(1a) Dr. Solomon, I've read that you perform the removal of rigid silicone implants, and any subsequent revision or repair . Here is a 4-Part Question:
(i) Would you advise patients who've had a rigid silicone implanted for penis enlargement to have it removed, even if there is no clear indication of complication or initial dissatisfaction (i.e. preemptive removal)? If so, why?
Patients often ask this question. I have seen only one man for whom my answer was to leave the device in place. He had no symptoms and no evidence of erosion or malposition of the device. I do caution men that if the device becomes more visible because of thinning of the skin, usually behind the glans, they should consider removal. It is my impression that the device will not last over time, either because it erodes, gets infected or breaks apart, but in general, I do not remove the device in men who are happy with it.
(ii) If I'm having issues with the implant, what are the nature and severity of complications that would warrant a medically-necessary removal?
There are a variety of reasons to medically remove the device. They are as follows: erosion through the skin, infection, seroma (this is a fluid accumulation around the implant), breakdown of the device, pain, difficulty having intercourse and erectile dysfunction.
(iii) Are there any drawbacks for removing the implant, regardless of the reason I'm having it removed?
Every operation has risks. Removal of the device may cause internal scarring that can cause loss of length. There may be loss of skin of the shaft due to thinning of the skin because of the device. There may be loss of sensation from the action of the device on the shaft skin or due to injury to the nerve to the glans from the patch that is used to fixate the implant in the penis.
(iv) Is it true I could lose length after implant removal, and if so, what can be done to mitigate length loss?
Yes this is true. I will often perform ligament release at the time of implant removal or corrective surgery. Patients also need to wear a weighted condom after surgery for six months for six hours a day to maintain the length.
(1b) Dear Dr. Solomon, Forum Moderator Hoddle10 asks: "What do you consider the ideal patient? What makes someone a good candidate for penis enlargement surgery? Are there instances you'd consider turning away a patient?"
Let me answer the last question first. I turn away almost one third of the men who seek my opinion. Most often, these are men who are either very unrealistic in their goals, or they have a very normal to large penis and I do not think the benefit of surgery outweighs the risks involved. The ideal candidate is a healthy male who wants to make his penis larger in one or more dimensions and has no issues with erectile dysfunction. The reality is that I see men of all types with variation in their health, so I do make exceptions for different medical conditions. I do not do girth procedures on smokers. I have found that smokers in particular have a high complication rate from girth procedures, so I will no longer treat them. The corollary of that is that men who have complications of fillers and are smokers are also at high risk of complications. I ask them to stop smoking for 3 weeks prior to surgery and 3 months after surgery. I have had men who start smoking after surgery and inevitably they need more surgery to get them healed.
Mark P. Solomon, MD FACS
(2a) Dr. Solomon, what are the advantages of using Surgimend over other dermal matrices (like Alloderm & Belladerm)? Are there varying options for thickness? Could I add more sheets of Surgimend in the future for more Girth?
This is an excellent question. Alloderm and Belladerm (among others) come from human sources. In particular, Alloderm is a donation from someone who has died while Belladerm often comes from remnants of abdominoplasty (tummy tuck) tissue that is removed at surgery. Human dermis is then prepared from these materials. Human dermis varies in thickness depending upon what part of the body it is from and the age of the donor. Human dermis gets thinner with age. As a rule, the thickest human dermis is not more than 2 mm and on average about 1.5 mm. Surgimend comes from fetal calf tissue. This has several advantages. It has never been exposed to bacteria, so it is sterile. Calf dermis is thicker than human dermis. This tissue is cut by machine. So its thickness is uniform and because calf dermis is thicker than human dermis, it is available in thicknesses from 1 to 4 mm.
My average Surgimend graft is 3 mm thick. This seems to be the "sweet spot" between giving a good result while allowing it to revascularize in a reasonable amount of time. I have used 4 mm grafts in some patients, as well as 2 mm grafts in some.
You can have a second wrap, but recovery is long and in several cases, the penis has been almost too thick for comfortable intercourse. I warn patients about these issues before performing additional Girth enhancement.
(2b)Dr. Solomon, do you offer any solutions for glans enlargement? If yes, could you describe how you go about safely augmenting the glans? If you don't offer any procedures for the glans, is it due to the anatomical risks associated with the glans, or simply a matter of preference?
I have tried many methods for glans enlargement. None of them provides a permanent solution, so I do not offer this to my patients. I am aware that some physicians use injections, mostly hyaluronic acid. This generally goes away, but has, on occasion has left some nodules that I have had to remove surgically. I have also tried fat grafting the glans and using dermal graft material. None of these methods provided a natural, long lasting glans enlargement, so I do not perform this procedure any longer.
Mark P. Solomon, MD FACS
Last edit: by PhalloBoardsSystemAccount.
(3a) Dr. Solomon, do you perform lengthening surgery (Ligamentolysis)? If so, what can patients expect to gain on average? Are gains limited to Flaccid length or will I see improvements in both Flaccid and erect lengths? Also, will there be a change in the angle of my erection post-op?
Penis length surgery, sometimes called Ligamentolysis is one of the most common procedures that I perform. It has a high degree of patient satisfaction and the questions here are good ones. I tell patients that the average increase in Flaccid length is 1 Inch (2.5 cm). The most I have ever seen is 2 inches (5cm). This is related to the amount of penis that is beneath the ligament. The increase in length that occurs is always in the Flaccid state. Some men tell me that they are longer when erect, but there is no way to know in advance if there will be a gain in erect length. Moreover, I do not measure patients in the erect length, so I have no data to answer this question in any greater detail. To my knowledge, there is no large study that discusses this. There are some reports of about an average of one-half Inch (1 cm) increase when erect after surgery. Many men think the angle of their erection will change after surgery, but I have not seen this in my patients. I do several things in the surgery itself to restore the angle. I also have my patients wear a weighted condom for 6 hours each day for 6 months after surgery to help prevent scar tissue from pulling the penis back.
(3b) Dr. Solomon, do you provide surgery to those who suffer from excessive scrotal webbing, sometimes called "turkey neck?" If so, can you detail some important things to expect like recovery time, whether it's an outpatient procedure, common techniques that are used, etc?
Scrotal webbing is an issue for many men. It can interfere with intercourse and be a source of irritation during exercise. There are several methods of correcting the web. The oldest method is known as z-plasty. Other methods include a U shaped skin excision and a V shaped skin excision. The decision about which pattern to use is based upon the extent of the problem, which varies with each patient. The surgery itself is not associated with much postoperative discomfort, but there is a large a mount of swelling. This takes the better part of a month to resolve and in that time men are restricted in terms of physical activity and sexual activity. Surgery is performed as an outpatient. Some patients require a drain to be used while others do not. This is a decision that I make at the time of surgery. The scars from these procedures are well hidden due to the nature of the skin of the scrotum. I use dissolving Sutures that do not need to be removed.
Mark P. Solomon, MD FACS
(4a) Dr. Solomon, do you perform testicular enhancement surgery? If so, how do you go about enlarging the scrotum and/or testicles? If not, what are your reservations with approaching this part of the anatomy?
I do perform testicular enhancement. This is one of the areas where I will use fat grafting. I work with a urologist in Beverly Hills to assure that the fat is placed in the proper plane around the testicle. The fat provides a natural feel along with a modest augmentation. Most men who seek this treatment have been taking testosterone and note a change in the size and consistency of their testes. I will occasionally place implants in the scrotum, again, working with a urologist in my Beverly Hills location. These can be placed along side of the existing testes or for men who have had their testicle removed. These implants are firmer than normal testes. I do not place caps on the testicle because they make it difficult to examine men for testicular tumors.
(4b) Dr. Solomon, if I wanted multiple procedures done (i.e. any combination of lengthening, Girth, scrotal webbing, etc), can they all be done on the same day at your Clinic?
Is it possible combining procedures all on the same appointment would increase the risk for edema, a longer recovery, and/or major complications? What are your thoughts?
I do perform multiple procedures in one sitting. However, I tell patients that the recovery is prolonged due to swelling. Most of the swelling arises from the Girth procedure. When Girth surgery is performed along with other procedures, the swelling takes longer to resolve than if the procedures were performed separately. In my practice, the risks of complications are low. Length and web procedures have few complications and they tend to be minor. Girth procedures have a more complicated operative course, so complications may occur. I have only had 3 patients who lost their grafts in more than 25 years. My style of practice is very “hands on.” I require my patients to stay in a hotel near my office (in either location) and I see patients every day until they return home. This is usually anywhere from 3-6 days after surgery. This allows me to manage drains, dressings and other concerns that patients have after surgery. It also minimizes swelling since patients are largely at bed rest and in the hotel, rather than out of the room. I find that early control of swelling reduces the overall recovery time. For patients who travel a distance for surgery, I advise staying in a hotel for 1-2 weeks. Patients often feel well in the hotel and then have issues when they arrive at home. This is due to the stresses of travel, the amount of walking needed to travel through an airport, greater swelling and the general anxiety created when patients are at a distance from me. While it can be inconvenient to stay in a hotel for 1-2 weeks, the value is that your activities are very limited. This limits the swelling and enhances the healing. Obviously, I cannot force anyone to stay longer, but I encourage boredom as a part of recovery from these procedures, which are real surgery with real potential for complications.
Mark P. Solomon, MD FACS
Last edit: by PhalloBoardsSystemAccount.
(5a) Dear Dr. Solomon, I have been asked on occasion about surgical or non-surgical options for men with micro-penis. Do you (or have you) ever performed surgery on patients with a micro-penis? What's your opinion on the condition, and what are some advice you can give to men with micro-penis?
I have performed surgery on men with true micropenis. The nature of the procedure is quite customized since there are often several components to the problem. The goal for these men is improvement. It is often impossible to get a true micropenis to be more than a modest penis, but for these men, that is often enough.
(5b) Dr. Solomon, I've read you're a Board Certified Plastic Surgeon. What other Male Enhancement services do you provide that aren't necessarily related to Phalloplasty?
Answer: Men have a variety of issues that I treat. Specific to men are surgery for gynecomastia (enlarged breasts) and pectoral implants. These implants are used for men who want to add definition to their chest that exercise won’t provide. Calf augmentation and bicep augmentation can be performed as well. Other procedures for men include liposuction and facial surgery. Facial surgery includes eyelid surgery, nasal surgery, chin surgery, forehead lift (also known as browlift) and facelift.
Mark P. Solomon, MD FACS
Thank you Dr. Solomon, this is invaluable information and insight for Elist victims (I won't call him Doctor since true doctors take an oath to above all else, do no harm). Is it possible to post an estimate of what a Revision surgery will cost? I will be in contact with your office very soon>
I'd call their office. These Q&A's are monthly submissions and you're more likely to connect if you contact them directly. Good luck!
Hello. What experience do you have performing Girth enhancement on patients who are not Circumcised? What have been results aesthetically?
(6a) Dr. Solomon, Forum Member "Chrisresearch" asks: "Hi Dr. Solomon, I have been reading your posts and researching Revision. Regarding PMMA Removal, can it be done if there is not much PMMA?"
PMMA causes an inflammatory reaction as it integrates with your tissues. Often, the amount of PMMA is relatively small compared with the reaction that it creates. If these areas can be readily identified on physical examination, then its Removal is fairly straightforward, regardless of the amount of PMMA injected.
(6b) Dr. Solomon, The Moderation Team would also like to add the last question: How do you gauge whether Removal or Revision of a penis filler is "safe" or "advisable." How does this assessment apply to all the cosmetic filler varieties (from PMMA to hyaluronic acid (HA) to silicone oil)?
All surgical procedures have risks. The question of safety relates to several issues. First, does the benefit of the procedure outweigh the risk? If, by removing the foreign material, a more normal contour can be restored with minimal risk to the patient, then the benefit outweighs the risk. This issue is of more concern in patients with pain in their penis or migration or erosion of the material through the skin. Second, it is important that patients understand the risks of the procedure. Injection of materials in the penis varies widely. I have seen patients with injections that are placed deep in the penis as well as superficial. Removal of these injections includes not only the material, but the body’s reaction to the material. For things like hyaluronic acid, this reaction is often minimal. For silicone, the reaction can be large, as it can for PMMA. This is due to the properties of these various materials. So the surgeon must account for the location of the injection, the reaction it has caused and the initial material injected. With all injections, there is an issue of loss of blood flow to the skin superficial to the injection. The skin of the penis is thin and its blood supply is often adversely affected by these various injections (and other procedures). Therefore, Removal of material is not only about the material and the reaction, but attempting to preserve blood flow to the overlying skin to avoid loss of skin that could require additional surgery to Repair the loss.
(6c) Dr. Solomon, you have two locations, one on the East Coast (Philadelphia, PA) and the other on the West Coast (Los Angeles, CA). Do you have a set schedule between the Clinics or is one a primary location with the other being on an as-needed-by-appointment basis?
Typically, I spend 25% of my time in Los Angeles and 75% in Philadelphia. With the onset of the Covid-19 pandemic, I have limited my travel to Los Angeles. This is because the disease is fairly well controlled in Philadelphia. Were I to go to Los Angeles at the present time, I would need to be quarantined for 14 days upon my return, which is disruptive to my schedule in Philadelphia. Therefore, until that restriction is lifted, I will need to limit my time to Philadelphia only. I do have a waiting list for surgery for patients in Los Angeles, so when I return, I will be operating and seeing patients in consultation. Until that time, I have been using telemedicine to provide secure, encrypted video meetings with patients who cannot travel to Philadelphia. These appointments are arranged by calling my office.
Mark P. Solomon, MD FACS
(7a) Dr. Solomon, do you believe attitudes toward male elective medicine (namely penis enlargement) will ever become as socially accepted or mainstream as the common "nose" or "breast" job? If so, how long do you predict this shift in attitude will take? If not, what are some reasons potentially holding it back from normalization (e.g. stigmas)?
I think that attitudes are definitely changing. I recently was asked to publish a paper in the journal Plastic and Reconstructive Surgery on this topic. In addition, I presented at our annual meeting and, as a reviewer for the Journal, I am seeing articles presented for publication almost monthly on the topic of penis enlargement surgery. Awareness of the topic is increasing, so it is likely that it will become more acceptable with time.
(7b) Dr. Solomon, concerning costs (*3 Part Question):
(i) how can I go about acquiring the costs for any given procedure?
My office gives a range of costs to patients who inquire on the phone. We do not provide costs by email. However, the only way to get an actual cost for surgery is after an evaluation by me. This is due to the fact that procedures are individualized for each patient. In many cases, patients ask about one procedure, but after an exam, they need something different, which may be less expensive than their original request. For example, men often inquire about getting both length and Girth, but after an exam, they may only benefit from one of those procedures, so the cost is less.
(ii) are there any procedures my insurance will accept?
There are several parts to this answer. First, medical insurance covers procedures that are defined as "medically necessary." Procedures for penis enlargement are cosmetic in nature (like breast enlargement). Cosmetic surgery is not generally covered by insurance. Your individual policy may have some exception to that rule, but only you can determine that by asking your insurance company or reading your insurance policy. Surgery for Revision after failed cosmetic surgery is also not generally covered by insurance. Most insurance plans will not cover cosmetic surgery or complications from cosmetic surgery. Again, the best way to determine your coverage is to review your policy or call your carrier. Even if you have coverage, you will need to find a surgeon who participates with your insurance carrier. Otherwise, the surgeon is considered "out of network", which means you will be responsible for the costs of surgery and you can ask your insurance to reimburse you according to your plan. Most times, they will reimburse only a portion of the costs in that situation.
(iii) is financing available? This was mentioned on your website, but I'd like to know more.
My practice works with several outside entities that provide financing for surgery. You need to apply to them directly to determine if you qualify. The two that we work with most often are CareCredit and United Medical Credit. They each have their own rules about financing and they make their decisions independent of my medical decisions.
(7c) Dr. Solomon, the Moderation Team would like to know if your Clinic has any exciting new plans, procedures, devices, locations, publications, and/or promotions for the new year (2021) & beyond?
I publish articles on penis surgery in the plastic surgery literature from time to time. These are designed for a medical audience and are not usually available to nonmedical people. You can access them by going to PubMed. I am always evaluating new methods for surgery, but will only discuss them once I have implemented them and have follow up data.
Mark P. Solomon, MD FACS
Can one successfully receive a lengthening surgery after getting a filler like PMMA? How long would one have to wait in between the two?
[From Dr. Solomon]
Length surgery can be done at any time.
As a general rule, it probably makes more sense to perform length surgery prior to PMMA for several reasons, but I have done it both ways,
Mark P. Solomon, MD FACS
(8a) Do you believe there is any validity to the claim that penis enlargement devices (example: pumps, hangers, etc.) and penis enlargement exercises (example: Jelqing, stretching, etc.) can increase the size of the penis?
There is no objective evidence that these methods do very much good. I am aware that they are very popular and that men would like to avoid surgery, but these devices do not have a great track record for most men. One exception is the use of a stretching device for penile curvatures. This does sometimes work and is worth a try, especially for mild curvatures that are not associated with a thick Peyronnie's plaque.
(8b) Do you believe there is any validity to the claim that supplements (example: Male Enhancement pills, topical creams, etc.) can work in increasing the size of the penis? If they are indeed scams, how have they been able to remain prevalent?
Supplements provide no long term benefit. Yohimbine, which is one type of supplement, can provide some short term benefit, but does not create a permanent change. Of greater importance regarding supplements is that they are not regulated by any agency in the US. Therefore, the makers of supplements can make any claims they want with little or no downside. An interesting study performed at the Children's Hospital of Philadelphia examined the content of supplements and found that many of them had little or none of the product claimed to be present. This included some vitamin supplements. I actively encourage my patients to stop taking supplements before surgery since they can create problems such as bleeding after surgery.
(8c) Do you see any benefit in employing the use of growth factors (like Platelet Rich Plasma treatment) to achieve size? Also, do you believe there is any merit to the idea of PRP-therapies improving the result of a penis enlargement procedure?
This is a hotly debated topic. Like the other topics in this thread, there is little evidence to support the use of PRP. I am aware of anecdotal evidence for PRP, especially with hair restoration. As for its use in penis enlargement, there is, at present, no evidence that supports its use.
Mark P. Solomon, MD FACS
(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