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a b c
Figure 10: Case 4. preoperative and 3 years postoperative view of girth enhancement with fat grafting in two sessions (30 + 40 mL). (a) Preoperative;
(b) 3 years postoperative; (c) pinch of implanted fat

for a long time. The racial controversy introduces
more variables, which can influence decisions
about justifying augmentation phalloplasty. [5,6] The
enhancement of penis size can be achieved using
surgical or nonsurgical procedures. Unfortunately the
uses of unproven techniques or synthetic fillers have
made these treatments notorious for their sequelae or
bad results. Nonsurgical techniques that use traction a b
[7]
by weights have been employed by many cultures Figure 11: Case 5. preoperative and 9 months postoperative view of
over the centuries and are based on cultural, religious girth enhancement with fat grafting (35 mL of fat). (a) Preoperative;
(b) 9 months postoperative
or aesthetic purposes. [8,9] The modern age of these
treatments began at the end of the 1990’s with the JES
Extender device. These techniques exploit the ability
of tissues to respond to physical stimuli as traction
or expansion with hyperplasia and cell division,
a well‑known behavior used by plastic surgeons
worldwide.
As in any medical or surgical procedure using expansion
or distraction, while using a penis extender a pulling
force of a certain intensity must be applied and must be
as continuous as possible and for a minimum time period
and hence that the biological phenomena responsible for
tissue modification are started. The use of these devices a b
often requires a great deal of diligences on the part of
patients to get results that are minimally satisfactory. Figure 12: (a) Preoperative view of fat graft overgrowth due to 26 kg of
weight gain 4 years after girth augmentation; (b) intraoperative view of
Erosions are sometimes produced by traction ring or complete lipectomy
by irregular use of the device and are some of the
factors that negatively affect the results, which may be available grafts (fat or dermofat grafts) or biological
minimal. In any case, an adequate knowledge about the implants (acellullar dermis) around the penis shaft
management of these devices must be present in the outside the albuginea and under the dartos fascia. More
armamentarium of the surgeon performing phalloplasties, advanced techniques using resorbable matrices together
since it can be an extremely useful complement to the with autologous fibroblasts have also been described
surgical procedure to secure, maintain and/or improve with good results. [12,13] Albugineal techniques get good
the outcome. The author always uses traction as an results in erection but none in flaccidity. The injection
[14]
adjunct to surgical treatment and never as a stand‑alone of synthetic fillers is probably one of the options
treatment. that are frequently performed, but may cause many
As in the case of surgical lengthening, there is not a deformities and complications. All of these techniques
single surgical solution to increase the thickness or are more invasive and thus can yield a greater number
perimeter of the penis. [10,11] Pericavernous techniques and severity of complications. Fat grafting is probably
provide girth augmentation in flaccid penises but little the least aggressive technique but requires fine control
or no improvement in erection. These techniques try to and technique to avoid complications and poor results.
obtain an increase in girth by implanting some of the It was introduced as a technique for girth enhancement

Plast Aesthet Res || Vol 2 || Issue 1 || Jan 15, 2015 31