TOPIC: Dr. Leonardo PhalloBoards FAQs

How much Girth/circumference can you achieve with Girth enhancement injections?

I never promise a circumference or number as many factors can affect the end result. The longer the shaft, the more product is needed to create the same Girth enhancement as a shorter penis. There's no accounting for how much initial Girth is a result of swelling from the procedure, local anesthesia placed under the skin prior to filling, and Radiesse which loves to swell. HA also craves water and holds on to it such that the retained Girth may be similar to dimensions from swelling. As such, it's tough to predict. To assist with expectations, just about all of my before and after photos are taken Erect with the amount of volume injected labeled. Most of the patients are 4.5-5.5" Erect. Some are longer, some shorter. After photos with steri-strips (strip bandages) are taken immediately after. After photos without steri-strips are typically at least 2 weeks after the procedure. With the hybrid blend of Radiesse + HA, often what you see immediately after, is close to what you retain after swelling has subsided.



How many sessions can a patient expect to achieve an ideal result?

It really depends on the patient's goal and budget. Most patients have been happy with 2 Hybrids (3mL Radiesse + 2mL HA) + 2HA (2mL) which equates to 7mL of volume. However, there is much more of a "WOW FACTOR" when the initial procedure is injected with 3 Hybrids (4.5mL Radiesse + 3mL HA) + 2HA (2mL) which accounts for 9.5mL of volume. Hence, this is my current minimum volume necessary to treat. Additional volume added during the same treatment is highly discounted if the client really wants to go bigger. Top ups start with 2 hybrids (3.0mL Radiesse + 2.0mL HA) for 5mL prior to discount pricing. The pricing breakdown makes it favorable to stage and build as the client's budget allows. Some top up every 4-12mos.



How long can filler injections take and what kind of anesthesia is used?

My appointments are at least 2 hours long. This is not an assembly line approach for me. I like to take my time. During the 2 hours, I take photos Flaccid, then I induce an Erection using an injection of Trimix, then take Erect photos.

I employ 4 levels of numbing which also takes some additional time. I use topical numbing cream which is applied for 20min, then I perform a dorsal penile nerve block (similar to what a dentist would do to numb teeth) and allow it to settle for 10min. I inject lidocaine with my first pass with the cannula under the skin. Then I fill with my blend of hybrid filler which is mixed with more local anesthesia. My patients are comfortable enough that they have no hesitation in returning for a top up.

After the shaft augmentation, I take Erect photos with measurements. Then proceed to glans augmentation if desired. The glans injections tend to be bloody such that it makes photography difficult. That's why I take measurements beforehand. The rest of the appointment is used to reverse the Trimix Erection and discuss post-care instructions.



Can Girth injections affect the function or sensitivity of the penis? What complications are there to consider?

The biggest fear with injecting filler is Vascular Occlusion (VO). That's when filler is inadvertently injected into an artery thereby starving the tissue it is meant to nourish resulting in tissue death/Necrosis. This is more likely to occur when a needle is used to inject the product. Use of a cannula reduces the risk since the tip is blunt. The larger the cannula, the more blunt the tip such that it becomes increasingly difficult to enter an artery. It is not absent of risk but much safer compared to injecting with a needle.

More common complications would include bleeding, bruising, and swelling. These are common with any injection technique. There can also be prolonged swelling/edema and contour irregularity. These can be easily treated with a light dissolve using hyaluronidase. In addition, positioning the penis upwards allows gravity to drain residual swelling. The hybrid is dissolvable even though it is composed of Radiesse. Contour irregularity from penile retraction (shrinkage) can be minimized by pre-screening the patient weeks prior to filler augmentation and pre-treating with Botox to facilitate relaxation of the penis in the Flaccid state.

Penile augmentation should not affect erectile function as the filler is placed between connective tissue planes but outside of the Corpus Cavernosa, the chambers of the penis that accept blood to engorge the penis. The filler does not affect blood flow unless the penis is overfilled resulting in a "compartment syndrome" where there is too much pressure in the confined space such that blood flow is compromised. The advantage of augmenting the penis while it is Erect is that I can gauge whether or not the penis can accommodate more volume. If the skin is too tight while Erect, I am aware no more filler can be injected. This may not be appreciated if the augmentation is performed on a Flaccid penis only to be later surprised during an Erection.

An augmentation free of any serious complications actually results in a more sensitive/pleasurable experience. The augmented penis feels fuller in one's hands. It's a tighter fit during oral, vaginal, or anal sex. The penis feels heavier. All of this adds to the sexual experience. Glans augmentation with filler is a treatment for premature ejaculation (PE). The filler acts as a barrier between nerve endings and stimulus. For those not experiencing PE, orgasm is not delayed appreciably.



-Dr. Leonardo
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How does a newly Girth enhanced penis feel?

It depends on who performed the procedure and their technique. I’ve had a few patients come to me after having been augmented superficially with HA filler. It felt squishy and appeared like a large blister on the dorsum of the penis.

I’ve used HA, HA + PRP, Radiesse, and Radiesse + HA injected deep below the superficial fascia. The texture is more solid and not squishy. Some of my clients have had the variety of choices but tend to favor the Radiesse + HA blend. It feels dense and heavy like their own flesh. On occasion, there may be a firm palpable Nodule that develops. It can soften over time without intervention or may be spot dissolved. Generally, my augmentation patients report improved sensitivity since their penis fits tighter in a mouth, vagina, anus, or hand.



How long can you wait before resuming intimacy or strenuous activity?

For the best results, I recommend 2 weeks of abstinence from masturbation, sex, and lower body cardio. I want the filler to settle into place during the time frame without too much repetitive forces acting on the product. Against my advice some patients have tested it out after only 1 week without issue, others developed contour irregularities.

One patient was so proud of his new bulge he wore his tight fitting cycling shorts and went for a 50km ride. Most of his filler settled to the right side of his penis. I refilled his left side. It looked great but he didn’t budget for this unplanned procedure. 2 weeks after filling, he was able to cycle without product displacement.

Against my advice one patient had unprotected vaginal intercourse after 3 days. He developed an infection because bacteria had seeded into the injection sites since they had not closed fully. I had to dissolve and drain an abscess, but he recovered after completing a course of antibiotics.

Patients are allowed to work out after 3 days. Strenuous activity prior to 3 days may lead to increased swelling. After 3 days exercise should be limited to upper body workouts. Lower extremity work outs should not be too repetitive during this time frame.

I tell my patients this could be the hardest 2 weeks of their life. Everyone is so eager to put their augmented penis to use but restraint and discipline leads to better outcomes.



Can you gain length from Girth injections?

Length increase after Girth enhancement is more apparent in those who suffer from retractions and have been pretreated with GROTOX® (penile Botox). Flaccid length can improve as there is more weight allowing the penis to hang especially if the glans is augmented with filler.



Any risk of Filler Migration?

Yes, especially if one does not adhere to the 2 weeks of abstinence from masturbation, intercourse, or lower body cardio. Please refer to my discussion from the earlier question.

The product is ideally placed deep sandwiched between the superficial and deep fascia. Since I use a cannula to administer the product, there is a chance that the product may backtrack to the superficial layer through the tunnel created by the cannula. There is also a chance the cannula tip may end up a little superficial since it is a blind technique. Although I aim deep, I cannot guarantee every single drop of filler is going to be placed and maintained in its ideal location. In the event of superficial placement or backtracking into the superficial layer, the product may appear as a hard lump/Nodule that can be spot dissolved with hyaluronidase. This goes for the Radiesse-HA blend as well.

After 2 weeks of abstinence from masturbation, intercourse, or lower body cardio, large scale filler migration is not as likely. There could be contour irregularities that develop from the breakdown of product over time or spot filler migration. These can be treated with either a spot dissolve or filler top up.



Granulomas: What are they, what are the risks, and how are they treated?

A granuloma is a small, localized cluster of immune cells that forms in response to inflammation or infection. They are essentially white blood cells that "wall off" substances that the body does not recognize as itself like bacteria or foreign objects. Granulomas are formed to protect the rest of the body from the foreign substances.

Certain fillers are more prone to granuloma formation like PLLA (Sculptra) and although rare, HA Vycross products (Voluma). PLLA relies on an inflammatory response to stimulate collagen production. PLLA are irregularly shaped spikey complexes that trigger immune cells.

Radiesse, on the other hand, are smooth microspheres that fly under the immune response radar. That’s why I enjoy using Radiesse for collagen and elastin production. Radiesse can form nodules, hard lumps, that tend to be self-limiting. This means that over time they can soften and become irrelevant. They can also be dispersed by normal saline and massage. The Radiesse-HA hybrid can be dissolved by Hyaluronidase.

Granulomas tend to be persistent scars. One treatment recommendation requires injection of a cocktail of 2 steroids and 5-FU, an antineoplastic agent. Steroids can break down collagen fibers, reduce inflammation, and weaken the immune response. 5-FU inhibits the proliferation of fibroblasts, the main cell mediators of scar formation. If injection therapy fails, granulomas must be excised leaving the patient with incisional scars.

Product choice, injection depth (deeper is better), and an aseptic/sterile technique (reduce bacterial load) are key factors in reducing the chances of Granuloma formation.



-Dr. Leonardo

After two augmentation appointments and 20ml of filler, I have a result that I wasn't even able to imagine before! I am THRILLED!
Now that I'm here however, I want to go further, to get BIGGER! The psychological effects of this procedure have been as surprising and thrilling for me as the physical improvements!