We thank Dr Solomon1 for his interest in our article.2 We agree that penile augmentation using injectable materials, including hyaluronic acid (HA), does have some disadvantages. HA fillers do slowly reabsorb over time and so are not a permanent solution. However, our in-progress research suggests that the nonpermanency of the procedure is potentially part of the appeal for at least some patients. These men consider a nonpermanent procedure on such an important part of their body, which they closely associate with their sense of masculinity, to be less daunting. In accordance with other studies,3,4 we have not observed “irregular” nodules in “every case” from HA absorption.1 Hyaluronidase completely dissolves HA fillers. However, as in the face,5 granulomas are a possibility in the penis. Without pathological reports provided by Dr Solomon, we wonder if these irregular nodules are potentially HA filler granulomas, which can be treated using injectable steroid, triamcinolone, combined with 5-fluorouracil.5 We also note that certain types of HA fillers are more prone to nodule formation and so their usage in the penis is not recommended.6 Furthermore, we propose that the injection technique may also have an impact on nodule formation. For this reason, we inject the HA into the penis in microthreads2 rather than boluses.7 As stated in both our paper and by Dr Solomon,1,2 no injectable filler has yet been approved by the US Food and Drug Administration for use in the penis. Although data are accumulating for HA,8 we encourage clinicians to undertake the controlled clinical studies needed to evaluate the safety and effectiveness of HA in the penis. Currently, HA fillers are approved for deep subcutaneous and supraperiosteal injection in the cheek.9 We propose that the plane between the superficial and deep fascia of the penis is a suitable location for injection of HA filler and HA is naturally found in the intercellular fluid in this glide plane.10 As we use a blunt cannula for delivery of the filler into this plane,2 veins are much less likely to be penetrated/damaged so “disruption” of the blood supply to the skin of the penis1 is unlikely. As Dr Solomon states, although surgical penile augmentation is permanent, complications do occur.1 The literature suggests that penile disfigurement and dysfunction are not uncommon,11,12 and this surgery is still considered to be “experimental.”13 The recent death of a patient after autologous fat transfer combined with suspensory ligament division14 is highly concerning. With men increasingly seeking penile augmentation procedures to address psychological and physical/sexual concerns around their penis size, we strongly encourage further research into safe and effective treatments, both medical and psychological, to assist these men. Disclosures Dr Sharp is a research consultant for Dr Oates’ private practice. Funding No grants were received to support the research, authorship, and publication of this article. Acknowledgment The authors made an equal contribution to this work as co-first authors. REFERENCES 1. Solomon M. Comments on “Nonsurgical medical penile girth augmentation: experience-based recommendations.” Aesthet Surg J . 2018; 38( 2): NP39– NP41. Google Scholar CrossRef Search ADS PubMed 2. Oates J, Sharp G. Nonsurgical medical penile girth augmentation: experience-based recommendations. Aesthet Surg J . 2017; 37( 9): 1032- 1038. Google Scholar CrossRef Search ADS PubMed 3. Kwak TI, Oh M, Kim JJ, Moon du G. The effects of penile girth enhancement using injectable hyaluronic acid gel, a filler. J Sex Med . 2011; 8( 12): 3407- 3413. Google Scholar CrossRef Search ADS PubMed 4. Perovic S, Radojicic ZI, Djordjevic MLj, Vukadinovic VV. Enlargement and sculpturing of a small and deformed glans. J Urol . 2003; 170( 4 Pt 2): 1686- 1690; discussion 1690. Google Scholar CrossRef Search ADS PubMed 5. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol . 2013; 6: 295- 316. Google Scholar PubMed 6. Siebert T, Chaput B, Vaysse Cet al. The latest information on Macrolane™: its indications and restrictions. Ann Chir Plast Esthet . 2014; 59( 2): e1- e11. Google Scholar CrossRef Search ADS PubMed 7. King M, Bassett S, Davies E, King S. Management of delayed onset nodules. J Clin Aesthet Dermatol . 2016; 9( 11): E1- E5. 8. Coskuner ER, Canter HI. Desire for penile girth enhancement and the effects of the self-injection of hyaluronic acid gel. J Cutan Aesthet Surg . 2012; 5( 3): 198- 200. Google Scholar CrossRef Search ADS PubMed 9. U.S. Food & Drug Administration. Juvederm Voluma XC. https://www.accessdata.fda.gov/cdrh_docs/pdf11/p110033c.pdf. Accessed October 23, 2017. 10. Schleip R, Findley T, Huijing P, eds. Fascia: The tensional network of the human body: The science and clinical applications in manual and movement therapy . London, UK: Churchill Livingstone; 2012. 11. Shprits S, Bahouth Z, Vardi Y. Penile enlargement surgery: is it feasible? J Genit Syst Disord . 2017; 6( 1):DOI: 10.4172/2325-9728.1000167. 12. Vardi Y, Har-Shai Y, Harshai Y, Gil T, Gruenwald I. A critical analysis of penile enhancement procedures for patients with normal penile size: surgical techniques, success, and complications. Eur Urol . 2008; 54( 5): 1042- 1050. Google Scholar CrossRef Search ADS PubMed 13. Sexual Medicine Society of North America Inc. Position statement: penile lengthening and girth enhancement procedures. http://www.smsna.org/V1/index.php/about/ position-statements. Accessed December 28, 2016. 14. Zilg B, Råsten-Almqvist P. Fatal fat embolism after penis enlargement by autologous fat transfer: a case report and review of the literature. J Forensic Sci . 2017; 62( 5): 1383- 1385. Google Scholar CrossRef Search ADS PubMed © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: email@example.com
Aesthetic Surgery Journal – Oxford University Press
Published: Feb 1, 2018
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