Penoplasty in Paris
Intimate male surgery at Henri Mondor Hospital
Penoplasty in Paris
Plastic, Reconstructive & Aesthetic Surgery in Paris Est Créteil
Demand for penile augmentation 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 hammams and spas (which are on the increase in Western countries).
Phallocentrism is the concept that the penis is central to male identity. Unlike the ancient Greeks, when small phalluses were valued, the male sex is now considered to represent virility, strength and youth.
However, this aesthetic augmentation procedure is controversial. The fact that practitioners have been criticised in the media and that the International Society of Sexual Medicine has made no recommendation in favour of this procedure should make us all the more vigilant.
Intimate male surgery
Penoplasty specialist in Paris
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 definite conclusions.
Penoplasty in Paris
Pr Hersant Plastic, Aesthetic & Reconstructive Surgery
The objectives of widening penoplasty:
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.
What are the indications for penoplasty?
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 that interest 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 uniform result is significant. The benefit-risk balance must always be assessed.
What happens during the consultation for a penoplasty?
The consultation, at least 1 before the procedure, should identify the patient’s precise expectations.
Measurements are essential, as are photographs. Measurements are taken for length, 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 must be pulled 3 times) and erect (to be done at home). 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 prior to the procedure by posthectomy (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.
Contraindications must also be identified:
– BDD or psychiatric disorders
– Phymosis, paraphymosis
– Lapeyronie’s disease
– Erectile dysfunction treated by intracavernosal injection.
– Haemostasis disorder
– Local acute infectious or inflammatory disease
Medical penoplasty using hyaluronic acid (HA) injections:
HA injections are a good alternative to lipofilling when the patient is very thin or does not wish to undergo surgery. The procedure is repeated every year or every 2 years, depending on the product used.
Unfortunately, there is still no CE-marked HA in this indication, and the practitioner is liable if there is a complication linked to the product. In the only 2 scientific articles with a sufficient cohort of patients, the HA used were Restylane Sub Q and Macrolane (which is no longer authorised in France).
It should also be borne in mind that the injection is made into an avascular plane, which is therefore a poor recipient site. Ideally, the HA should be of good quality, reticulated, with good biointegration, with the ability to be modelled 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, and a thick layer of topical anaesthetic must be applied one hour before the injection. In the event 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 done correctly. However, in the event of difficulty, a penile block can be performed at the base of the penis.
The use of a rigid cannula of good calibre is essential. The injection is made in the same way as lipofilling against the albuginea without damaging it, as there is a risk of haematoma.
The quantity 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, but the final result can be seen after one month.
In the event of complications, there is an antidote to hyaluronic acid called hyaluronidase. It is not uncommon for results to persist after 2 years.
The advantages of penoplasty over lipofilling :
Performed under local anaesthetic, in consultation.
Predictable early result.
Reversible procedure if necessary: Hyaluronidase
Possibility of top-ups or touch-ups in consultation
Possibility of treating very thin or athletic patients
Disadvantages of penoplasty compared with lipofilling
- Temporary penoplasty to be renewed
- Use of a foreign body with risk of biofilm
Surgical penoplasty using lipofilling
This is a procedure performed under general anaesthetic or spinal anaesthetic. An average of 40 ml to 80 ml of micro lipofilling (fat) must be injected to obtain a satisfactory result in the long term.
Like medical penoplasty, it is necessary to inject with a cannula in contact with the albuginea but without breaching it and to be tangential to the penis. The injection is made in a retro-traceable manner.
Massage is recommended in order to distribute the fat correctly and do not hesitate to ‘knead’ between the 2 hands in the transverse plane to avoid the appearance of fatty deposits. A second operation may be necessary to complete the operation.
A modelling dressing is necessary. Urinary catheterisation is not recommended.
On average, 50% of the fat is likely to disappear and post-operative oedema disappears within 6 weeks. The enlargement may therefore appear impressive immediately after the operation, but this is not the final result.
The advantages of penoplasty over HA
Permanent penoplasty
Autologous product (own cells)
Improvement in skin quality by fat stem cells
Secondary benefit of liposuction
Addition of a penile lengthening procedure during the same operation
Disadvantages compared with hyaluronic acid
Less predictable results (depending on the quality of the lipofilling)
Late final result
Risk of oily cysts
Need for a 2nd operation in the event of dissatisfaction or complications
Conclusion
The medical 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 and cost.