Dr. Solomon, do you perform testicular enhancement surgery? If so, how do you go about enlarging the scrotum and/or testicles? If not, what are your reservations with approaching this part of the anatomy?

I do perform testicular enhancement. This is one of the areas where I will use fat grafting. I work with a urologist in Beverly Hills to assure that the fat is placed in the proper plane around the testicle. The fat provides a natural feel along with a modest augmentation. Most men who seek this treatment have been taking testosterone and note a change in the size and consistency of their testes. I will occasionally place implants in the scrotum, again, working with a urologist in my Beverly Hills location. These can be placed along side of the existing testes or for men who have had their testicle removed. These implants are firmer than normal testes. I do not place caps on the testicle because they make it difficult to examine men for testicular tumors.

Dr. Solomon, if I wanted multiple procedures done (i.e. any combination of lengthening, girth, scrotal webbing, etc), can they all be done on the same day at your Clinic?

Is it possible combining procedures all on the same appointment would increase the risk for edema, a longer recovery, and/or major complications? What are your thoughts?

I do perform multiple procedures in one sitting. However, I tell patients that the recovery is prolonged due to swelling. Most of the swelling arises from the girth procedure. When girth surgery is performed along with other procedures, the swelling takes longer to resolve than if the procedures were performed separately. In my practice, the risks of complications are low. Length and web procedures have few complications and they tend to be minor. Girth procedures have a more complicated operative course, so complications may occur. I have only had 3 patients who lost their grafts in more than 25 years. My style of practice is very “hands on.” I require my patients to stay in a hotel near my office (in either location) and I see patients every day until they return home. This is usually anywhere from 3-6 days after surgery. This allows me to manage drains, dressings and other concerns that patients have after surgery. It also minimizes swelling since patients are largely at bed rest and in the hotel, rather than out of the room. I find that early control of swelling reduces the overall recovery time. For patients who travel a distance for surgery, I advise staying in a hotel for 1-2 weeks. Patients often feel well in the hotel and then have issues when they arrive at home. This is due to the stresses of travel, the amount of walking needed to travel through an airport, greater swelling and the general anxiety created when patients are at a distance from me. While it can be inconvenient to stay in a hotel for 1-2 weeks, the value is that your activities are very limited. This limits the swelling and enhances the healing. Obviously, I cannot force anyone to stay longer, but I encourage boredom as a part of recovery from these procedures, which are real surgery with real potential for complications.

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2a) Dr. Solomon, what are the advantages of using Surgimend over other dermal matrices (like Alloderm & Belladerm)? Are there varying options for thickness? Could I add more sheets of Surgimend in the future for more girth?

This is an excellent question. Alloderm and Belladerm (among others) come from human sources. In particular, Alloderm is a donation from someone who has died while Belladerm often comes from remnants of abdominoplasty (tummy tuck) tissue that is removed at surgery. Human dermis is then prepared from these materials. Human dermis varies in thickness depending upon what part of the body it is from and the age of the donor. Human dermis gets thinner with age. As a rule, the thickest human dermis is not more than 2 mm and on average about 1.5 mm. Surgimend comes from fetal calf tissue. This has several advantages. It has never been exposed to bacteria, so it is sterile. Calf dermis is thicker than human dermis. This tissue is cut by machine. So its thickness is uniform and because calf dermis is thicker than human dermis, it is available in thicknesses from 1 to 4 mm.

My average Surgimend graft is 3 mm thick. This seems to be the "sweet spot" between giving a good result while allowing it to revascularize in a reasonable amount of time. I have used 4 mm grafts in some patients, as well as 2 mm grafts in some.

You can have a second wrap, but recovery is long and in several cases, the penis has been almost too thick for comfortable intercourse. I warn patients about these issues before performing additional girth enhancement.

(2b)Dr. Solomon, do you offer any solutions for glans enlargement? If yes, could you describe how you go about safely augmenting the glans? If you don't offer any procedures for the glans, is it due to the anatomical risks associated with the glans, or simply a matter of preference?

I have tried many methods for glans enlargement. None of them provides a permanent solution, so I do not offer this to my patients. I am aware that some physicians use injections, mostly hyaluronic acid. This generally goes away, but has, on occasion has left some nodules that I have had to remove surgically. I have also tried fat grafting the glans and using dermal graft material. None of these methods provided a natural, long lasting glans enlargement, so I do not perform this procedure any longer.

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(3a) Dr. Solomon, do you perform lengthening surgery (ligamentolysis)? If so, what can patients expect to gain on average? Are gains limited to flaccid length or will I see improvements in both flaccid and erect lengths? Also, will there be a change in the angle of my erection post-op?

Penis length surgery, sometimes called ligamentolysis is one of the most common procedures that I perform. It has a high degree of patient satisfaction and the questions here are good ones. I tell patients that the average increase in flaccid length is 1 inch (2.5 cm). The most I have ever seen is 2 inches (5cm). This is related to the amount of penis that is beneath the ligament. The increase in length that occurs is always in the flaccid state. Some men tell me that they are longer when erect, but there is no way to know in advance if there will be a gain in erect length. Moreover, I do not measure patients in the erect length, so I have no data to answer this question in any greater detail. To my knowledge, there is no large study that discusses this. There are some reports of about an average of one-half inch (1 cm) increase when erect after surgery. Many men think the angle of their erection will change after surgery, but I have not seen this in my patients. I do several things in the surgery itself to restore the angle. I also have my patients wear a weighted condom for 6 hours each day for 6 months after surgery to help prevent scar tissue from pulling the penis back.

(3b) Dr. Solomon, do you provide surgery to those who suffer from excessive scrotal webbing, sometimes called "turkey neck?" If so, can you detail some important things to expect like recovery time, whether it's an outpatient procedure, common techniques that are used, etc?

Scrotal webbing is an issue for many men. It can interfere with intercourse and be a source of irritation during exercise. There are several methods of correcting the web. The oldest method is known as z-plasty. Other methods include a U shaped skin excision and a V shaped skin excision. The decision about which pattern to use is based upon the extent of the problem, which varies with each patient. The surgery itself is not associated with much postoperative discomfort, but there is a large a mount of swelling. This takes the better part of a month to resolve and in that time men are restricted in terms of physical activity and sexual activity. Surgery is performed as an outpatient. Some patients require a drain to be used while others do not. This is a decision that I make at the time of surgery. The scars from these procedures are well hidden due to the nature of the skin of the scrotum. I use dissolving sutures that do not need to be removed.

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(1a) Dr. Solomon, I've read that you perform the removal of rigid silicone implants, and any subsequent revision or repair . Here is a 4-Part Question:

(i) Would you advise patients who've had a rigid silicone implanted for penis enlargement to have it removed, even if there is no clear indication of complication or initial dissatisfaction (i.e. preemptive removal)? If so, why?

Patients often ask this question. I have seen only one man for whom my answer was to leave the device in place. He had no symptoms and no evidence of erosion or malposition of the device. I do caution men that if the device becomes more visible because of thinning of the skin, usually behind the glans, they should consider removal. It is my impression that the device will not last over time, either because it erodes, gets infected or breaks apart, but in general, I do not remove the device in men who are happy with it.

(ii) If I'm having issues with the implant, what are the nature and severity of complications that would warrant a medically-necessary removal?

There are a variety of reasons to medically remove the device. They are as follows: erosion through the skin, infection, seroma (this is a fluid accumulation around the implant), breakdown of the device, pain, difficulty having intercourse and erectile dysfunction.

(iii) Are there any drawbacks for removing the implant, regardless of the reason I'm having it removed?

Every operation has risks. Removal of the device may cause internal scarring that can cause loss of length. There may be loss of skin of the shaft due to thinning of the skin because of the device. There may be loss of sensation from the action of the device on the shaft skin or due to injury to the nerve to the glans from the patch that is used to fixate the implant in the penis.

(iv) Is it true I could lose length after implant removal, and if so, what can be done to mitigate length loss?

Yes this is true. I will often perform ligament release at the time of implant removal or corrective surgery. Patients also need to wear a weighted condom after surgery for six months for six hours a day to maintain the length.

(1b) Dear Dr. Solomon, Forum Moderator Hoddle10 asks: "What do you consider the ideal patient? What makes someone a good candidate for penis enlargement surgery? Are there instances you'd consider turning away a patient?"

Let me answer the last question first. I turn away almost one third of the men who seek my opinion. Most often, these are men who are either very unrealistic in their goals, or they have a very normal to large penis and I do not think the benefit of surgery outweighs the risks involved. The ideal candidate is a healthy male who wants to make his penis larger in one or more dimensions and has no issues with erectile dysfunction. The reality is that I see men of all types with variation in their health, so I do make exceptions for different medical conditions. I do not do girth procedures on smokers. I have found that smokers in particular have a high complication rate from girth procedures, so I will no longer treat them. The corollary of that is that men who have complications of fillers and are smokers are also at high risk of complications. I ask them to stop smoking for 3 weeks prior to surgery and 3 months after surgery. I have had men who start smoking after surgery and inevitably they need more surgery to get them healed.

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