PENOPLASTY OR PENILE AUGMENTATION ON NUN’S ISLAND, IN MONTREAL
Lipopenosculpture for Thickening and Lengthening in Montreal
The demand for penile augmentation has been steadily increasing for many years. In order to meet this demand, it was important to devise a global strategy that takes into consideration the desires of patients as well as technical limitations.
The perception of the size of one’s penis often varies significantly from one patient to the other, depending on his age and socioeconomic milieu. However, embarrassment can be so great that it can turn into a complex and then an inhibition, to the point where it becomes a real hindrance to social and intimate interactions.
The size of the shaft varies greatly from one patient to another. When flaccid, the average shaft is 10 cm long and 9 cm around. When erect, it is on average 15 cm long and 12 cm around. The shaft is composed of four erectile structures and four sheaths. The erectile organs include two corpus cavernosa, which extend from the pubic bone to the gland; the corpus spongiosum, through which the urethra passes throughout its length; and the gland.
The four sheaths of the shaft, from the outside in, are as follows:
The skin, thin and very mobile
The dartos, a sub-cutaneous muscular layer
A highly vascularised cellular layer
A fibroelastic envelope, or fascia, that contains the corpus cavernosa and the corpus spongiosum
The shaft is connected to the abdominal wall, the pubic symphysis and the pubis thorough the suspensory ligament. It consists of three bodies – one medial and two lateral.
LIPOPENOSCULPTURE, OR LPS
Penile surgery has two components that can easily be combined: thickening and lengthening.
For decades, liquid silicone and other filler agents were used to thicken the shaft. These methods were ineffective and often harmful because of the formation of granulomas or the migration of the product.
Today, autologous grafting of adipose tissue, which is effective and non-harmful, is the safest and most reliable method.
EXTRACTION OF ADIPOCYTES
This is done at the level of the pubis, from the inner and outer thighs, the abdomen or sometimes the buttocks.
In fact, these sites are rich in adipocytes with a2 receptors, which are less sensitive to diet and weight fluctuations, contrary to adipocytes with b1 receptors (arms, thorax), thus allowing the graft to be maintained more effectively over time.
INSERTION OF THE GRAFT
We use a 1.2 mm diameter cannula. The cannula is mounted on a 10 ml syringe, placed in a pistol-shaped device designed for this purpose, with notches on its barrel which allow for the smooth and even distribution of the graft and control of the contours using low and uniform pressure.
The two entry points are in the ventral and distal parts of the body of the penis, in the preputial skin or the balanopreputial crease. We have chosen the entry points at the level of the balanopreputial crease, immediately below the gland, because that puts us naturally in the proper anatomical plane, and the procedure is easier than using a peno-pubic approach. The transplant is inserted all the way to the base of the penis, at the correct pubic angle. It must be deposited following the parallel spaces in each histological layer, between the skin and the tunica albuginea, without compromising the integrity of the dartos and Buck’s fascia.
The deposit consists of filling the sub-cutaneous spaces in equal quantities (averaging 0.5 cm³), placed in bays superimposed along the flaccid penis, without compromising the integrity of the sheaths. It is important to avoid depositing too much fatty tissue at the same time in order to limit the risk of cytosteatonecrosis, which may be unsightly and embarrassing for the patient. The usual amount grafted is between 50 and 70 cm³. During subsequent procedures, we graft 70% of the previous volume. It is also important to avoid inserting the graft too close to the surface, in order to avoid the risk of necrosis.
The procedure for lengthening the penis developed later, towards the 1980s, and is the result of the disinsertion of the corpus cavernosa from their attachment to the pubic bone, by sectioning the suspensory ligament. The use of these procedures has allowed the techniques to become standardised and reliable.
The surgical procedure of lengthening consists of performing a partial sectioning of the suspensory ligament of the shaft, a dissection and incision of the superficial areas of the medial and lateral fascia of the ligament and cutaneous reconstruction.
After measuring the girth of the penis at its base as a reference, we draw two vertical lines measuring 1 cm toward the tip, which we connect via a horizontal line. We incise the skin following these lines, and then extend the incisions toward the bottom of each side, also by one centimetre. We make two horizontal incisions at the natural peno-pubic folds. Once the skin is incised, the two lateral counter-incisions are opened up to allow for the first scaling of the penis toward the bottom. We dissect between the spermatic cords, which we are careful not to damage, to reach the fascia of the suspensory ligament that we section while maintaining contact with the pubic bone.
Having estimated the maximum detachment allowed within the space created, we fill the empty space between the bone and the corpus cavernosa with the funicular fat, in order to create a cushion that will prevent a possible secondary adhesion between the bone and the corpus cavernosa. We close the cutaneous incision by suturing the lateral angles of the initial incision at the external extremity of the lateral counter-incisions. This cutaneous reconstruction phase is crucial to maintaining the scaling toward the bottom of the initial incisions. In the end, the scar will present a vertical medial section and two lateral sections at the body of the penis.
The global LBS is performed under general anesthesia as outpatient surgery, and lasts an average of 30 minutes. The bandage is made from thick, non-compressive fat tulle and under an antibiotic cover. It is changed daily for 5 days.
Sexual activity is not recommended until one month after a global LPS, or two weeks after thickening alone. Patients are seen again at the clinic the day after the surgery, then again one week, one month, three months and one year later. Aside from overall penile enlargement, the main criteria for satisfaction are maintaining a natural look, maintaining an identical degree of sensitivity and the absence of embarrassment during sexual relations.
Irregularities in the insertion of the graft
Cosmetic problems related to these irregularities
Rejection of the fat graft
Frequent swelling (27 % of cases) with no ensuing problems. Uncircumcised patients must be informed of the possibility that swelling could prevent them from easily moving the foreskin for three to five weeks.
Separation of the scar tissue (10 % of cases) that heals in a few days
Cutaneous necrosis, extremely rare
Infections where the patient suffers no adverse consequences
Fibrosis, calcification, or fatty cysts
Granulomas caused by cytosteatonecrosis