Publication Phalloplasty

Enhancement Employing Autologous Fat Transplantation :
A Preliminary Report

The evolving techniques of augmentation phalloplasty and penile autologous fat transplantation (AFT) are described with historical correlation. Experience derived from 200 procedures is presented, relating to patient selection, informed consent, biophotography, intraoperative technique, skin transfer, ans postoperative care. While total corporal length remains inchanged, an outward gain of 1 to 5 cm (overage 3 cm) can be obtained. Success with simultaneous AFT has been variable, and touch-ups may be required, reabsorption of fat (zonal and complete), seen especially with smokers, emergence of fatty noduls minimized by more thorough undermining, and one case of mucosla shaft and hyperesthesia still in follow-up. In general, patients are pleased and thus there is encouragements to refine ans continue in appropriately selected cases.

INTRODUCTION

When Drs Pyush Joshi and Ali Kahn presented their film « Augmentation Phalloplasty », at the 1986 AUA meeting (New York), reporting a gain of 2 to 5 cm, a more universal application of penile augmentation was conceived. Beneficiaries might be broadened to include penile prosthesis candidates otherwise destined for a stubby erect mode, as well as diminutive potent men. Resection of the fundiform ans suspensory ligament has been well described, but limited to developmental anomalies refractory to testosterone stimulation (Notes 1, 2, 3) and trauma cases (Notes 5, 6). Release of the suspensory ligament permits outward extension of the infrapubic corporal arch, thus allowing the penis to emanate perpendicularly to the body surface line.
Shortly following the New York prensentation, the ongoing experiences of pediatric urologists Mazels et al. (7 patients) ans Schapiro (80 patients) were published chronicling commonly encountered variants, and their surgical approach in each situation (Notes 7, 3). The mainstay of their procedures most often involved resection of the suspensory ligament of the penis, with pubic lipectomy ans release of a penoscrotal web as needed. Devine, in a pediatric newsletter, described dysgenetic bands (extension of Scarpa’s) in the dartos fascia as a cause of penile concealment ? The more distal the attachment (e.g. subcoronal) the greater the degree of recession. Lysis must procede consideration of circumcision.
Whereas pediatric articles emphasize the need to fixate the infrapubic skin to the pubic symphysis to better define the base of the penile shaft, my experience with trial suture placement in adults has evinced an unsightly cutaneous recession ans a modification of this technique seems to work better (vide infra).
With adults, penile length gains following suspensory ligament resection have ranged from 1 to 5 cm (3/4 to 2 in), with an average of 2.5 to 3 cm (1 to 1½ in), not similar from the experience of Subrini 10. In 1984 be reported a mean gain of 3 cm after release of the suspensory ligament in 49 during simultaneous penile prosthesis surgery.
Articles relating to penile enlargement almost defy subject search because the index nomenclature does not appear to be standardized. Elusive homologues include « buried penis » , « concealed penis » and « penis advancement » 11,12. Subrini’s contextually mentioned contribution would not have easily accessible before the advent of « Key words » – the title of his paper related to the penile prosthesis.
Many aspects of AFT have been described (Notes 13, 14, 15, 16), but penile girth enhancement by subcutaneous injection of liposutioned fat, first performed by Ricardo Samitier (17), has not to my knowledge been reported in peer review literature. In 1989 a patient of his proposed, in a classic example of recycling, that liposuctioned abdominal fat be injected into the penis. This was done, and given a few revisions to contour irregularities, the results have been enduring. In the face of professional cynicism that tranplanted fat does not survive (Notes 18, 19), this result persists convincingly 2 years post-implantation.
As experience with both procedures evolved, it became apparent that the fat could be grafted subcutaneously into the penis via a limited infrapubic incision, obviating an unnecessary cut of the penis.

METHODS AND MATERIALS

Selection of patients
Three distincts classes of patients request evaluation : potent adult males, impotent males, and young lads brought in by worrisome parents. Of course, infants and boys with quesqtionable sexual development should receive prompt endocrinologic evaluation, with hope that the therapeutic goal of normal appareance is achieved ideally prior to psychosexual self-recognition (18 months), and certainly before school enrollment. Much has been written on micropenis, which is defined as being 2½ standard deviation below the mean (less than 99.4% of a normally distributed population 10). For adults, this would equate to a stretched or erect penile length of 9.3 cm (3 2/3 in). Whereas with children stretched penile measurements are obtained from the pubic bone to the glans, in my practice adults are meseared skin to skin, because their concern is a limitation of functional length.
That an enveloping fat pad can be cutgrown verges on mythology. Any dieting short of emaciation will do little to reduce this « privileged » fat (vis-à-vis responsive upper abdominal fat). The treatment for lipodystrophy or steroma is lipectomy 21.
The candidate selection process includes discouraging from surgery those patients with bilateral lower abdominal incisions. These patients are prone to penile lymphedema which could preclude coitus for a few months, and thus they are not a happy lot. Inveterate smokers (impaired wound healing) and emotionally stable patients are disqualified.
Measurements
The flaccid circumference and erect length are compared with nomograms of Schonfeld ans Beebe (1 500 males, ages 1 through 25 [Note 22]). Noteworthy correlation has facilitated insurance precertification. Initially stretched penile length were obtained preoperatively in lieu of erect measurement, because the authors reported little variance (.983). Howerver, after many of my patients challenged the accuracy of these results, the alternative became clear, and seemed more advantageous to all concerned. A pharmacologically induced erection bolstered by visual stimuli was measured with the patient standing setting the ruler gently against the pubis. A draping panus is best appreciated then. Measurements are confirmed photographically along with the prensence of any sideways deflections or angulations. These findings are then posted on the informed consent ans certified by the patient.
The informed consent
An advisory on penile fat grafting is presented to all patients and initialed. Separate consents are obtained for length and girth. Pertinent aspects include : mention of an eclectic approach ; agreement to no penetrating sex for 6 weeks ; having sought approval of the sexual partner ; complications generic to any surgical procedure ; no guarantee of a specific result ; and abstinence from smoking or nicotine by-products for 2 weeks prior and for 2 months after surgery. At this time, patients contemplating autologous fat transfer are told the procedure is controversial, is in clinical trials, and that fibrous fat nodules with dystrophic calcifications have been reported (18). The possiblity of zonal or complete reabsorption of fat is disclosed, and the vasoconstrictive effects of nicotine are discussed.
Fat grafting should not be considered a « one-stage » procedure. Touch-ups may be required especially by fastidious patients who seek a perfectly cylindrical result. While our policy is not in charge for revisions, we do insist the patient wait 3 months to allow optimal healing, before scheduling a redo.
Those considering this type of procedure should have adequate time to pose questions ans reflect upon their motivations, the anticipated postoperative course, and risks. Patients with a history of an emotional disorder require a letter of psychiatric clearance. Surgical lab is routine for all patients, and for those over 40, medical clearance.

TECHNIQUE

If dermatolipectomy is planned, the patient stands for marking in the bolding unit. While patients are allowed to specify an anesthesia of choice, epidural is favored because it is perhaps safer, associated with less bleeding than general, and provides a residual benefit of analgesia for several hours.
Liposuction, or dermatolipectomy if required, are performed first. In preparation for liposuction, the pubis and the adjoining lower abdominal wall are injected with a buffered solution of anesthesic ans vasoconstrictor. Typically 5 cc of lidocaine 1% and 5 cc of bupivicaine 0.25% (both with 1/100 000 epinephrine) are added to 100 cc of Ringer’s lactate and brought to a pH of 7 into the mons and oft-seen contiguous fatty extensions into the upper lateral scrotum.
Liposuction is accomplished via 2 oblique ports, each 3 mm long, located about 5 cm above the pubic escutcheon and 7 cm lateral to the midline. The cannula fenestra are kept 7 mm below skin surface. Criss-crossing of strokes minimizes ridging. Sixty-cc syringues prefilled with 10 cc of bufferred Ringer’s lactate soften aspirate impact and commence the cleansing process. If a fat trap is used in conjunction with floor model suction, vacuum pressures should be reduced to minimize trauma.
The earliest aspirations contain the last coagulum and these syringues are strored vertically and covered on the back table for later use. As the fat rises, the lower aqueous fraction is discarded periodically and replaced with additional washes of buffered Ringer’s.
A 4 cm tranverse incision made in the mid moos is carried through the vacuolated septae. This incision is then shifted infrapubically. The supercifial infrapubic fascia is entered longitudinally close to midline. A vertical spreading technique on either side minimizes transection of efferent penile lymphatics. Although the dorsal shaft is easily visualized in this loose fibroareolar infrapubic space, the ligaments are transected as close as the pubic symphysis as possible.
Stretching the penis caudally defines the fundiform ligament (extension of Scarpa’s) ans more deeply the suspensory ligament of the penis. The deep dorsal vein thinly covered by Buck’s fascia is seen trifurcating just before entering the retropubic space. Later tenting the penis anteriorly identifies the last vestiges of restraining fibrous fascicles. Ultimately dorsolateral corporal release has proceeded 1 to 1.5 cm along the inferior rami.
The anatomic considerations that dissuade further proximal dissection are :

• lolo avoidance of injury to the dorsal nerve and the penile arteries
• lolo belief that beyond certain point no appreciable gain in length will accrue when measured penpendicular to the body surface line (although the penis may dangle lower)
• lolo desire to conserve the excellent fascial support of the proximal crura
• lolo reluctance to sever or injure the dorsal vein, in a situation where a cosmetically desirable keybold incision precludes facile ligation (Devine et al., however, do report dorsal vein ligation when « leakage » exists concurrently with Peyronie’s surgery [23]).

Cozing responds well to gentle cautery, lap pad tamponade, or as needed absorbable hemostatic gauze. Blood loss approximate 80 cc Following mid-procedure packing, attention can be diverted to fat preparation as the scrub nurse keeps a cautious eye on the incision.
That portion of fibroareolar tissue just caudal to the pubic symphysis is brought together in the midline with sutures of 2-0 polyglactin to suppress the penile arch. Bilaterally subcutaneous sutures of polyglactin are then placed with a glancing bite into proximal Buck’s fascia. When tied this suture elevates the penile shaft anteriorly. If skin retraction is noted on the first throw, the reach of the suture is reduced, or the skin undermined inferiorly with a tenotomy scissors.
Penoscrotal weebing is taken down by Z-plasty or V-Y recession. Cases of severe fusion may be treated by ventral extension of a circumcising incison that permits transfer of the prepuce to the distal shaft as described by Redman (24).

GIRTH ENHANCEMENT

Complete mobilization of penile skin with preservation of septae is accomplished with a Potts-Smith scissors using a spreading-only technique except for snipping a somewhat consistent adhesion in the dorsal coronal sulcus. This preparation is requisite for a uniform result. About 70 cc of fat is infused by cannula under a proximal penile tourniquet into the distal penile subcutaneous tissues. Overrinjection compensates for volume depletion (estimated to be 40%) secondary to fluid absorption and attrition of injured fat celles. Afterward the fat is molded into a cylindrical form. The proximal tourniquet is released. A surplus of fat sequestered in the distal shaft is expressed proximally. Uncircumcised patients require the placement of an additional tourniquet distally to prevent dissection of fat into the prepuce.
A gaping incision is commensurate with length gain, and must not be closed under tension lest the penis retract inward. Undermining abdominal skin eases closure, as the lower lip is relatively immobile. Drains are not employed routinely. A postoperative photograph confirm the immediate outcome. The penile shaft is wrapped with a soft gauze and Coban. A snugly applied abdominal binder secures a compressive dressing. A Foley catheter spares many nursing calls and permits patients ideally to maintain bedrest until the next day. Those who request same day discharge have had their catheters remove without ill effect.

POSTOPERATIVE CARE

Erections are encouraged, but penetrating sex is proscribed for 6 weeks. Keeping the penis fully exteriorized is important and the patient is instructed to pull on the glans down and out (allowing the penis to accomodate) several times a day. If this exercise is done too agressively, bruising occurs and the patient must desist.

COMPLICATIONS

In deference to those patients with minimal gains, it might be said that the most infortunate complication of this procedure is disappointment. Among 200 procedures, 1 hematoma occured which drained spontaneously. Another patient following dermatolipectomy required reinstitution of a Jackson-Pratt drain for seroma. A third patient had a perplexing low-grade praraphimosos induced by lengthening, probably because the prepuce would no longer extend beyond the glans. He underwent circumcision. Some degree of submucosal edema and hyperesthesia persists. A cicattrix of his upper scrotum was treated with intralesional triamcinolone. On patient had 3 distincts fat collections in the dorsal shaft, prior to the advent of undermining. He has been advised to have the excess removed.
No petient has been rendered impotent, although one patient thought his erectile strength might be somewhat reduced. However, he penetrates ans maintains his erections well with unaltered frequency. Thus far there have been no cardiovascular incidents, embolic events, neurological injury or infections.

DISCUSSION

While total corporal length is unaffected by this procedure, what is accomplished is a resetting of the partition between in and out. True even men with micropenia may adapt well heterosexually and achieve reasonable psychosexual adjustment 25, but the issue is, given a choice – would they not opt for a more normal apearance ? Does one have to be below the 0.4 percentile to merit serious urological concern ? That patient far removed from the realm of micropenia who presents with a « shave bush » (localized removal of hair from the shaft and base of penis) is quietly fulfilling a need to present larger. This is an often unappreciated although significant finding.
For candidates who seek more than an illusion, skin cover must be made available to cloak the extended corpora. Uncircumcised and loosely circumcised men have the advantage of a natural transfer. Unless some provision is made for tightly circumcised men, truncation of the base of the penis will occur during erection as surrounding skin is drawn onto the shaft. Hopefully releasing lower abdominal skin will bridge the void, otherwise a flap must be devised. In that some incisions heal imperceptibly and others do not, flaps are performed reluctantly because they are at one time a concession to function and a compromise to cosmesis. This option should be preplanned with patient approval.
The « big dipper » scrotal transfer of Joshi and Kahn is a means of draping the proximal dorsum, as are the rhomboid pubic flaps of Kramer suggested for epispadiacs 26. In my hands, infrapubic Z-plasty has not worked well because lengthened pubic skin is not transferable to the dorsum of an nonprosthetized penile shaft.
Fat grafting will remain controversial as long as reports are issued of the somewhat predictable outcomeof elevating poorly vascularized depressions. In this regard, the penis is a unique host because it is not the site of prior cicatrix, and as tissues planes go, vascularization is excellent. Additionally its fibroareolar space is anatomically well contained, except at the base. Factors which promote uniform graft uptake include undermining of penile skin, use of buffered solutions, Coban wraps, and abstinence of smoking.

SUMMARY

This report is not intended to serve as a definitive tutorial for a technically involved and innovative procedure. Rather, it is offered as a preliminary description of a process which has evolved to the point of a reproductible methodolgy. Concerns regarding loss of potency, neurological injury and vascular misadventure, have not been realized thus far. Penile edema, unless due to paraphimosis is managed expectantly. Contour irregularities could require limited revision.
Urologists who make incursions into gynecology, ultrasonography and laparoscopy, may now venture out to meet an aesthetic calling. Penile lengthening and girth enhancement has entered the lexicon of public awareness and will remain a patient-driven procedure, as long as we can provide a consistency of pleasing results. Today’s patients must be imbued with realistic expectations based upon our experiences thus far, although further refinements are anticipated.
Good rapport, so essential to this type of work, is born of candor, compassionate postoperative support and avoidance of specific promises

REFERENCES

• Joshi PN, Kahn SA : Augmentation phalloplasty. J Urol., pt 2,135 : 136 A, abstract 130, 1986
• Crawford BS : Buried penis. Brit J. Plas. Surg. 30:96, 1997
• Wollin M, Duffy PG, Malone PS, Ransley PG : Buried penis, a novel approach. Brit. J. Urol. 65:97, 1990 (concealed in subcutaneous tissues)
• Johnston JH : Lengthening of the congenital or acquired short penis. Brit J. Urol. 46:485, 1974
• Radhakrishnan J, Reyes HM : Penoplasty for buried penis secondary to « radical » circumcision. J. Ped. Surg., 19:629, 1984
• Kabalin JN, Rosen J, Perkash I : Penile advancement and lengthening in spinal cord injury patients with retracted phallus who have failed penile prosthesis placement alone. J. Urol. 144:316, 1990
• Maizels M, Zsontz M, Donovan J, Busnick PNFurlit CF : Surgical correction of the buried penis : Description of a classification system and technique to correct the disorder. J. Urol. 136:268, 1986
• Shapiro SR : Surgical treatment of the « buried » penis. Urol. 30:554, 1987
• Devine CJ, Jordan GH, Horton CE : Concealed penis. Soc. For Ped. Urol. Newsletter. p 115, nov 14 1984
• Subrini L : Surgical treatment of Peyronie’s disease using penile implants ; survey of 69 patients. J. Urol. 132:47, 1987
• Donahoe PK, Keating MA : Preputial unfurling to correct the buried penis. J. Ped. Surg. 21:1005, 1986
• Horton CE, Vorstman B, Teasley D, Winslow B : Hidden penis release : Adjuncting suprapubic lipectomy. Ann. Plas. Surg. 19:131, 1987
• Lewis CM : The current status of autologous fat grafting. Presented at the 9th annual Meeting of LSNA. September 22-26, 1991, Seattle
• Carraway JH, Mellow CG : Syringue aspiration and fat concentration : A simple technique for autologous fat injection. Ann. Plas. Surg. 24:293, 1990
• Agris J : Autologous fat transposition : A 3-year study. Amer. J. Cosm. Surg. 4:95, 1987
• Bircoll M : A nine-year experience with autologous fat transplantation. Amer. J. Cosm. Surg. 9:55, 1992
• Samitier R : Personal communication, 1992
• Ersek RA : Transplantation of purified autologous fat : A 3-year follow-up is disappointing. Plas. Reconstr. Surg. 87:219, 1991

HAROLD M. REED, MD