Intimate male surgery in Paris

Demand for penile enlargement for aesthetic purposes has increased considerably over the last ten years. The probable reason for this increased demand is the explosion of exposure of the genitals in pornographic photos or films on the Internet, in the press and in activities such as steam rooms and spas (which are on the increase in Western countries).

Phallocentrism is the concept that the penis is central to male identity. Unlike in ancient Greece, where small phalluses were valued, the male sex is now considered to represent virility, strength and youth.

There are currently 2 techniques for penile circumference augmentation: surgical penoplasty using lipofilling and medical penoplasty using hyaluronic acid. The highly effective procedures involving implanting a prosthesis in the corpora cavernosa are only indicated in cases of associated erectile dysfunction or buried penises with impaired function.

The medical literature on penoplasty using lipofilling and hyaluronic acid is fairly sparse and does not allow us to draw any formal conclusions.

The main objective is to restore a man’s confidence, particularly in the flaccid state (at rest), by improving the volume of the penis. The circumference can be increased by 2 to 3 cm, and by making the penis heavier, an increase of up to 1 cm in length can be seen with either lipofilling or hyaluronic acid.

However, this procedure does not improve sexual capacity and has no impact on sexual or urinary function. Although it has been shown that a feeling of confidence about the size of the penis can improve erectile capacity through psychological processes.

The main indication in aesthetics is the ‘vestiary complex’, i.e. a feeling of shame or embarrassment about the size of one’s sex at rest. Certain situations put patients at risk: sports changing rooms, public swimming pools where swimming trunks must be worn, saunas or steam rooms, prisons….

The average size (in Caucasians) in circumference when flaccid is 9 cm and 11 cm when erect; in length 9 cm when flaccid and 14 cm when erect.

There are 3 categories of penis size of interest to us for this procedure:

Micropenis: the size in erect length is less than 8 or 7 cm depending on the references. The treatment of a micropenis by cosmetic procedures is very often disappointing.

The small penis is situated at the lower limit of 2 cm below the average, i.e. between 7 and 9 cm in circumference in the flaccid state. This is the indication of choice in terms of satisfaction and quantity of products to be used.

The normal-sized penis is between 9 and 11 cm in circumference in the flaccid state. There is a real complex developed despite reassuring measurements. A penoplasty can be performed in this case if there is a strong demand with psycho-social repercussions, provided that a ‘Body Dysmorphic Disorder’ (BDD) is ruled out. A consultation with a sexologist is then recommended.

There may be purely aesthetic requests from patients with a larger-than-normal penis, but the quantity of products to be used to obtain a homogeneous result is significant. The benefit-risk balance must always be assessed.

This is a procedure that helps to restore a man’s confidence, particularly in the flaccid state (at rest)2. Some men may have lost confidence in their virility, particularly when comparing their sex with that of others, during military service or in the changing rooms of sportsmen and women, etc.

This procedure does not improve sexual ability or pleasure for the partner. Female orgasm is in no way dependent on penis size. Some studies have shown that a 5 cm penis is capable of fulfilling its physiological and reproductive functions. The request for lengthening or enlargement must come from the patient and not from his partner.

The figures put forward by the press and the pornography industry are incorrect. On average, the length of the penis in the flaccid state is 9 cm, and 14 cm when erect; in circumference (this is the perimeter and not the diameter), the size of the penis is 9 cm in the flaccid state and 12 cm when erect. These measurements are taken from American and European publications. Contrary to popular rumour, it has been scientifically demonstrated that shoe size is not correlated with penis size.

The consultation, of at least 2, should identify the patient’s precise expectations.

Four measurements are essential, as are photos. The length is measured on the dorsal surface of the penis, from the base at the pubo-penile junction to the urinary meat, in the flaccid state, semi-erect or ‘stretched’ (the penis is pulled 3 times) and erect (ask the patient to take the measurement at home when fully erect). The circumference is measured using a flexible tape measure at the middle part of the penis.

It is also necessary to look for genital malformations and the existence of plaques that may cause curvature (Lapeyronie’s disease).

Analysis of the foreskin is essential: circumcised, narrow or phimosis, etc. Phimosis must always be treated beforehand by partial circumcision.

If the foreskin is tight or narrow, the procedure should be discussed: partial posthectomy or manual dilatation using retractor rings (Phimostop, Phimocure, etc.).

Dermatological analysis of the glans penis and the balanopreputial fold is necessary for prior treatment or to rule out surgery: atrophic lichen sclerosus, malignant lesions, condyloma, herpetic disease, etc.

A urological, dermatological, sexological or psychological assessment may be necessary before any operation.

The contract must be clear about possible expectations and the patient’s commitment to comply with post-operative instructions.

• Psychiatric disorders
• Phimosis, paraphimosis
• Lapeyronie’s disease
• Erectile dysfunction treated by intra-cavernous injection.
• Haemostasis disorders
• Local acute infectious or inflammatory disease

Injection of HA is a good alternative to lipofilling when the patient is very thin or does not wish to undergo surgery and includes repeating the procedure every year or every 2 years depending on the product used. The ideal product is a good quality, cross-linked HA with good biointegration, with the ability to shape itself and which lasts over time (ideally 2 years). These injections are carried out under local anaesthetic in consultation under strict sterile conditions. You should allow at least one hour for this type of injection. Assistance may be required to ensure that the balanopreputial groove is correctly exposed so that the cannula can be correctly inserted into the sheath of the penis. It is essential to apply a thick layer of topical anaesthetic one hour before the injection. In case of pain or stress, Méopa can be inhaled.

It is not necessary to inject lidocaine at the injection port if the topical preparation has been carried out correctly. In the event of difficulty, however, a penile block can be performed at the base of the penis. The injection is made in the same way as lipofilling against the albuginea without damaging it, as there is a risk of haematoma; in a retrotractive manner in the radii of 1h, 5h, 7 and 11h to avoid the vascular-nervous pedicle at 12h and the urethra at 6h. The amount of HA (between 10 and 20 ml) depends on the patient’s anatomy. A larger quantity should be anticipated for normal or large sized penises to obtain a homogeneous result. A massage or modelling dressing is necessary at the end of the procedure. The result is visible rapidly after the disappearance of the lidocaine. The final result is visible after 1 month. A touch-up may then be necessary. It is not uncommon for results to persist after 2 years.

• Performed under local anaesthetic, in consultation.
• Predictable early results.
• Reversible procedure if required: Hyaluronidase
• Possibility of supplements or touch-ups in consultation
• Possibility of treating very thin patients

• Temporary penoplasty to be repeated
• High cost of between €2,500 and €5,000.
• Risk of inflammation in the event of infection

The procedure is performed under general anaesthetic or spinal anaesthetic. On average, between 40 ml and 80 ml of micro lipofilling must be injected to obtain a satisfactory result in the long term. Injection is performed using a cannula with retro-tracking.

A modelling dressing is necessary.

The average fat loss is 30 to 50%. Post-operative oedema disappears in less than 6 weeks. Enlargement may therefore appear impressive immediately after the operation, but this is not the final result.

• Permanent penoplasty
• The cost
• Autologous product taken extemporaneously
• Improvement of trophicity by fat stem cells
• Secondary benefit of liposuction
• Addition of a penile lengthening procedure during the same operation

There are currently 2 techniques for penile circumference enlargement: surgical penoplasty using lipofilling and medical penoplasty using hyaluronic acid.

The scientific literature does not allow us to decide between medical and surgical penoplasty. The choice of technique must depend on the patient and his or her morphology.

Lipofilling remains the method of choice for permanent penile enlargement. Hyaluronic acid is an interesting alternative, but has a number of disadvantages, such as shelf life, lack of CE marking in this indication, cost, etc.

In summary, for a patient who is overweight and/or requires liposuction of the abdomen or pubis and/or needs a procedure to lengthen the penis, we would opt for penoplasty by lipofilling.

For slim or undecided patients, hyaluronic acid is the preferred option.

The suspensory ligament of the penis is extended between the lower part of the pubic symphysis (4 to 5 cm below the skin) and the dorsal surface of the penis.

A V-shaped incision is made halfway between the lower part of the symphysis and the penis to avoid damaging the vasculo-nervous pedicle of the penis and to lower the V towards the scrotum. The ligament is resected transversely in a subtotal manner to maintain erectile stability.

This section allows a lengthening of 1 to 2 cm. The dissection space may give rise to a hematoma, which needs to be filled.

Closure is achieved by a V-Y plasty in order to increase the length of the cutaneous part.

At the penile-scrotal junction, there is a skin adhesion or scrotal web which can be the subject of a large Z-plasty in order to increase the length of the skin. The central bar of the Z should be placed on the midline of this web. A simple suture using separate stitches is all that is required.

The above techniques are combined with a cure for pubic ptosis if necessary. The cure of pubic ptosis consists of a cutaneous fatty resection of the pubis. The scar is hidden in the abdominal fold.

With ageing and obesity, the penis can tend to bury itself in the pubis. This can have major psychological and functional consequences: the inability to urinate while standing, or even to soak oneself, or to have penetrative sexual intercourse.

Hygienic and dietary rules are very important. To improve these patients,

We can also combine penile lengthening techniques with a pubic lift if necessary.