TOPIC: Dr. Solomon's Monthly Educational Q&A

(9a) In a previous Q&A you've stated spending 25% of your time on the West Coast and 75% of your time on the East Coast. There has been recent news that you've been expanding or relocating, is it possible you'll be working more frequently out of your West Coast Office?

As the pandemic has progressed, it has been easier to go back and forth between coasts. At the present time I am able to go for one week a month. As things pick up in LA, I expect the time there will increase, probably in the latter part of this year. One new exciting development has been what I call ";naturally larger" for testicles. Many men who take testosterone note that their testicles become smaller or softer. Up until now, the only treatment plan has been to use an implant for the testicle. With Dr. Paul Turek, my Urology colleague in Beverly Hills, we have been placing micro-fat grafts inside the plane that surrounds the native testicle. This provides for a natural feeling testicle enlargement. It requires both of us to perform the procedure. I expect the demand for this method will grow.


(9b) It's known that you prefer dermal graft matrices for Girth enhancement (i.e. Surgimend), but do you also offer fat injections (FFT) as an alternative option?

While I do place fat in the testicle, I do not use free fat grafts in the shaft. There is no fat in the skin of the penis and fat is soft. It provides an irregular, soft augmentation of the shaft that is not natural. I have considerable experience removing fat from the penis. The main principle behind the use of a dermal graft for Girth enlargement is that in plastic surgery, there is a concept known as replace like tissue with like tissue. If there is a bone defect, replace it with bone or a bone substitute. If there is a fat defect, or something like fat, replace it with fat. If there is a fascia or dermis issue, replace it with a similar tissue. The use of a dermal graft is similar in "feel" to the native tissue of the penis, so I use Dermal Grafts.


(9c) Some physicians have used "spacers" (whether silicone or tissue) to prevent the reattachment of the suspensory ligament during penile lengthening surgery -- what are your thoughts on this and do you employ similar measures?

With regard to spacers after ligament release, I have experience in removing them. I have never used one. I have removed them because they migrate from the space up toward the surface, which creates discomfort for the patient. They were popular, especially in Europe, about 15 years ago. I have not seen one in a while. There are safer ways to stabilize the penis after ligament release that have worked well for me over the years.


(9d) There has been much discussion about how uncircumcised penises see a higher frequency of aesthetic irregularity or complication via Dermal Filler injections (Hyaluronic Acid, PMMA, etc) versus Circumcised men.

A member (username Moses) of this forum asked whether or not your grafting technique (presumably Surgimend) also has this problem? In other words, would you strongly recommend or require Circumcision for a man who undergoes your procedure, or is the patient's Circumcision-status (cut or uncut) irrelevant/trivial to the success of your procedure?

Thanks for this question. I perform my grafting procedure in a slightly different manner in uncircumcised men. I think the complications for fillers will be higher in uncircumcised men due to potential disruption of blood flow to the glans. In order to prevent that in my method, I perform what I describe as a widening rather than a full wrap method. This way, there is less disruption of blood flow to the glans and it preserves a band of skin on the top of the shaft for drainage of blood to help with healing. This is separate from blood in the Corpus Cavernosa.


Mark P. Solomon, MD FACS

(10a) What's the most common motivation or explanation by your patients as to why they seek out Male Enhancement procedures?

Men who come to for enhancement are looking for one of several things. First, they often have an issue that can be corrected. For example, often men have buried penis or a scrotal web. Other men have a discrepancy between their length and Girth. Some men have a short, wide penis and they want length. Others have a long, thin penis and they want Girth. The last group is men who want more confidence and feel that a larger penis will be helpful in this regard.


(10b) What are your thoughts on the future of Phalloplasty and where it might go? Is there any credence to the idea that stem-cell advancements will pave the way for future aesthetic medicine, including penis enlargement?

Penis enlargement is still not widely accepted in medicine. It will need to become mainstream and at that point, will be more widely available. True stem cells are very expensive to produce. Most present claims of stem cell treatment are not using true stem cells. Given that fact, stem cell treatments are a very distant hope for penis enlargement.


(10c) Is there a reason to believe Mons Pubis (a.k.a. "fat pad") liposuction can aid in length gains, and do you perform this procedure?

Mons pubis reduction can be performed with liposuction, skin Removal or both. These procedures can, for the right patient, create the appearance of a larger penis without doing anything to the penis itself. I often combine pubic liposuction with penis length surgery to enhance the result of the ligament release.


Mark P. Solomon, MD FACS

(11a) Do you perform Adult Circumcision? If so, do you have a preference for the type of cut (i.e. high & tight, high & loose, low & tight, low & loose)?

I do perform Circumcision. The terms describe different end results. In my practice, the goal is to provide a natural look that varies with each patient. Most of the circumcisions that I perform are revisions.


(11b) What do you believe are the strengths of Plastic Surgeons in the field of Phalloplasty/surgical Male Enhancement? What makes them a more attractive specialization than other Cosmetic Clinics that operate without surgical backgrounds?

My perspective is that plastic surgery is a specialty that uses surgical principles to reconstruct or enhance anatomy. The specialty has no anatomic boundaries, but instead uses those principles everywhere on the body. I advise patients to be aware that there is often more than one way to treat a problem, and the best answer for one patient may be different from that for another patient. Things such as fillers are deceptively easy to perform, but the physician may not be aware of the long term consequences of their treatment, or how to manage their complications. For that reason, I encourage all of my patients to do their research and consult with more than one specialist, if possible.


(11c) Is it possible to undergo surgical augmentation (e.g. Surgimend, and/or lengthening) even if prior work has been performed on the penis, namely dermal fillers?

It is possible to perform grafting after prior procedures have been performed. However, the risk of complications is increased after prior procedures. Prior procedures, both surgical and non-surgical (such as fillers or fat grafts) will disrupt normal blood supply to the skin and make healing more challenging for the patient, with increased risks of wound breakdown and infection, among other things.


Mark P. Solomon, MD FACS

(12a) Regarding your lengthening (Ligamentolysis) procedure, a two part question:

(i) Can the ligaments reattach overtime?

No the ligaments don't reattach, but men can get scar tissue that acts in a similar fashion. I advise the use of a weighted condom in the healing period to help minimize that occurrence.

(ii)- If they can, do you employ the use of a spacer, and if so, what kind?

I have removed many spacers over the years that were placed by other surgeons. They can migrate and incite scar tissue that creates other issues. They can also get infected, so I do not think they are helpful.


(12b) You've answered questions about adult Circumcision, saying you mostly perform revisions. Is it possible to give men who were Circumcised low and loose to become more high and tight, and vice versa? In other words, is it possible to revise the very nature of a man's Circumcision?

The terms "high and tight" are not medical. They are more stylistic. Circumcision can be more involved than men understand. I certainly revise them and also perform primary circumcisions. Provided there is an excess of skin to remove, the only other issues are the amount of skin and the pattern used to remove it. These are individualized depending upon each patient's situation.


(12c) Sticking to the topic of Circumcision, which has been an off-again on-again topic on the PhalloBoards, what are your feelings on Foreskin restoration and do you perform any type of procedure for this?

I don't have a good answer for this. Some of my patients have used devices akin to a weighted condom to stretch the skin over many months. I have no data on success rates or the time that this takes and how well it does or does not work.


(12d) Are men with mild cases of Peryonie's Disease disqualified from penis enlargement surgeries (as they would presumably be inoperable cosmetically in severe cases)?

Most men with Peyronie's disease that I have seen are more focused on correcting their issue and are grateful to get a straight penis. As Xiaflex becomes more widely used, it may change the treatment paradigm. Regardless, there is always a risk of complication from any enhancement and this is the same with, or without, Peyronie's disease. In my experience, I have not had any patients with Peyronie's ask for enhancement. I would consider each patient on an individual basis for that reason.


Mark P. Solomon, MD FACS

When Girth surgery is performed along with other procedures, the swelling takes longer to resolve than if the procedures were performed separately.

Girth procedures have a more complicated operative course, so complications may occur.

Dr Solomon-When several procedures are performed within a single surgical event such as a Girth enlargement, scrotal webbing procedure, and a testicular/scrotal enhancement utilizing a dermal fat graft, would you opt for putting the patient under general anesthetic or would you prefer to stay with the local anesthetic?

Two more questions:

You've clearly explained how dermal fillers should be contraindicated for use in their "off-label" form in Phalloplasty, but do you use them in other areas of your practice for various facial rejuvenation procedures?

Also, you've mentioned the use of a "weighted condom" a few times for post-operative care after Ligamentolysis. Is that something that you've invented in your practice and provide to your patients or do you provide instructions on how to construct it out of common materials? Could you describe how it's made or maybe post a photo of the set-up? What weight do you have them start at initially and what weight do they end with at the end of the protocol?

Lastly, I REALLY appreciate the very thorough, well-articulated, and frank responses that you've provided throughout this forum. I feel like I've learned a tremendous amount from you which will help me make more wise and responsible decisions for my sexual health and well-being.

Thanks!

Phallocy wrote: When Girth surgery is performed along with other procedures, the swelling takes longer to resolve than if the procedures were performed separately.

Girth procedures have a more complicated operative course, so complications may occur.

Dr Solomon-When several procedures are performed within a single surgical event such as a Girth enlargement, scrotal webbing procedure, and a testicular/scrotal enhancement utilizing a dermal fat graft, would you opt for putting the patient under general anesthetic or would you prefer to stay with the local anesthetic?

Two more questions:

You've clearly explained how dermal fillers should be contraindicated for use in their "off-label" form in Phalloplasty, but do you use them in other areas of your practice for various facial rejuvenation procedures?

Also, you've mentioned the use of a "weighted condom" a few times for post-operative care after Ligamentolysis. Is that something that you've invented in your practice and provide to your patients or do you provide instructions on how to construct it out of common materials? Could you describe how it's made or maybe post a photo of the set-up? What weight do you have them start at initially and what weight do they end with at the end of the protocol?

Lastly, I REALLY appreciate the very thorough, well-articulated, and frank responses that you've provided throughout this forum. I feel like I've learned a tremendous amount from you which will help me make more wise and responsible decisions for my sexual health and well-being.

Thanks!

Sorry for the delay in getting a response - Dr. Solomon is currently in the process of relocating from his Philadelphia location to the Beverly Hills Office and for this reason isn't at fully capacity with work-related functions & surgery. I will try and get a response sooner than later, and I know he intends on providing a thoughtful answer.