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simultaneously or in stages. If it is assumed that the penis signed the corresponding informed consent. The age of
is a cylindrical body, a more successful outcome should patients ranged from 23 to 57 years with a mean age of
seek to increase the entire volume (diameter and length) 38 years. All cases of girth enhancement with fat grafts
than only one of the dimensions [Figure 1]. There is only were performed under local anesthesia with sedation on an
one exception to this approach which is the treatment of ambulatory basis; composite phalloplasty were performed
a buried or partially buried penis. In this case, given the under spinal anesthesia on an ambulatory basis as well. All
importance of adequate pubic skin redraping and marking pre and postoperative measures and pictures were taken in
the new peneopubic angle, the author recommends girth forced flaccidity (applying a light traction on the penis for
enhancement in a second staged step. about 3 s). Postoperative measurements were scheduled on
the day after the operative procedure and again at 1, 4, 6,
An important factor that is difficult to standardize is the and 12 months postoperatively.
measurement of penile length and girth in flaccidity and
erection. Several ways to do this are postulated, with the Girth enhancement with fat grafting
main objective of obtaining an accurate estimate of the The technique of fat grafting used in this series has been
increase in these measures in postoperative follow‑up for published previously. [2,3] Briefly, lipoaspirate is harvested
comparative purposes. As a general rule the established with a 20‑hole 3 mm cannula (Quirumat, Spain). The
mean normal values of flaccid length are between 7.2 cm lipoaspirate is washed with Ringer’s lactate, and layer
and 11.0 cm measured from the peneopubic angle to the separation is obtained by decanting for about 30 min. Once
tip of the glans, with an average of 9.5 cm. A normal girth processed, the washed fat is injected under the dartos and
will vary between 7.7 cm and 12.0 cm, with an average Buck’s fascia. The engrafting process must be performed
of 9.56 cm. It is extremely important that the surgeon with extreme caution, placing fat fragments of no
[1]
standardize the method for taking these measurements to > 3 mm in diameter to ensure a proper take and prevent
maintain consistency in daily practice. necrosis and cyst formation. Whether girth enhancement
is performed alone or in combination with suspensory
The author presents his experience in a retrospective ligament release, the infiltration cannula is advanced
study of 275 augmentation phalloplasty procedures. from the peneo‑pubic angle towards the preputial skin or
The final analysis focuses on the main increase in penis circumcision scar. The fat is injected in a retrograde fashion
measurements (girth and length) in the flaccid state and and distributed all around the girth; this is tailored to the
the stability of improvement over time. needs of each patient, from the peneo‑pubic angle to the
coronal sulcus scar (if the patient is circumcised) or to the
METHODS foreskin proper (if he is not circumcised). The distribution of
fat is particularly important in the penis foreskin to prevent
The author analyzed retrospectively the outcomes of unaesthetic nodules or bulges or the presence of an offset
275 augmentation phalloplasty procedures performed in devoid of fat when the patient removes the foreskin. This
259 patients. The main motivation for all patients was to technique can be performed alone (127 + 16 cases in our
achieve greater penis size without the development of any series) or preferably at the same time as the suspensory
form of impotence or sexual dysfunction. Mean preoperative ligament release (148 patients in our series).
penis dimensions in the flaccid state were 8.9 cm in
girth (range, 6.5-10.2 cm) and 9.2 cm in length (range, The behavior of fat grafted to the penis is mostly the
7.4-12.2 cm). Of the 275 procedures, 127 underwent girth same as when performed in other body areas. Although
enhancements with fat grafting and 148 were undertaken postoperative swelling usually takes about 6 weeks to
for composite phalloplasties (girth enhancement with fat disappear, the volume loss in the grafts should stabilize
grafting and length improvement by suspensory ligament by 3-4 months; at this timepoint the improvement in girth
must be stable.
release). In 16 patients, these procedures were performed
in two surgical stages, not < 6 months apart. All patients Composite augmentation phalloplasty
Figures 2 and 3 summarize the sequence of steps
performed during suspensory ligament release as done in

a b
Figure 1: The penis can be approximated to a cylinder, and thus,
enhancement of girth and length at the same time improves real volume. Figure 2: (a) Anatomy of the suspensory ligament: (A) deep neurovascular
From left to right: original size, length improvement, girth improvement, bundle; (B) suspensory ligament; (C) surgical approach. (b) Pick‑ups are
both simultaneously shown grasping the most caudal and superficial aspect of the ligament
28 Plast Aesthet Res || Vol 2 || Issue 1 || Jan 15, 2015