ALARGAMIENTO POR ENDOSCOPIA Y AUMENTO CON INJERTO GRASO
ENDOSCOPIC LENGTHENING AND GIRTH AUGMENTATION WITH FAT GRAFTS

ABSTRACT
It is possible by surgical means to enhance the length and girth of the penis. Currently there are many techniques in use. Generally these techniques require wide incisions. The development of a special videoendoscope to work in the subcutaneous tissue with minimum incisions, allowed the authors to accomplish penis enhancement this technique.
The purpose of this paper is to document our experiences beginning on January 28, 1997 with the videoendoscopic enhancement phalloplasty procedure.

SUMMARY
It is possible by surgical means to enhance the length and girth of the penis. Currently there are many techniques in use. Generally these techniques require wide incisions. The development of a special videoendoscope to work in the subcutaneous tissue with minimum incisions, allowed the authors to accomplisch penis enhancement through this technique. The purpose of this paper is to document our experiences beginning on January 28, 1997 with the videoendoscopic enhancement phalloplasty procedure.

INTRODUCTION
For over a decade, penile enhancement surgery has been winning followers all over the world. One of the first publications on penile lengthening for treatment of congenital deformities was that of Johnston (1-2), in the United States in 1974. In China a country also considered a pioneer in the field, the surgeon Dr. Long Daochao (3) developed the technique of the penile lengthening. This technique was introduced in United States in Miami in 1991, by the urologist Harold Reed (4). Starting in 1992 it spread throughout the country, and from there to the rest of the world. Presently , it is included in the list of techniques that make up aesthetic surgery. In Brazil, one of the authors of this paper presented its use in penile liposculpture (5) in 1993.
We verified that, as for back as the most temate and outlandish of times in the history of markind; (6) the size of penis has been important psychologically and undeniably linked to masculine self-esteem and self image. This can be observed in the oldest art expressions, depicted in drawings, paintings and scupitures from the most primitive civilizations. (7) It seems to us that independent of the culture or of the peoples socioeconomic or religious situation, this concept has overcome all borders, throughout the ages, and brought along a symbolism of power, manliness and domain, and definitely present in the life of modern man. The studies published in our field show that the patients that seek penile enhancement are common men: executives, husbands, and family heads that have penises that function normally even if they are anatomically small, many times hidden inside a fat pubis. Some may even have a penis that is actually average or normal sized. These patients main complaints are related to traumatic situations from their childhood or teenage years or to embarrassing moments that occured when they used a public bathroom, a sauna or a gym dressing room ( athletes). There are even cases of body builders their penises a disproportionate size when compared to their muscular bodies. Thus, they refer to the size of their sexual organ as a genuine anatomical anomaly that directly affects their self-image and self esteem and consequenthy interferes with their romantic, social and professional relationships.

MATERIAL AND METHODS
It was understood that penile enhancement is a process that consists of surgery and physiotherapy to avoid scar tissue retraction and beyond that, additional gain. (8) There was a post-operative use of the weight device (9) and the use of the JES Extender (10) beginning 20 days later. The duration of JES Extender treatment to be determined by the development of each case.
The patients selection for the indication of videoendoscopic surgery followed the same approach as conventional surgery (11- 1 2), wich are as follows:

a) AESTHETICS
We have observed the great majority of the patients that seek this type of surgery have penises that are within the range of what is considered a medium size. In spite of efforts by doctors to explain to the patient that his penis is normal from a functional perspective this does not give them emotional relief. In general, they are more interested in a surgical solution that will give them a visible aesthetic result than in psychological treatment which many consider ineffective. We have found in our practice that the best candidates for this surgical procedure are those that are mature and socially balanced, those that are genuinely deformed or have a penis of a disproportionate size, and that are not unbalanced or have strong neuroses resulting from these problems. The more real and evident the deformity, the more realist and honest our clarifications and committments to our patients and the greater their satisfation.

b) FUNCTIONAL
The indication for functional reasons would be when the penis presents an inadequate size for normal intercourse. According to the norms established at the lst Annual Scientific World Congress of the American Academy of Phalloplasty Surgeons held on 11 - 13 October, 1996 in Aspen, Colorado. Which are as follows:

I - length of less than 10cm when in a state of erection
II - perimeter of less than 9cm when in a state of erection
III - post - prostheses penis that presents poor residual erection
IV - penile deformation that affects size such as: micropenis, hipospadias, epispadias, post traumatic, fibroses, etc...

The videoendoscopic procedure was used on 14 patients beginning on 28 january, 1997 with ages varging between 27 and 62, with an average age of 36.3. The aesthetic indication was the most frequent, comprising 10 cases. The surgical procedure for the increase of the length of the penis consists of the sectioning of the suspender ligament and fundiforme that fasten the penile dorsum to the inferior part of the pubic bone, (figure 1) allowing the past of the penis hidden below the bone to emerge, increasing the external portion of the penis, as per the conventional technique (9-13-14).

The difference here being that the section of the ligaments is udde by videoendoscope, while the traditional techniques use incisions in M and VY, which leave unpleasant scars are have a more aggressive manipulation of the tissues. We accomplished the whole procedure by may of a small 3cm incision (figure 2), hidden in the pubic hair area. Through this incision, and with the aid of video surgery, we identified and sectioned the ligament that fastens the penile dorsum to the pubic bone, allowing the intrapelvic part of the penis to emerge there by increasing the length of the pendular portion of the organ by an average of 2.5 to 3.Ocm. This technique is different from the videolaparoseope and other endoscopic procedures because it does not need a liquid or gas chamber, permitting the direct visualization inside the tissue . This device was developed by a Brazilian doctor and is used quite frequently in plastic surgeries of the subcutaneous tissue in mamoplasties, abdominoplastias and others with minimal scars (16-17).
The increase in girth is accomplished by a fat graft to the subcutaneos of the organ. The fat used in this procedure is removed preferably from the pubic mound, crotch area or from the lower abdomen, doing a liposculpture in these areas and improving the projection and look of the penis, following the techniques previously described ( 4-5-9-13-14).

Figure 2: Small incision

The use of physiotherapy with weights for traction began on the first day and continued for 20 days after the surgery (figure 3) .

Figure 3: the weigth device

Then we switched to the JES Extender to avoid scar retraction (figure 4).

Figure 4: The JES Extender

Liposuction was done in the pubic area, the lower abdomen and the crotch area to make the organ even more visible and projected. To have a proportional increase in diameter, we had improved the girth previously by may of a graft with the liposuctioned fat. The anesthesia used was raquidiana with 5% lidocane and all patients were treated as out-patients, leaving the clinic 4 hours after the procedure began.

RESULTS
A follow up visit 6 months after the surgery showed a gain in length that varied from 1.5cm to 6.2cm, with on average of 3.9. As for as the diameter is concerned, the gain was 1.9cm to 3.4cm, with an average of 2.5cm. The increases in length and in girth are similar to those in previous studies (13-15) which document the conventional technique, without a significant statistical difference in the results (figures 5 - 6 - 7).

Figure 5: Before surgery	Figure 6: After surgery

Figure 7: four months after surgery

DISCUSSION
The unwanted incidences after surgery will surely be fewer because this technique handles the issues in a more delicate manner and due to two fact that optical advantages being 40 times grater than an unassisted human eye, giving greater technical conditions during surgery. The need for a second surgery to correct asymmetry of the fat infusion should be equivalent to the conventional technique that is 15 to 20% according to previous studies (9-15). But regarding the scar hipertrofica that is frequent because of a disaligament of the tension lines in the VY and M techniques and zetaplastia; it would not happen when a minimum incision size through videoendoscopy and because there is no disalignment in skin tension lines.
Moreover, we emphasize that the skin in this area has a significantly elastic quality that is not in any way a limiting factor in penile enhancement. Also the surgery does not interfere with the functioning of the organ. Possible complications are as follows: partial absorption of the fat grafts, small nodules of the transplanted fat, hematomas and infections (15). Twenty percent of the patients underwent additional procedures of fat graft or nodule removal. Sexual activity was begun by most patients 8 days after the surgery. Despite not being statistically significant, in absolute values the gain in length of these current results is greater. We understand this to be a result of the surgical expertise and mainly to the application of continous traction provided by the JES Extender (8). This new technique was presented last February at the 8 th Andrology Congress held on 5-7 March, Spanish Association in Seville, Spain and at the 2nd World Congress of Phalloplasty Surgeons (American Academy) held on 17 - 18 October, 1997 in Aspen, USA.
The innovations presented in our proposals were very well received by the scientific community, where those present look forward to making this a standard technique internationally.

CONCLUSION
The videoendoscopic technique for penile enhancement, presents advantages in relation to the conventional technique, not as far as the gains accomplished but rather as being less aggresive and mainly, in its ability to eliminate the most frequent post-operative complaint - scar hipertrofica.

Bibliography

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