TOPIC: PERFORMING AUGMENTATION ERECT VS FLACCID

Bottom line is the end result should look great Flaccid and Erect. The penis can look completely different from one state vs the other. Some guys have concerns about their appearance when Erect. For example, they may have a curvature or tapering that bothers them. It’s best to see them Erect while filling these areas of deficiency.

I inject Trimix (a combination of 3 vasodilators) via a tiny needle to induce the Erection. The response and dose is variable based on any underlying ED, level of anxiety, and appropriate placement of the medication. It should be injected into the corpus cavernosum. Sometimes there is misplaced administration.

Assuming we achieve an Erection, it may last for the duration of the procedure or longer. Overly aggressive dosing may lead to Priapism which needs to be reversed with phenylephrine or drainage by large gauge needle aspiration. Some providers may not be prepared to handle this. If an Erection does not ensue, we can still proceed with treatment. Although, It may take a little more guess work in terms of where to fill volume deficient areas.

Other reasons I prefer Erect augmentation? It frees up my nondominant hand. I don’t have to hold the penis in constant tension throughout the procedure. It allows me to pinch the tissue while I advance the cannula to deeper planes without worrying about keeping the penis stretched. I inject as deep as possible to sandwich the product between 2 connective tissue layers: Buck’s Fascia and Dartos. Anything too superficial leads to product viability, contour irregularities, and a spongy blister-like appearance. It allows me to place the product throughout the entire length of the penis in long linear threads. It allows me to palpate the cannula tip to determine the exact location again without having to keep the penis in tension. The cannula also glides better under the skin when the penis is at full length. I use my non dominant hand to pull the skin in the opposite direction I want to advance my cannula and the cannula just glides without bunching up in the tissue plane. Upon completion of the procedure, I perform a light massage and roll the penis between my hands to even out the texture. This really allows the product to smooth out between the connective tissue layers.

Furthermore, it allows me to determine the maximum dose of filler. If I can no longer pinch the skin because it is too tight/full, I cannot possibly inject more volume safely. The penis has a confined space determined by the elasticity of the skin. Overfilling the penis may compromise blood flow, a phenomenon known as “compartment syndrome”. I have this reassurance when I’m injecting large volumes in one sitting. Imagine stuffing a Flaccid penis with more product than what the skin is able to accommodate during an Erection. It’s an unwelcome, dangerous surprise.

Yes the penis is more Flaccid than Erect during its existence but the point of augmentation is to improve the sexual experience. If it looks great Flaccid but odd Erect, that leads to embarrassment and perhaps performance anxiety. As such, I screen for shrinkage and pretreat the patient with Botox to limit shrinkage or drastic length changes. This helps mitigate contour irregularity from the product bunching up when Flaccid and shrunken.

Those are my reasons for performing augmentation in the Erect state. Again, it is not mandatory but it certainly facilitates the procedure and gives me various clues that I do not get when the patient is Flaccid during the procedure.

Attached are photos demonstrating correction of a curvature and taper. There is another photo demonstrating the relaxation of the penis using Grotox (Penile Botox) such that it hangs longer in the Flaccid state, thereby creating less length disparity compared to its Erect length.