A Plastic Surgeon's Approach to Penis Enlargement
When a patient comes to the clinic for consultation, the first thing we determine is whether the
patient is a candidate for penis enlargement. There are two types of people who want penile
enlargements. The first is the patient with really small penis, the so-called “micro-penis.” The
second is the individual with a normal-sized penis, but who wants to be bigger. Both types are
good candidates for penile augmentation.
Who Should Not Have Penis Enlargement.
There are patients who should not be operated on, such as those who have unrealistically high
expectations. For example, I had one patient request that I add another 9 inches to his penis,
which was about 5 inches long when fully erect. Such patients should be excluded from surgery
due to their unrealistic expectations.
Another type of patient who is a bad candidate for penile enlargement is one with psychological
problems, such as schizophrenia, which can be difficult to detect at times. Also unsuitable for
penis enlargement are individuals with poor body image, such as body dysmorphic disorder.
These patients are obsessed with their body image. Minor imperfections upset them and they
want to have it corrected. These are the patients you have to be careful about and avoid doing
surgery on. If there is any doubt, a psychological evaluation may be requested.
Good Candidates for Penile Enlargement.
The most common patients who are good candidates for penile enlargement surgery are those
with a really small penis or those who are normal in size but want a size increase for improved
performance.
Surgery Or No Surgery?
Many patients consult me for penis enlargement and one of the first things they say is: "I don't
want surgery, no matter what." But after discussing the pros and cons of surgery, many
patients decide on having surgery. I am not suggesting surgery for everyone seeking penis
enlargement. What I am advocating is the right procedure for the right indication. The right
procedure can be either non-surgical or surgical, or it could be both. Some patients do much
better with non-surgical treatment while others may require surgery to attain their desired
result.
When is surgery indicated for penis enlargement? Generally, there are two aspects of penis
enlargement, the length and the girth. For patients who want an increase in the erected length,
the only way is by minor surgery done through a small incision concealed by the pubic hair
above the base of the penis. The length of the penis when flaccid, will also be increased with
this surgical procedure. However, very often the length of the penis when flaccid will also be
increased after non-surgical girth enlargement such as by injection of fillers or fat. Briefly, the
only way to get an increase in erected length is by a minor surgery.
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.
I wish, now, to discuss the procedures for augmentation of the penis.
Non-Surgical Procedures
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 a normal penis when touched. Additionally, more than 50% of
the injected fat will disappear. The fat that is 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.
The Uncircumcised Patient
Another limitation of filler injection for augmentation is whether the patient is circumcised. If
the patient is not circumcised, the filler can migrate into the foreskin and may cause a condition
called phimosis, which is the thickening of the foreskin, making it impossible for the head of the
penis to be extruded. This creates difficulty in cleaning the area, resulting in irritation or
infection of this area. The only effective treatment is to do a circumcision. Therefore, when a
patient does not want circumcision, injection of filler should either not be done, or done only
under the condition that the patient agrees to a circumcision if phimosis occurs.
Injection with filler can increase the circumference of the shaft of the penis (“girth”)
significantly, the limitation being the unnatural feel of the penis. Filler can only increase the
length of the penis when flaccid, not when the penis is erect. When the penis is erect, its length
is much the same as it was prior to filler injections.
Surgical Approach
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.
The L.A.R.G.E. and L.A.R.G.E.R. Procedures
The most popular procedures done in my clinic are the L.A.R.G.E. and L.A.R.G.E.R procedures.
L.A.R.G.E. stands for “Length And Real Girth Enlargement” and the “R” in L.A.R.G.E.R. is for
“rehabilitation.” The L.A.R.G.E. procedure includes detachment of the suspensory ligament,
insertion of sleeve using Alloderm or Surgimend, and injection of fat or filler in the shaft. This
may or may not be supplemented by injection of filler into the glans.
The L.A.R.G.E.R. procedure comprises the above “L.A.R.G.E.” plus penis rehabilitation to
improve the erection. This is done by shockwave treatment or electrical stimulation plus PRP
injections which increase the size of the blood vessels as well as strengthen the muscles of the
penis. When a patient has a better erection, the penis becomes larger. For those with erection
issues, treatment for rehabilitation will consist of shockwave treatment or bio-stem treatment
plus PRP injections. This benefits patients suffering from erectile dysfunction. It also gives
people with normal erections a stronger erection, thereby achieving an increase in the girth and
length of the penis. The L.A.R.G.E and L.A.R.G.E.R. procedures represent a package of different
treatments and carry substantial discounts off the individual procedures.
Other Helpful Procedures
Other procedures that can increase the relative size of the penis include scrotal webbing
correction and reduction of pubic fat and skin.
The scrotum normally starts at the base of the penis. However, in some patients, the scrotum is
attached more distally and, in some cases, right at the tip of the penis. This produces a relative
decrease in length of the penis. By re-attaching the scrotum to near the base, the length of the
penis, whether flaccid or erect, is relatively increased. For patients who are obese, the fat
accumulation and excess skin drooping in the pubic area covers the base of the penis
significantly. Sometimes, the whole penis is covered and cannot be seen. Correction of these by
plastic surgical procedures using liposuction and lift of the pubic skin can increase the exposure
of the penis and, therefore, the length of the penis.
There are certain cases in which the penis of non-obese patients is buried into the fat and skin
of the pubic area. Correcting this increases the length of the penis.
The scrotum size may be disproportionate to the penis. If the scrotum is too big, it can reduced
using a technique similar to the one used for correction of scrotal webbing. If it is too small, it
can be enlarged by injection of fillers.
Premature Ejaculation
Treatment of premature ejaculation is a common request by patients. It can be done
simultaneously with other male enhancement procedures. Premature ejaculation can be
alleviated by making the glans less sensitive. Commonly, this is done by injection filler to the
glans in an attempt to desensitize it, but in some patients, it may not be effective.
Another option is to reduce the number of sensory nerves to the glans. These nerves are very
distinct in the shaft on their way to the glans. Usually, about 30% of these nerves are
deactivated by cauterizing them, thereby decreasing sensitivity in the glans, but keeping intact
the sensations of touch and pleasure. In some patients, the premature ejaculation is somewhat
improved.
In summary, the only way to increase the length of the penis is by minor surgery. The girth can
be increased by non-surgical injection of filler or fat, or by insertion of a collagen sleeve plus
injection of filler or fat. These procedures offer immediate and permanent results. Stretching
and PRP injections may improve erections, giving the illusion of increased penis size. For
patients who are uncircumcised and who do not want circumcision, girth augmentation should
only be done by insertion of a sleeve.