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37 Penis Enhancement andReshaping withAutologous Fat

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methods associated with local and loco-regional anesthesia techniques. On the basis of such scientic support, we have opted for the following anesthesia protocol.

37.3.1 Sedation

Premedication: Midazolam 0.04–0.05mg/kg.

Induction: Fentanyl 0.7–0.8 g/kg + Propofol 0.8–

1.6mg/kg. Maintenance: Propofol 0.3–0.5mg/kg/h. Only in rare cases (n=6) it was necessary to use addi-

tional amounts of Propofol (0.5–0.8mg/kg) and/or Fentanyl (0.4–0.8g/kg) to guarantee adequate sedation.

37.3.2 Local Anesthesia

Anesthesia in the pubic and penile region was executed by the surgeon using deep inltration in the zone of the suspensory ligament of the penis and the cutaneous/sub-cutaneous zone affected by the surgical aggression:

Lidocaine 2%, 20mL. Mepivacaine/carbocaine 2%, 10 mL (total solution

30mL).

10mL of the above-mentioned solution was used in its

pure form for cutaneous and deep peri-nervous inltration, while the same was diluted in 230mL of 0.9% sodium chloride with 1mg epinephrine (1/250,000) for inltration in the subcutaneous region where adipocytes will be harvested. In our experience, such procedure resulted in being fully ideal for allowing surgical treatment, devoid of complications and major side effects, widely liked by patients and guaranteed brief protected discharge times (180±30min).

37.4 Surgical Procedure

37.4.1 Fat Harvesting andPurication

Prior to the operation, the patients were photographed while standing. The operation began after disinfection of the skin, with the harvesting of the adipose tissue. This was performed by explanting fat bilaterally from the thighs if the patient was tendentially thin and from the periumbilical region if the patient was normo-weight or overweight and from the suprapubic region if there was any localized adiposity. This latter area of harvesting permitted, in certain cases, the reduction of the suprapubic adipose panniculus (suprapubic lipectomy) rendering the point of insertion of the penis deeper and visually increasing the length of the external portion of the penis.

Thereafter inltration of the donor site was performed

with a tumescent solution. After a few minutes of waiting,

necessary to consolidate the vasoconstrictor effect of the epinephrine, adipose explant was performed using a thin cannula (2mm) and a 10cc Luer-lock syringe (Fig.37.3). The quantity of fat explanted varied from subject to subject on the basis of the volume to be lled, but it was never less than 80mL.That volume comprised inltration material which was then removed by decantation rst and then centrifugation later. Such a process of purication is of primary importance since it determines the percentage integration of fat in the penis. In our surgical center, we rst performed the decantation through sedimentation of each 10cc syringe in such a way as to put the harvested material through an initial process of purication. Each syringe was lled with fat again and each time the inltration material was removed, repeating the decantation by sedimentation process many times. Once a seemingly stable mixture was obtained, the syringes of crudely puried fat underwent centrifugation for 2min at 1000rpm (Fig. 37.4). Reducing the time and the number of rpm, with respect to the original Coleman’s technique, which involves centrifugation for 3min at 3000rpm, the integrity of the adipose globules whose integrity is in turn responsible for the good integration of the fat was safeguarded.

37.4.2 Fat Transfer

Once the penile elongation operation had been performed, the test tubes containing the puried adipose material were extracted. They typically contained three layers: the most supercial was oily, the middle contained the puried fat and the lower was made up of blood and inltration material [48]. The inferior and superior layers were eliminated and the puried material was implanted. Two mini-incisions of about 4 mm were made close to the pubo-penile junction at 10 o’clock and 2 o’clock, respectively. The puried adipose material contained in the 10cc syringes was decanted using a specic connector into 2.5cc syringes better suited for the job. A blunt-tip cannula 2mm in diameter was used for the implantation. The puried fat was then implanted into the subdartoic space (Fig.37.5) taking care of the tunnel using the cannula and arranging the implant symmetrically. The space addressed was relatively avascular, and, as a result, the formation of localized hematomas was rarely observed. In the few cases where hematomas were observed, bandaging was applied.

Adverse events are summarized in Table37.4. The quantity to be implanted varied considerably depending on the space to be lled, also considering that 30% of the implant would be resorbed within the rst/second month. Therefore, we decided to inject a modestly superior quantity to take into account its predicted partial resorption. At the end of the implantation, the surgical wound was closed and sutured

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Urethra

VERNOSUM

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Fig. 37.3 Surgical tray. Adipose explant was performed using a thin cannula (2mm) and a 10cc Luer-lock syringe

Fig. 37.5 The puried fat is implanted into the subdartoic space,

between Dartos fascia and Buck’s fascia

Fig. 37.4 Once a seemingly stable mixture was obtained, the syringes of crudely puried fat underwent centrifugation for 2min at 1000rpm

Superficial Dorsal Vein

Dorsal Nerves

Dorsal Artery

Deep Dorsal Vein

DARTOS FASCIA

BUCK’S FASCIA

Cavernosal Artery

Tunica Albuginea

CORPUS CA

Corpus Spongiosum

37 Penis Enhancement andReshaping withAutologous Fat

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Table 37.4 Summary of adverse events

Adverse events (%) Loss of erectile function 0 Decrease of erectile function (temporary) 0 Penile edema 8 Long-standing hematoma 4 Seroma 3 No increase in girth 7 Fat loss (>30%) 32 Fat nodules, fat lumps 3 Fat migration 1 Sclerosing lipogranuloma 1 Loss of sensation (mild) 2 Fibrosis 0 Deep infection 2 Paradoxical penile shortening 0 Penile deformity 3 Penile asymmetry 4

using resorbable thread, a maneuver of manual “kneading” of the penis was then performed [49] to aid in the uniform distribution of the implanted fat, and nally, a cohesive elastic bandage of adequate thickness was applied. The bandage has the important function of preventing the formation of crude asymmetries caused by posture and/or frequent erections during the rst month after the operation. In fact, statistically at least 30 days are needed for the implant to be consolidated and the fat integrated, and it is useful to limit the movement of the fat during this period using the elastic bandage. At the end of the operation, a modestly compressive dressing was applied, and ice locally. The patient was discharged that evening with directions for medical therapy at home and adequately informed of the recovery period. In particular, the patient was urged to abstain from sexual and masturbatory activity for 30days. The duration of the operation was recorded from the moment of sedation until the nal suture and it was about 40min.

Table 37.5 Baseline descriptive statistics of patients’ demographics

Baseline Age (years)

Number of values

Minimum 19 56 167 5 25%

Percentile Median 36 74 178 8.3 75%

Percentile Maximum 63 99 192 13.3 Mean 38.08 75.13 177.4 8.377 Std. deviation 10.81 8.969 5.126 1.213 Std. error of

mean Lower 95%

CI of mean Upper 95%

CI of mean

355 355 355 354

29 68 173 7.5

46 81 181 9.1

0.5737 0.476 0.2721 0.06445

36.95 74.2 176.8 8.25

39.21 76.07 177.9 8.504

Weight (kg)

Height (cm)

circumference at rest

(cm)

37.4.3 Statistical Analysis

Penis circumference data was analyzed using a one-way analysis of variance (ANOVA) with Dunnett’s post-hoc test for comparison of each time point with baseline. Data are presented as mean± standard error of the mean (SEM). A p<0.05 was considered signicant (Table37.5).

37.5 Results

Following surgical procedure, circumference at rest signicantly increased at 2 (11.5±0.09), 6 (11.36±0.09), and 12 (11.06±0.1) months, compared to baseline (8.3±0.06) (all p<0.0001) (Figs.37.6, 37.7, 37.8, and 37.9).

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Fig. 37.6 Results: immediately post-op result

Fig. 37.7 Results: immediately post-op result

37 Penis Enhancement andReshaping withAutologous Fat

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Fig. 37.8 Result: post-op after 12months

Fig. 37.9 Result: post-op after 12months

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37.6 Discussion

The inhomogeneities of the surgical techniques and the

selection criteria of the patients render it difcult to compare

We found that cosmetic phalloplasty signicantly improves circumference at rest at 2, 6, and 12months post-surgery.

The growing demand for autologous fat transplant (AFT) beginning at the end of the 1980s is linked to the advent of liposuction. The current methods of fat transfer were popularised and extensively described by Sydney Coleman [48, 50,

51] who in 1986 began to transplant fat in iatrogenic defor-

mities from liposuction and subsequently in the face. AFT is today a widely tested procedure, appreciated by patients and very widespread among plastic surgeons even for reconstructive surgery [52–58] despite no consensus has been reached regarding the best technique or its success rate.

The fat injection is the most common technique of penile girth enhancement. The fat harvested from the patient is implanted into the subdartoic space with the objective to symmetrically and uniformly increase the circumference of the penis [59].

Table 37.6 Overview of result obtained by phalloplasty surgical techniques

First author, year N Method

Austoni (2002) [60] 39 Autologous saphenous graft 9

Perovic (2006) [61] 204 Biodegr. scaffolds coated w/

autologous broblasts

Shaeer (2006) [62] 1 Supercial circumex iliac

artery island ap

Bin (2009) [63] 20 Saphenous grafts, PTFE

articial vessel patches

Jin (2011) [64] 69 Biodegr. scaffolds coated w/

autologous broblasts

Alei (2012) [65] 69 Porcine dermis graft 6.12 3.1 2.4

Referral action Wessels (1996) [66] 12 SLD (N=12)+VYP, FI

(N=10)

Alter (1997) [67] 30 SLD+VYP, FI Klein (1999) [6] 58aSLD (N=10), FI (N=1),

SLD+DFG (N=6), SDL, FI (N=41)

Roos (1994) [8] 260 SLD, Y (Z/M ap) 4 (N=100) 4.0 Shirong (2000) [68] 52 SLD+scrotal ap/skin graft,

VYP

Spyropoulos (2005) [69]

Li (2006) [70] 42 SLD (N=42)+silicone spacer

Panlov (2006) [49] 88 SDL, FI (N=31) FI (N=57) 12 2.42 1.0–4.0 Mertziotis (2013) [71] 82 SLD+VYP, DFF (N=35) 12 1.92 2.21

Monreal (2015) [72] 259° SLD, FI (N=148) FI (N=127) 6 (N=160)

Xu (2016) [73] 23 SLD+DFT 2.27 1.67

Data obtained from questionnaires administered in several surgical centers by at least 10 different surgeons

°Total number of procedures: 275

11 SLD, VYP (N=5) SLD, DFG

(N=3) SBL, SLD (N=2)

(N=27), VYP (N=17)

Circumcision ligamentolysis, DFF (N=47)

the results obtained by our center with those found in literature and reported from other clinics (an overview of surgical techniques employed for phalloplasty and result obtained is summarized in Table37.6).

In our experience, cosmetic phalloplasty has evolved in time moving in the direction of increased safety. Patients who undergo combined elongation and girth enhancement phalloplasty are particularly satised compared to those who undergo a single operation which is probably linked to the availability of an overall greater penile volume [72]. In Italy, there is no validated test for measuring patients’ satisfaction in cosmetic penoplasty, and the absence of a measurement of patients’ satisfaction is a limitation of our study.

In line with other authors, we believe that, even in its relative simplicity, cosmetic phalloplasty requires a profound knowledge of anatomy and surgical technique and that the selection of candidates is a fundamental and essential element together with

Follow-up (months) Gain in length (cm) Gain in girth (cm)

Flaccid Erect Flaccid Erect

24 (N=84) 3.15

6 9.5 8.5

1–5years 1.0–2.3 1.5–3.0

1, 3, 6 4.01 2.92

12.2 3.0 0.76 2.52 2.03

6 (N=20) 3.5–6.5

1.6 2.3/2.6

16 1.3 (stretched)

2.11 2.0

3.1 3.2 1.7 1.6

12 (N=87)

1.1–2.1 (∅)

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Fig. 37.10 Complication: prepuce edema

scrupulous information regarding not only the operation and the obtainable results but also post- surgical conduct since resuming of sexual activity prior to 30days after the operation can compromise the results (Figs. 37.10, 37.11, 37.12, 37.13, 37.14,

37.15, 37.16, and 37.17).

While conrming that cosmetic phalloplasty very rarely

produces spectacular results and that there is an objective

necessity to improve the stability of the fat in time, we retain that the data from our center show that the surgical technique we utilize is safe, repeatable, and produces concrete and measurable results. Finally, the operation, last resort to improve the patient’s discomfort, can considerably improve the patient’s self-esteem and improve the quality of his sex life and, in turn, his relationships.