There are two phases to the procedure:

• Lengthening

• Increasing girth

These can be addressed in a single operation or separately.

Lengthening
The basic premise here is that a portion (1/4 – 1/3) of the penis is retro-pubic (behind the pubic bone).  If this segment can be brought forward, external length is achieved. There may also be an element of direct tissue stretching that can be achieved over time, as in other tissue distraction techniques.

There are two restraining or check ligaments, the fundiform ligament and the suspensory ligament. Both of these ligaments must be released.  It may not possible to release the entire deepest portion of the suspensory ligament without entering the urethra, but this last bit can be stretched both at surgery and later with external weights. This is a meticulous dissection, and I feel should only be done with magnification. At times Gortex or derma fat has been placed in the area of release to prevent re-adherence. Recently, progressive enlargement of this space with tissue expanders has been utilized. A supra-pubic horizontal, or a midline vertical skin incision is employed.

Length Increase
How much additional length can be expected?

From the thousands of procedures that have been conducted to date, the average seems to be over one inch; occasionally a gain of up to three inches has been achieved. Rarely a man may experience no gain in the erect state, while there is almost always a gain in the flaccid state.  Twenty-percent (20%) of patients fail to gain 3/8" inch in the erect state, the other 70%, however, gain from ½" to 1 ½", and 10% gain more. There is no reliable way for Dr. Gutstein to know how much additional length you can expect to gain until the incision is made. What determines the amount of gain is the nature of the ligament (with tighter ligaments one can generally expect better gains), how much of the penis is within the body (this influences how much can be extracted), and also of great importance is the degree of diligence in post-operative care, especially the use of weights for traction.  Each one of Dr. Gutstein's patients who undergoes a surgical penile lengthening is fitted with a weight device. Most patients are delighted with the result, which becomes apparent within three months after surgery, and may continue to show improvement for up to eighteen months.

Realistic Expectations
Progress is being made toward achieving even better results. However, one of the major points that need to be stressed is the need for realistic expectations.  Remember that surgical penile lengthening has its limits; it can make a size 4 a size 5, and a size 6 a size 7, but it will never transform a size 3 into a size 10.  Surgeons cannot magically "create" length. He can only work with the natural endowments.  Although the lengthening procedure generally produces a 1 or 1 ½" gain, once must not be disappointed if only a ½" gain is achieved. Nonetheless, on a 4" penis, a gain of 1 ½" is an increase of over 1/3 the total length.  There is just no way to guarantee a specific gain in length.  A moderate increase in girth can, however, be expected.

Girth Increase
Fat Autographs
Fat is removed by machine or by syringe suction from a donor area where there is some excess, and injected evenly into the penis through two tiny incisions. In earlier times, a large amount of fat was used and much more nodularity, irregularity and re-absorption were evidenced.  Now, about 30-50 cc per session is injected without pressure and evenly distributed. This can be repeated in 6 weeks if necessary. Although less is injected, the chance for that which is inject to obtain a new blood supply and survive is increased.

Advantages:  Quicker with no donor site problem. If the patient has an area of excess fat, this can be reduced at the same time.

Disadvantages:  Re-absorption may necessitate secondary injection.  Surgeon may not be able to find good quality fat for survival in a very lean and athletic man.

Derma-Fat Graphs
The problems (especially earlier) with shrinkage, nodule formation and asymmetry encountered in fat injection led to the use of deepithelized dermafat grafts. After harvesting two grafts (approximately 10 X 4 cm each), the grafts are inserted lengthwise through a tunnel made on each side of the shaft.

Advantages:  Smooth and uniform, more may survive than injected fat.

Disadvantages:  Donor site scar, possible wound healing problems, longer procedure.

Flaps
Turndown supra pubic flap, originated by Dr. Gutstein, is raised through parallel subcutaneous suprapubic incisions.  This tissue retains blood supply at its base and is tunneled under the shaft skin and anchored near the rim of the head.

Advantages:  Donor site is largely within the hair-bearing pubic area. Lengthening can be done through the same incision. No need to turn patient to obtain buttock tissue as in dermafat grafts.  Theoretically, the best survival since some blood supply is preserved.

Disadvantages:  Micro-dissection takes time.  Some bulge at turnover area at base of penis which reduces over time.

New research and work on penile augmentation is ongoing with Alloderm, Fascian, Gortex and Radiance.

Steps to Follow:

• Intra and Post-operative antibiotics are given
• Light pressure dressing for two days.
• Elevation recommended and jockey shorts for support.
• Manual stretching at one week.
• Weight at two weeks (if lengthening procedure only), or three weeks for fat autografts, and four to five weeks for derma fat grafts or flaps. PLD (penile lengthening device) or Mega Trac or Grip weights ½ - 4 pounds are used for 20 minutes, twice daily. The pulley stretch system may be used overnight.
• Sex at 4-6 weeks.

Patients are advised to evaluate results only after 6-18 months.

Adjunctive treatment: supra-pubic liposuction when appropriate to reduce pubic fat pad, revealing more of the penis.

Patients may wish to circumcise first or at the time or surgery.  This avoids maceration, swelling and wound healing problems when grafts or flaps are used.