TOPIC: Seeing more clinics “discover” HA-first staging before PMMA…

Hey, guys! We've been noticing a pattern lately: more and more PMMA providers are now saying they “prefer to start with HA first” before moving to PMMA, often framing it as a way to make things safer / lower complication risk (including granuloma/inflammatory issues).

What’s interesting is… this “HA-first staging” approach isn’t new for us.

At Rejuvall, Dr. Kenneth J. Carney (urologic + cosmetic/plastic surgical training, plus pharmacology background) has been using a staged protocol like this for nearly a decade, largely because of what he kept seeing in real-world Revision/Repair work from other injectors:

• HA is a reversible “test run.” It lets you dial in shape, distribution, and how your body responds before committing to anything permanent.
• Staging can reduce guesswork. In our experience, many “problems” start when someone tries to do too much permanent product too quickly, without a clear plan for tissue behavior, immune response, symmetry, and layering.
• It can lead to a more conservative PMMA plan. If the aesthetic target is already mapped (and in some cases partially achieved) with HA first, the “permanent phase” can be approached more deliberately, with less pressure to push volume fast.

To be clear: nobody can ethically guarantee a specific complication outcome (and anyone claiming they can is overselling). But the logic behind staging is pretty straightforward: more control, more predictability, and fewer rushed decisions with permanent material.

The part I wanted to put on the community’s radar is that a lot of clinics are presenting this as a new “innovation,” when it’s really a best-practice evolution that came out of years of repairs and refinement.

If you’ve had PMMA done, I’d genuinely love to hear:

• Did your provider offer HA staging first?
• If yes, did it change your PMMA plan (volume, rounds, placement)?
• If no, do you wish you’d had a reversible “trial” phase before going permanent?

Not medical advice, just sharing what we’ve learned on the clinical side after seeing a lot of “what went wrong” cases up close.

I'm the opposite order so I'm not sure if it's relevant but nonetheless I'll at least mention it. I had a couple rounds of PMMA done and a few years later had HA added in addition. The reasons were multi faceted. Logistics were one of course (no one here will do it). But also trusted the doctor and liked his aesthetic results (and aesthetics over time were one of the things I initially wanted to improve). Eventually I decided to stick with it because I was happy with the effects and feel and also wanted to experiment with going very large, so at least there'd be a potential way to reverse that. Over time we added more in small sessions and also used PDRN as an injectable which seemed to enhance the results. I've never noticed any breakdown/reduction/degradation, but I've also slowly added here and there.

I can 100% see the merit and reasoning behind doing some HA first and then slowly adding PMMA to make the results permanent and more accurately control the aesthetics.

Can this idea (“HA-first staging” approach) also be applied to FFT? (like FFT-first staging” approach)
Whats your recommendation @Rejuvall ?

Can this idea (“HA-first staging” approach) also be applied to FFT? (like FFT-first staging” approach)

Sorry, I'm not quite clear on what you're asking. You mean first undergoing FFT and then adding PMMA?

Yes, exactly right! What I meant was that for similar reasons as in the HA-first staging approach - someone goes with the route/journey FFT-first staging approach. …In order to then possibly continue with the significantly more permanent (or considered completely permanent) PMMA.

What I meant was that for similar reasons as in the HA-first staging approach - someone goes with the route/journey FFT-first staging approach. …In order to then possibly continue with the significantly more permanent (or considered completely permanent) PMMA.

@PmmaFan Thanks for the thoughtful question. Yes, now I understand exactly what you mean by “FFT-first staging” as a concept.

The tricky part is that “FFT” isn’t one standardized thing the way HA injections are. There’s huge variability between surgeons in how fat is harvested, processed, and placed, what planes it’s layered into, how much is done per round, how they manage overcorrection/undercorrection, post-op protocols, and even what they consider “success.” Because of that variability, it’s honestly impossible to give one universal rule like “FFT-first always makes PMMA safer” (or vice versa) without knowing the exact technique and the patient specifics.

On the “priming” idea specifically: fat itself generally isn’t used for “immune priming” the way some clinicians think about HA staging. HA is sometimes viewed as a way to create/condition a tissue plane and see how the area behaves before introducing something permanent. With FFT, you’re not doing that same “reversible conditioning step,” and the mechanism is different. (Also, any procedure can trigger inflammation from the trauma of surgery/injection, but that’s not the same thing as a purposeful “priming” effect.)

From our perspective at Rejuvall, there’s another important point: our fat transfer approach is intended to be a permanent solution, not a temporary stepping stone to PMMA. If a patient wants more size after FFT, the most logical next step is usually adding more fat (a planned second round if needed), because it stays within the same surgical strategy and maintains consistency in texture and aesthetics.

So in practical terms:

• If someone is planning FFT as a “try it first, then maybe PMMA” pathway, we’d ask: what’s the end goal that fat can’t accomplish with an additional round?
• If the patient still wants more after fat, the cleaner answer is typically another fat transfer (when appropriate), rather than switching materials.
• In the rare scenario someone wants to go beyond what additional fat can reasonably achieve (or if they’re not a candidate for further fat transfer), that’s when a permanent filler discussion might come up — but it’s not something we’d treat as a default “stage 2.”

@Rejuvall
Okay. I understand. And also there is the scenario that some people first want to start with smth what is not a foreign material (like pmma). … And after they re more into that girth enhancement world - they continue with BellaFill - since as you said with Pmma is more achievable what fat can ever provide.

Also I read one time on Dr C. Webpage that prior Fat transfer creates like tissue „mutation“ (positive fibrosis?) where then the pmma is more easy to work in. +And also that (possible) irregularities from pmma are more hidden then.

some people first want to start with smth what is not a foreign material (like PMMA)

Hyaluronic Acid is a material naturally produced by the body as well.

since as you said with PMMA is more achievable what fat can ever provide.

I apologize, but I don't understand what you're trying to get at here. Are you saying that I said you can get more Girth from PMMA than you could ever get from fat transfer? I apologize if I was unclear, but that is not the case and not what I was trying to convey.

Also I read one time on Dr C. Webpage that prior Fat transfer creates like tissue „mutation“ (positive fibrosis?) where then the PMMA is more easy to work in. +And also that (possible) irregularities from PMMA are more hidden then.

I'm not sure which "Dr. C" you are referring to here. I have never heard of this before, and I haven't ever seen anything about it on Dr. Carney's site, but I could check with Dr. Carney tomorrow and see if he's ever seen this phenomenon in his vast reconstructive and PE Repair work over the past several decades.

Edited to add:

And also that (possible) irregularities from PMMA are more hidden then

If you have a good provider with the proper training, experience, materials, and technique, there should be no irregularities from PMMA. Not to call anyone out or shame anyone, but far too many providers are saying that cosmetic irregularities and a need for touch-ups is "normal" or "to be expected" when it absolutely 100% is not.

@Rejuvall

Yes, I apologize for stating that PMMA delivers better results than fat grafting; I may have been relying too heavily on my subjective opinion. But this forum is also very much in favor of PMMA…

With Dr. C, I meant Casavantes (Avanti).

Since this discussion is currently about the best practices / approaches and procedures of clinics, I would also like to ask why some clinics consider combining fat grafting and PMMA?

This is not the first time I have discovered this.

Here's an example:

emermaleclinic.com/fillers/

"Combination Treatments
Depending on the results you desire and your current situation, Dr. Emer may recommend a combo of fillers and fat grafting during your consultation."

But this forum is also very much in favor of PMMA

Yes, I realize that, but just because something is very popular does not mean it is the best available material/process for every man wanting Girth enhancement. In fact, most of the filler Repair cases we see on a weekly basis are PMMA cases, and many of them went to well-known and respected (non-Urologist) providers for that PMMA.

I would also like to ask why some clinics consider combining fat grafting and PMMA?

That's a very good question, but since I do not work for those other clinics, I cannot answer as to why they would offer something that is medically inappropriate.

This is not the first time I have discovered this.

Here's an example:

emermaleclinic.com/fillers/

"Combination Treatments
Depending on the results you desire and your current situation, Dr. Emer may recommend a combo of fillers and fat grafting during your consultation."

Just so you're forewarned, Emer is a Loria affiliate. So I'm actually not surprised that his website markets another pathway that is medically inappropriate.

@Rejuvall
Yes the community is all about Pmma

But let's say someone had FFT with Dr. Carney and later, for various reasons he decides for Pmma (e.g., because he thinks PMMA has a even better consistency/feel) (lets say, hypothetically, cause of his own wish)
Is a PMMA session then possible without any problems? Or is this not advisable? Or could it cause any difficulties?

But let's say someone had FFT with Dr. Carney and later, for various reasons he decides for Pmma (e.g., because he thinks PMMA has a even better consistency/feel) (lets say, hypothetically, cause of his own wish)
Is a PMMA session then possible without any problems? Or is this not advisable? Or could it cause any difficulties?

That depends on the patient. It could be possible for one person, but not for another. Whenever it comes to penile enhancement of any sort, you have to think about things like age, wound-healing ability, weight and body habitus, any other work they've had done elsewhere, the list goes on, before formulating any kind of treatment plan. You have to remember that penis enlargement is medical, not purely cosmetic, and that the penis is a vascular organ with complexity akin to that of the . What might work for one man could be dangerous to another man. Sadly, we see so many repair cases that come to us after they've had enhancement done by a non-urologist provider that only offers "one-size-fits-all" solutions.