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D. Fasano et al.
The quantity of fat to be harvested depends on the objective of the treatment: reshaping, localized augmentation, or
global augmentation. In our experience, corresponding with
the prevailing literature, the volume retention rate is at most
70% [25]. Because of this, 30/40% excess fat has to be
injected to obtain a satisfactory result. It is well known that
after centrifugation almost 50% of the fat is useless.
Considering all these aspects, if 100 cc of fat has to be
injected, between 250/300cc of fat has to be harvested. It is
evident, therefore, that the procedure is time-consuming, and
a standardized and well-organized team is important to
reduce the operative time.
36.3.2 Fat Processing
Fat tissue was always processed by centrifugation in 10cc
syringes (3300 rpm for 1 min), and after removing the
superior oily portion and the inferior serum bloody portion,
the intermediate pure fat portion was ready to be injected.
The procedure can be time demanding considering that in
some cases 4–10 centrifugation cycles can be necessary to
obtain an adequate quantity of graft. Despite this, in our
experience, this is the rst choice fat processing procedure
in terms of predictability of fat take and long-lasting volume maintenance.
In all the patients treated, a moderate overcorrection (30–
40% more) was obtained, avoiding excessive tension of the
skin envelope and the consequent ischemia of the underlying
fat.
Clinical experience and an adequate learning curve of the
technique are fundamental requirements for the procedure’s
success and predictability.
36.3.4 Postoperative Care
At the end of the surgery, a compressive garment was worn
in the donor site; compression of the breast was strictly
avoided.
The donor sites were treated as usual after a liposuction
procedure. A light bra was recommended for 1 month; after
this period edema and bruising were generally resolved.
Massages and breast manipulations were contraindicated.
36.4 Results
The results were considered stable after 3–4 months. In the
referred indications, the satisfaction rate has been high.
Secondary procedures have been uncommon in our experience because of the high satisfaction rate and the undesired
request for another procedure.
36.3.3 Fat Injection
Fat injection was made following the preoperative plan,
without anesthetic solution administration to the recipient
site. Several incisions were made to obtain a multidirectional
fat deposit. At the beginning, 10cc. Luer lock syringes and
Coleman small injection cannulas were used following the
“micro and multi tunnel” technique with the fat released
under light pressure in a multilayer fashion, as previously
described [13, 19].
If expansion is needed, “rigottomies” are extremely
important: a 16 gauge needle is inserted percutaneously in
multiple sites with radial multidirectional oscillations to cut
the brotic tissues and expand the donor site permitting a
better insertion of fat tissues [7, 10].
Fat was injected initially into the retroglandular plane to
augment the volume and in the subcutaneous plane to shape
the new breast as desired; the intra and retromuscular planes
were injected if necessary [33, 34]. The mammary gland was
avoided, but, in our opinion, the absolute avoidance of glandular injection seems to be illusory.
When most of the procedure was done, the patient was
seated to evaluate the result, and the appropriate corrections
were marked. The nal touch-up was performed with a 1cc
syringe.
36.4.1 Complications
Donor site complications appear to be minimal and related to
the liposuction technique.
Local complications of lipolling of the breast include the
palpable area of induration, fat necrosis, oil cysts, calcications, and infections.
In a systematic review of 42 articles published up to
2014, the reported complication rates were low (<15%);
lipolling can lead to initial complications, including infections, hematoma, inammatory reactions, and wound
dehiscence. Very few media to long-term complications
have been reported, but the average follow-up was limited
to 22months [35].
In a review of 24 studies, 207 complications were
reported and fat necrosis accounted for 62% of all complications [36].
In another review of 22 articles, 3565 patients with follow- up periods ranging from 12 to 136months were included.
The complication rate was 17.2% and the most frequent was
indurations (33.3% of all complications), followed by persistent pain (25%) and hematoma (16.4%), fat necrosis (6.6%).
Mammograms revealed microcalcications (9%) and macrocalcications (7%) [25].
36 Simultaneous Body Liposuction andBreast Remodelling by Fat
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477
Case 1 (Fig. 36.1) 21 years old, female, 167 cm height,
70kg, with a weight loss of 20kg by diet, stable for 1 year.
She presented with a breast asymmetry with right breast ptosis and left breast relative hypoplasia, with a presumed difference of 150cc. She had localized fat deposits in the inner
thighs and skin laxity. The planned treatment was harvesting
fat from the inner thighs, inner thigh lift according to
Pascal—LeLouarn, right round block mastopexy, and left
breast 250cc fat injection according to the presented technique. Postoperative result at 1 year.
Case 2 (Fig. 36.2) 31 years old, female, 160 cm height,
72kg weight, with a weight loss of 25kg by diet, stable since
1 year. She presented with breast ptosis with an empty skin
envelope and important fat deposits in the lateral thighs and
the inner thighs with skin laxity. She did not want implants,
but just remodeling of the breast. The planned treatment was
harvesting of fat and liposuction of the lateral and inner
thighs with an inner thigh lift according to Pascal—
LeLouarn, superior pedicle vertical mastopexy and fat transfer in the medial quadrants to reduce the intermammary
distance with an injection of 130cc per side and in the upper
quadrant to achieve more fullness of the upper pole with an
injection of 100 cc per side. Postoperative result at 1 year
(Fig.36.2).
Case 3 (Fig. 36.3) 26 years old female, height cm 166,
weight 63 kg.
Diagnosis: Left Poland syndrome, right ptotic breast with
severe asymmetry.
abc
de fg
hjk
Fig. 36.1 Breast asymmetry with right breast ptosis and left breast hypoplasia, with fat deposits in the inner thighs and skin laxity. (a–d)
Preoperative. (e, f) Operative plan. (g–k) Result a 1year
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ab c
de f
D. Fasano et al.
gh
Fig. 36.2 Breast ptosis with an empty skin envelope after 25kg loss and important fat deposits in the lateral thighs and in the inner thighs with
skin laxity. (a–d) Preoperative. (e–h) Result at 10months
The planned treatment was:
Left side: Periareolar approach, insertion of a round full
projection silicone gel textured breast implant (360mL) in a
sub-glandular pocket, and fat grafting to the anterior axillary
pillar and upper/inner breast pole. 290cc of pure fat were
injected basically in the subcutaneous plane.
Right side: Periareolar approach, insertion of a round
medium projection silicone gel textured breast implant
(220mL) in a type I dual plane pocket, and nal periareolar
mastopexy.
Fat donor site: Abdomen, anks, and inner thigh (900cc).
Case 4 (Fig.36.4) 34 years old man (transgender), height
cm 178, weight 82kg.
Patient wishes: Breast volume augmentation without an
implant to improve shape and volume despite hormonal therapy and trunk remodelling.
Planned treatment was:
Liposuction of the abdomen, anks, and back. 1900mL
of fat tissue were collected, prepared according to the
described technique and injected into the breast (320mL in
the right side and 340mL in the left one), basically in the
subcutaneous plane.
36 Simultaneous Body Liposuction andBreast Remodelling by Fat
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abc
def
g
479
Fig. 36.3 Left Poland syndrome, right ptotic breast wity severe asymmetry. (a–c) Preoperative. (d) Operative plan. (e–g) Result at 4months
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ab c
de
D. Fasano et al.
hjk
Fig. 36.4 Transgender looking for breast volume augmentation without implants and trunk remodelling. (a–d) Preoperative. (e, f) Operative plan.
(g–j) Result at 4months
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Penis Enhancement andReshaping
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withAutologous Fat
LittaraAlessandroGiuseppe andMeloneRoberto
Contents
37.1 Introduction 483
37.2 Penile Size 483
37.3 Anesthesia 486
37.4 Surgical Procedure 487
37.5 Results 489
37.6 Discussion 492
37.7 Conclusions 497
References 497
37
37.1 Introduction
Male genital image is correlated, albeit not in a necessarily
linear manner [1], to overall body image, psychosocial variables and sexual health [2]; in turn, sexual health is correlated to genital image [3]. Concern over genital endowment
has archaic roots [4, 5]. It typically emerges during adolescence [6, 7] and is triggered more by comparison among men
than by the fear of not satisfying the partner [8]. Discomfort
over genital size can inuence satisfaction and men’s sexual
function and push them to look for surgical and non-surgical
solutions for penis alteration.
37.2 Penile Size
The remarkable differences in the penile measurements
reported by various authors can be explained by the methodological differences and the variety of the characteristics,
even ethnic, of the populations studied (Tables 37.1 and
37.2). Furthermore, these measurements were rarely con-
ducted on statistically adequate samples. The availability of
L. A. Giuseppe (*) · M. Roberto
Sexual Medicine Center, Blumar Medica, Milan, Italy
e-mail: info@robertomelone.it
regulatory data per dened population would be essential
not only for diagnostic and therapeutic purposes but also to
reassure patients who display feelings of inadequacy [1, 7,
15, 46] and to manufacture correctly sized prophylactics
[20]. Penis size is an anthropometric measurement [19] and
is correlated to anthropometric measurements such as
height, weight, and body mass index (BMI) [19, 29]. These
measurements are intercorrelated [29] and they are polygenic traits subject to multifactorial inuences [31]
(Figs.37.1 and 37.2).
Men’s satisfaction and sexual function is inuenced by
discomfort over genital size which leads to seek surgical and
non-surgical solutions for penis alteration. We report the
results of a retrospective study of 355 cases of enlargement
phalloplasty. We found a signicant improvement in circumference at rest at 2, 6, and 12months post-surgical procedure
(all p <0.0001). This study is clinically relevant due to the
large cohort of patients.
This study was registered on 04/04/2017 (ISRCTN number: ISRCTN60774878), and 355 men participated in this
retrospective clinical study. They came to our center in Milan
(Italy) for a cosmetic phalloplasty. The patients’ medical history was gathered, and they underwent a medical examination that included an objective examination of the external
genitals and the prostate, routine blood tests, basal penile
ultrasound scan to verify the presence of nodules, plaques, or
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A. Di Giuseppe et al. (eds.), Fat Transfer in Plastic Surgery, https://doi.org/10.1007/978-3-031-10881-5_37
483
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Table 37.1 Global published data of mean penile size (excluding self-reported measurements)
First author, year Country N Age (years; range) FPL (cm) SPL (cm) EPL (cm) FPG (cm) EPG (cm)
Loeb (1899) [9] Germany 50 17–35 9.41
Schonfeld (1942) [10] USA 71 18–19 13.11 8.50
54 20–25 13.02
Kinsey (1948) [11] USA 2770 20–59 9.07 15.05
Aimani (1985) [12] Nigeria 320 17–23 8.16 8.83
Bondil (1992) [13] France 905 17–91 10.07 16.74
Da Ros (1994) [14] Brazil 150 14.05 11.92 Proximal
Wessells (1996) [15] USA 80 21–82 8.85 12.45 12.89 9.71 12.3
Smith (1998) [16] Australia 184 15.71
Chen (2000) [17] Israel 55 21–78 8.03 12.05 13.06
Adaikan (2000) [18] Singapore 208 8.05 12.03 8.0
Ponchietti (2001) [19] Italy 3300 17–19 9.0 12.5 10.0
Schneider (2001) [20] Germany 111 18–19 8.60 14.48 9.68
32 40–68 9.22 14.48 9.02
Sengezer (2002) [21] Turkey 200 20–22 8.98
Shah (2002) [22] UK 104 17–84 13.0
Spyropoulos (2002) [23] Greece 52 19–38 12.18
Son (2003) [24] Korea 123 19–27 6.9 9.6 8.5
Savoie (2003) [25] USA 124 59.1 (avg.) 9.0 13.0
Pereira (2004) [26] Portugal 498 20:26 9.85 15.14 9.39
Awwad (2005) [27] Jordan 271 17–83 9.3 13.5 8.98
109 22–68 7.7 11.6 11.8
Mehraban (2007) [28] Iran 92 20–40 11.58 8.66
Promodu (2007) [29] India 500 18–60 8.21 10.88 13.01 9.14
Kamel (2009) [30] Egypt 949 12.9 8.9
78 11.2 8.8
Nasar (2011) [31] Egypt 1000 8.37 13.77 10.48
Khan (2012) [32] Scotland 609 16–90 10.2 14.3
Söylemez (2012) [33] Turkey 2276 18–39 8.95 13.98 8.89
Chen (2014) [34] China 5196 6.5 12.9 8.0
311≈
Shalabi (2015) [35] Egypt 2000 22–40 13.84
Veale (2015) [36] UK 15,521 17–91 9.16 13.12 9.31 11.66
Habous (2015) [37] Saudi Arabia 778 20–82 12.53/14.34 11.50
Salama (2016) [38] Egypt 239 7.4 11.8 8.7 11.3
Hussein (2017) [39] Afghanistan 223 9.8 12.6
FPL accid penile length, SPL stretched penile length, EPL erect penile length, FPG accid penile girth, EPG erect penile girth, (avg.) average
12.9 10.5
L. A. Giuseppe and M. Roberto
11.05 Distal
Table 37.2 Global published data of mean penile size (self-reported measurements only)
First author, year Country N Age (range) FPL (cm) SPL (cm) EPL (cm) FPG (cm) EPG (cm)
Richters (1995) [40] Australia 156 15.99
Bogaert (1999) [41] USA 935 30 (avg.) 10.41 16.4 16.4 9.65 12.57
Harding (2002) [42] UK 312 15.25 12.55
Schaeer (2012) [43] Middle East 804 15.6
Herbenick (2013) [44] USA 1661 17–91 14.15 12.23
Shaeer (2013) [45] USA 1133 52.38 (avg.) 13.1 15.6 16.3 10.6
FPL accid penile length, SPL stretched penile length, EPL erect penile length, FPG accid penile girth, EPG erect penile girth, (avg.) average
4187 30 (avg.) 9.83 15.6 9.40 12.19
37 Penis Enhancement andReshaping withAutologous Fat
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485
Length dimensions (cm)
22
20
ERECT
18
FLACCID
16
14
12
Penile Size
10
8
6
4
2
0
0% 10 20 30 40 50
Girth dimensions (cm)
17
15
13
11
9
7
5
0%
Source: The Authors of the Veale paper, BJU international
(1) Veale, 2015
Percentile of sample
ERECT
FLACCID
10 20 30
40 50 60 70 80 90100
60 70 80 90 100
Average length
FLACCID
9.16 cm
(3.6 in) (5.21 in)
Average girth
9.31 cm
(3.66 in)
Fig. 37.1 Average measured normal measures, in adult male
ERECT
13.24 cm
11.66 cm
(4.59 in)
Average measured
“normal” measures,
adult male
(1)
FLACCID ERECT
Penile Size
(1) Wessels, 1996; (2) Francoeur, 1991; (3) Klein, 1999
Fig. 37.2 Range of reported measure, adult male
Penile Length
Penile Girth
(circumference)
Range of reported
measures, adult male
Flaccid (cm)
7.6–13.0
8.5–10.5 11.3–13.0
Erect (cm)
12.7–17.7
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L. A. Giuseppe and M. Roberto
lesions in the internal tissues of the penis and measurement
of the circumference of the penis at rest (accid). All patients
signed the informed consent to undergo the procedure and
for the video to be published.
Measurement was always performed in the same room,
by the same operator, and using the same exible measure
after a brief introductory interview, performed to put the
patient at ease. The measurement was performed before the
ultrasound scan to avoid variations caused by changes in
temperature. The circumference of the penis was measured
at rest at mid-shaft. In all cases (100%), we found that the
measurements were coherent with the morphometric values
of reference of adult men according to Wessels and Ponchietti
[15, 19] and this information was shared with the patients.
After measuring height and weight using routine methods
employed in the clinical setting, the general medical examination continued with an in-depth interview conducted in
order to investigate the patients’ motivations and his expectations, discuss the foreseen method and the results and provide in-depth answers to the patients’ questions. A meeting
between the patients and the anesthetist occurred separately.
At the end of the general examination, patients received
instructions to be followed the night before and the morning
prior to the surgical operation. In addition, we gave our availability to answer the patients’ questions at any time until the
procedure. The information summarized in Table 37.3 was
also discussed with all the patients during the general medical examination.
Table 37.3 Information regarding the enlargement phalloplasty discussed with the patients during their general examination
Elements discussed by the physician with the patients during the
general medical examination
(a) The estimated results given by our center (+20–35%
circumference) refer to an increase between a minimum and
maximum obtained from a historic average of all the patients
operated. The availability of a vast collection of pre- and postsurgical photographs shown during the general examination
conrmed such variability
(b) It is possible that an increase cannot be achieved following the
procedure and the achievable increase in each case can only be
partially foreseen and depends on subjective variables such as
metabolism and lifestyle which can increase or accelerate the
reabsorption of the implanted fat
(c) The increase acquired is markedly more visible in conditions of
accidity than in erection, with a ratio of about 2:1
(d) Occasionally, implanted fat can be subject to excessive
reabsorption during the rst 3 months after surgery and in that case,
if the patient wishes, a new denite transplant can be performed
(e) In enlargement phalloplasty the different consistency between
the fat and the cavernous bodies causes a change in the tactile
consistency of the penis; along the shaft, such change is progressive
so that no “steps” are felt, and there is no variation in the quality of
the erection or local sensitivity
(f) Exceptionally, nodularity can occur in the implanted fat; such
nodularity is, however, transitory and almost always resolves
spontaneously
The enlargement cosmetic phalloplasty candidate is a
healthy and potent man with no congenital or acquired
abnormalities or urogenital diseases. In this study, exclusion
criteria were:
(a) Coagulopathies, cardiopathies, neoplasies, chemo-
radiotherapy, infections in progress, prior pelvic surgeries for urogenital conditions or trauma, severe systemic
conditions and psychiatric conditions
(b) Unrealistic expectations; patients who requested results
superior to those declared by the center or who felt entitled to obtain the maximum penile increase within our
historic series were excluded
(c) Revision surgery; patients requesting a re-operation
because of the failure of a previous cosmetic phalloplasty were excluded
(d) True hypoplasia (micropenis) dened as length <2.5 per-
centile points according to Mondaini [6] (these patients
were referred to an andrology center)
(e) Signicant anxiety, distorted body image, a history of
suicidal thoughts and/or attempted suicide linked to presumed genital inadequacy with psychogenic sexual
dysfunction.
The time that elapsed between the rst examination and
the surgical procedure was 2–6months. Among the motivations for seeking this surgical procedure, the most frequently
cited by patients were psychological discomfort in homosocial situations, discomfort towards women—almost always
linked to one or more devaluing observations made during
intimacy, the desire to “dazzle” women, the well-founded
perception that genital size was incoherent with their body,
the desire to improve an already generous natural endowment for narcissistic or professional reasons, the desire for
better correlation or proportions between dimensions at rest
and during erection, and the desire to move from the lowest
limits of the normal range towards the morphometric median.
The most common concerns relative to the operation, which
coincided with the patient expectations from the procedure,
were: (a) the surgery “beyond suspicion,” (b) the preservation of the quality of erection and local sensitivity, (c)
achievement of the mathematical average of the declared
results, in terms of the circumference, and (d) the result aesthetically impeccable.
37.3 Anesthesia
The choice of anesthesia for cosmetic phalloplasty must be
in line with the criteria of clinical adequacy, minimum invasiveness, and rapid discharge. Among the different choices
of anesthesia, a vast array of scientic documentation [47]
exists to support the decided clinical advantages of sedation
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