This patient has a couple of issues, and we will continue to work with him to improve the result.
The patient will see us sometime soon for more Ellanse at no cost.
We continue to be cautious about using Ellanse, particularly in regard to patients who have not tried Hyaluronic acid first.
This patient was the first in our clinic who jumped the HA step and went straight to Ellanse. The other approx 90 Ellanse patients who preceded him were all original HA patients and none have had significant problems with HA or subsequently with Ellanse.
We think that patients should first try HA to see whether they have any aspect of their anatomy that is unusual or more likely to lead to sub-optimal results.
In some patients, dermal filler is more likely to migrate, particularly down to the foreskin region and it can be difficult to keep it out of there. Other patients have one or two circumferential bands of tighter tissue halfway down the penis, which resist expansion... after filler, it can look like the penis has a rubber band around the centre. Other patients have quite a lot of room in the layer in which the filler is injected, nearly until the foreskin when that layer abruptly tightens leading to a cliff edge. These problems and some others are best discovered first with Hyaluronic acid, a filler which we can easily dissolve.
In this particular case, Ellanse has migrated into the area under the foreskin, leaving two lumps. One lump was successfully reduced with Kenalog40, the other remains stubborn and Dr Horn is proposing to either excise it, or break it up using other surgical instruments. The patient also has a tight circumferential band of tissue just before the foreskin. Although our
aftercare instructions
for dermal filler are I believe sufficiently comprehensive, it is possible that I could have improved the outcome of this particular procedure by providing additional coaching on moulding and pressing filler out of the under foreskin region. This is a second reason to try HA first before Ellanse... to gain experience in moulding and aftercare with a reversible filler first, before proceeding to a filler which can't be altered (or at least not easily altered).
If a patient wishes to try Ellanse, they are recommended to first try a small amount of an inexpensive HA, for example, 8ml MD/Pluryal for £1,400 / US$1,800.
This is to make sure, using a very safe substance which we can easily reverse, that there is nothing unique about their anatomy which makes them a difficult candidate for dermal filler, and this also gives patients some practice with dermal filler moulding and aftercare. Ideally, they will like HA enough after trying it, that they will not bother with a higher-risk product.
After trying HA, if they still want to proceed to an Ellanse procedure, we will credit them half the cost of their HA practice round, against the price of the Ellanse procedure.
They can keep the HA, or have it dissolved away prior to Ellanse. This means it will have cost them an additional £700 / $900 to try HA first, I would do this myself, and as it happens, have done.
In other developments regarding Ellanse, the UK distributor Sinclair has told us that Ellanse E (4 years) is no longer available, and potentially Ellanse L (3 years) will also be withdrawn, leaving only the Ellanse S (1 year) and M (2 years). This takes away a lot of the benefit of the product in terms of longer duration. However, I believe the main benefit of Ellanse remains the hardness, the difference being particularly noticeable versus HA when we start to talk about more than a 0.75 inch / 2 cm gain in circumference.
