For certain men, the size of their penis can hinder their ability to enjoy a satisfying sexual life with the problem being both physical and mental. Most individuals who feel that their penis is short, whether flaccid or erect, are usually of average length. This perception can lead to reluctance in exposing themselves in communal settings such as locker rooms or during intimate sexual encounters.
Men who possess a penis smaller than the average size may face challenges with proper insertion or achieving orgasm, either for themselves or their partners, which can adversely affect their sexual relationships, self-esteem, and mental well-being. Conversely, men with larger penises may still desire to increase their length for unknown reasons.
This is quite different from patients with “micropenis”, a condition in which the penis is really very small and needs reconstructive surgery.
To achieve an increase in penile length, it is necessary to release the suspensory ligament and subsequently use penile weights after the surgical procedure. The release of the ligament partially detaches the penis from its connections to the pubic bone, resulting in a lower positioning that may create the illusion of greater length. Nevertheless, the actual length increase resulting from the ligament release alone is minimal, typically measuring less than one inch.

1. Flaccid length gain can be achieved after suspensory ligament release surgery but the degree of gain varies, some patients may have minimal gain.
2. To get erect length gain after suspensory ligament surgery, patients have to use penile stretchers for a couple of hours everyday for 1-2 years for permanent length gain.
3. Weight based stretchers are more effective than spring based stretchers and the weight needs to be progressively increased every 2 weeks.
4. Some patients can have a weak erection as the weight put on increases.
5. The penile girth may appear thin as the length increases.
6. Some patients may not gain any length increase even after ligament surgery and use of stretchers.
7. Length increases of 1-2 inch are considered as EXCELLENT.
8. V-Y advancement flaps produce POOR results and are not done.
9. Ligament surgery should not be combined with girth increase surgery in the same sitting because application of stretcher may be painful.
10. Erections should be attempted as early as possible to prevent re-attachment of the ligament.

The surgery is typically done under local anesthesia without any form of sedation.
The area of the suspensory ligament is infiltrated and a small transverse incision is made close to the root of the penis. The fundiform and suspensory ligaments of the penis are cut and the vacant area so formed is filled up with fat flaps.
The incision is then sutured back.

• Patients should start erections as early as possible so that ligament reattachment does not happen.
• Refrain from sexual activities and contact sports for about a month after surgery.
• Initiate penis stretcher use after a period of 7-10 days as directed by the surgeon. Despite this, often no length gain is seen.

Please contact with Dr Adhikari directly to see before/after pictures.

Some patients feel that their penis is “thin” and they want an increase in size. This notion comes mostly from pornographic films where huge penis are shown which makes patients compare their own size with what they see. In reality, most patients who come for surgery have a penis girth that is within the normal range.
Also known as penis enlargement surgery or penis augmentation surgery, the increase in girth can be achieved using a number of ways. The simplest is by injection of various materials like hyaluronic acid, fat and so on.
More extensive procedures incorporate the use of dermal strips, dermofat grafts and a host of flaps like SEPA flap and SCIP flap. Penile implants can also be inserted which can be of various types.

1. Surgery for penis girth increase can have a lot of complications, so the patient must be aware of those prior to going in for the surgery.
2. Procedures incorporating fat can lead to fat necrosis, abscess formation and exudation of oil from one or many routes.
3. In all invasive cases there is gross edema of foreskin which would take a few days to recover.
4. Healing may be delayed in many cases, more so in smokers.
5. A dorsal slit of the prepuce or a circumcision may be added to address the foreskin edema.

This involves liposuction in an area of the body and then utilizing the fat obtained to increase the girth of the penis through injections.

Usually the lower abdomen or sometimes the thighs are the source for fat from where it is aspirated by liposuction.

The fat so obtained is purified to ensure that no blood, fluids or unwanted materials are injected.

The processed fat is then injected into the penis via small slits.

Manual distribution is done so that the injected fat is distributed in an even manner and avoid clumps in one area.

• Natural look although the feel may be spongy.
• When compared to fillers, the procedure offers long term results as the fat that stays will stay on.
• No risk of allergy or rejection as seen with foreign materials.
• Simple procedure, low rate of complications.
• Low morbidity and faster healing time.

• Formation of oil cysts which may spontaneously come out or may require drainage.
• Infection.
• Temporary swelling in the penis and sometimes bruising.
• Uneven absorption may lead to differential texture.
• Fat resorption occurs usually requiring multiple sessions.

A variety of materials can be inserted into the penile shaft to increase its girth and the simplest of them is dermofat graft. Other materials such as various flaps, Alloderm and implants can also be used to increase girth of the penis.

Dermofat is usually harvested from the lower abdomen or groin or buttocks or any other area as decided upon by the patient.

The outer layer of the skin or epidermis is taken out and the inner layers comprising of dermis and a thin layer of subcutaneous fat are taken and the donor site is then stitched.

Usually a half-circumference incision is given in the inside of the penis and dissection done to create a space for insertion of the dermofat graft.

The dermofat graft is inserted below the skin of the penis and is secured at multiple places followed by closure of the incision.

• Natural feel to penis.
• No risk of rejection as it is an autologous material.
• Lifelong increase in girth when taken up by the body.
• Multiple sessions of dermal strip insertion can be done if required.

• More morbidity because of the invasive nature of the surgery.
• Large donor site scar.
• Oil cysts may form which may require drainage, this is more when a thicker fat layer is taken.
• Sometimes the overlying skin may break down although this can be managed conservatively.
• Gross penile edema in the postoperative period, most marked in the foreskin which may take quite some time to resolve.
• Infections.

A variety of flaps can be used to augment the penile shaft, the most common of which are SEPA flaps and SCIP flaps. The technique is similar to harvesting of dermofat graft although the donor sites vary and the inherent blood supply of the flap is preserved so that less resorption of fat occurs. Benefits and complications are the same as seen with dermofat grafts.

A hidden penis, often referred to as a buried penis, arises when the penis is either partially or completely obscured by adjacent tissue, typically adipose tissue. This condition may result from several factors, such as congenital anomalies, obesity, or significant fat deposition in the lower abdominal area.

• Congenital, where it is present from birth.
• Obesity, the most common cause, in which the suprapubic fat increases and descends down to cover up the penile shaft.
• Excessive fat accumulation around the penis.
• Penoscrotal lymphedema or an aggressive circumcision.
• Balanitis Xerotica Obliterans which causes thickening and scarring of penile skin.
• Abnormally developed dartos muscle.
• Sometimes a V-Y plasty to increase the penile length can also cause development of buried penis.

Treatment is surgical and comprises of the following components.

– Panniculectomy or removal of excess fat which conceals the penis, this can be done directly or via liposuction.
– Removal of extra skin as may be required to avoid redundancy, this is usually done in the lower abdomen.
– Anchorage of the dorsal skin to the abdomen.
– Anchorage of the ventral skin to the penoscrotal junction.
– Rarely a release of the suspensory ligament of the penis may be needed.

• Infection.
• Urinary problems like daytime wetting or dribbling may occur in rare cases.
• Sexual dysfunction associated with erectile dysfunction.
• Swelling of penile shaft in the early postoperative period.
• Occasional painful erections.
• Reduced sensation in the genital area.
• Delayed wound healing.
• Abnormal scarring in the incision site.
• Damage to testicular cords.
• Trapped penis.
• Recurrence of buried penis.

Penis Girth Augmentation Using SEPA Flaps and Dermofat Grafts
https://pubmed.ncbi.nlm.nih.gov/38189069/