the patient and use of extension devices. None of the commercially available devices are
satisfactory. We have, therefore, custom-made a device which we provide to the patient.
Common Enlargement Questions
Over the last 25 years, the number of male patients seeking aesthetic, cosmetic and plastic surgery services has increased by 500% — from 3% of patients to more than 15% and growing every year. Not only are we seeing an increase in cosmetic procedures that enhance men’s physiques, but we are also seeing a growing number of procedures that improve men’s physical and sexual health as well as libido.
If I had other treatments (fat injections, Penuma, etc.) and am not happy with it, can I still get filler injections?
Generally, filler injection after a person had surgical insertion of Penuma or Surgimend for penis augmentation is safe and do able. However, it is not advisable to do surgical insertion after the person had filler injection because of the adhesions resulting from the injections making it very difficult and even unsafe to perform. One of the problems with Penuma is that it is firm and
sometimes it is palpable on the skin surface and does not look natural. One way to treat this would be with filler injections. Some patients had fat injection for girth enlargement and complain that the penis feels too soft and looks uneven. This is a common problem with fat injections because some of the fat may be absorbed unevenly and of course fat feels soft. This
can be improved by injecting filler intradermally (inside the skin) to give a “shell” and also inject subdermally (underneath the skin) to even out. It is best to see and be examined by the treating surgeon before a final decision on what is best for you.
Can I have ligament detachment and Surgimend insertion done at the same time?
Yes, this can be done and is frequently done together, saving the patient a lot of time. The anesthesia and surgical incision at the base of the penis can be used for both procedures, and the recovery period for both procedures simultaneously is the same as doing the procedures separately. For instance, following a procedure, the patient should abstain from sex for at least 35 days. Therefore, if the two procedures are done at the same time, abstinence from sex is 35 days, but if done separately, the patient will undergo two 35-day recovery periods.sometimes it is palpable on the skin surface and does not look natural. One way to treat this would be with filler injections. Some patients had fat injection for girth enlargement and complain that the penis feels too soft and looks uneven. This is a common problem with fat injections because some of the fat may be absorbed unevenly and of course fat feels soft. This can be improved by injecting filler intradermally (inside the skin) to give a “shell” and also inject subdermally (underneath the skin) to even out. It is best to see and be examined by the treating surgeon before a final decision on what is best for you.
I had a penile implant surgery and my penis seems to be generally shrunken especially the head of the penis. Can this be corrected?
When a penile implant is inserted, it sometimes does not fit perfectly, resulting in areas of pressure and protrusion which may cause problems and deformity. Even when the implant is put in perfectly, there may still be problems because while the implant remains unchanging, the penis will change in shape and deteriorate with age. For example, the head of the penis, the
glans, has engorgement of blood during a normal erection, but in the case of erectile dysfunction, there is no engorgement. Therefore, this will atrophy with time. The outline of the implant may become visible or palpable, causing pain to the patient or his partner. This can be corrected with filler injection into the area, smoothing out the edges and enlarging the penis as well, often a very welcome addition to the treatment for the patient.sometimes it is palpable on the skin surface and does not look natural. One way to treat this would be with filler injections. Some patients had fat injection for girth enlargement and complain that the penis feels too soft and looks uneven. This is a common problem with fat injections because some of the fat may be absorbed unevenly and of course fat feels soft. This can be improved by injecting filler intradermally (inside the skin) to give a “shell” and also inject subdermally (underneath the skin) to even out. It is best to see and be examined by the treating surgeon before a final decision on what is best for you.
I am 60 years old and am having issues with my erection. Can I have ED treatment and penis enlargement done at the same time?
Yes. Erectile dysfunction can be treated at the same time as penile enlargement. Usually, this is done with shock wave treatment followed by injection with PRP or bone marrow aspirate and then the injection for the filler can be done after that, or even the Surgimend procedure can be done at the same time.