Frequently Asked Questions (FAQ)

Answers by Dr Rados Djinovic are verbatim quotes in blue italics. Answers by the case manager | patient advocate are like this.

For how many persons has Sava Perovic Foundation performed penile girth enhancement surgery using tissue engineering and scaffolds after the original international study about it?

>100.

(We stopped counting in 2008.)

Are there persons that have reported permanent results of less than the 1.8 cm of the original international study? If yes, how many?

Yes, roughly 30%.

Are there persons who have reported permanent results of 1 cm or less than that? If yes how many?

Yes, roughly 15%.

Are there persons that have reported permanent result of zero cm? If yes, how many?

None yet.

Are there persons that have reported permanent result of more than the 3.0 cm of the original international study? If yes, how many?

Roughly 5%.

What is the minimum reported result?

0.4 as I remember.

What is the maximum reported result?

About 4.5 cm.

Why do some patients get greater than average and other patients get lesser than average size increases from penile girth enhancement surgery using tissue engineering and scaffolds?

These cases are not clear to me too. For those men who get significantly ‘lesser’ gains, we can offer to repeat the surgery for only the basic cost of clinic and scaffolds.

Is it true that in 2009 Dr Perovic announced a major revision in the post-op therapy which he prescribes for men getting penis girth enhancement surgery using tissue engineering and scaffolds?

Regarding postoperative physiotherapy — it is best to start with an Andropenis stretcher about two weeks post-operatively (when the wounds have healed). In the beginning, hold it 2-3 times per day for about 20-30 minutes each time in the beginning and slowly increase the time so eventually, after 3-4 weeks, you hold your penis for 5 or 6 or 7 hours/day Using a vacuum device is better postponed until about four weeks after surgery with the same protocol as published online.

How soon after penile enhancement surgery can a patient return to work?

After 3-4 days.

How soon after penile enhancement surgery can a patient go swimming, play contact sports and have sex?

Swimming after 2-3 weeks, contact sports and sex after 6-8 weeks.

Can interested persons view more before and after photos and testimonials of penis enhancement surgery like those already published on the web site?

I have, but I need some time to locate them and send for publication.

What have been the most recent patient complications with penis enhancement surgery? Infections? Scarring? How many have occurred?

Only seromas, and maybe in approximately 10% of cases lately.

Does penis enhancement surgery have any impact upon future possible surgeries to the penis or groin area such as the prostate or penile implants for impotence and erectile dysfunction?

No.

During post-op therapy following penis enhancement surgery, why would weights be required only for some patients and can you increase length gains through the use of weights or traction devices?

Weights are not needed but traction devices such as that of Andropenis are very good. These are needed by patients who have a penis with pronounced retractility.

How many days after surgery do patients begin using a vacuum device?

Usually 2-3 weeks.

How many times per day must the vacuum device be used?

Two times every day for 10-15 minutes.

How long must the post-op therapy using the vacuum device be continued?

Approximately 3-6 months – until the healing process is finished.

Is the incision for ligamentolysis penis enlargement surgery in the pubic area?

NO, we do it through a subcoronal incision in the majority of patients.

Is it correct that no V-Y Plasty is used for ligamentolysis penile lengthening?

Yes, we do not use, nor do we like, V-Y Plasty due to the ugly scar and this technique places thick, fatty pubic skin at the base of the penis.

(V-Y Plasty, also known as a VY flap, is a surgical method for lengthening tissues in one direction by cutting in the lines of a “V”, sliding the two segments apart, and suturing in a “Y” shape to gain additional tissue.)

Are both the fundiform and suspensory ligaments cut during ligamentolysis penile lengthening?

Yes, in the majority of patients, we actually cut the ligaments that cause abnormal high insertion on the penis and which naturally pull it inside the body.

Is something inserted between the cut ligaments to prevent their re-attachment after penile lengthening?

Yes, we mobilize penile skin and fix it low to the tunica abuginea. Also we mobilize and insert fatty tissue from the pubic area when needed.

Will my erection angle be lower after ligamentolysis phalloplasty lengthening?

Only slightly or not at all because we never cut all suspensory ligaments, but only their distal part which does not affect penile angle.

Do scaffolds for penile girth enhancement completely convert into newly generated tissue within 6 to 16 weeks?

Yes.

Is it correct that between the bucks fascia and the shaft skin there is another fascia called the dartos? And in Dr Perovic's tissue engineering penile girth enhancement is the PLGA scaffold placed underneath the dartos and on top of the bucks fascia so it doesn’t actually touch the skin?

You are correct about the dartos and about the placement of the scaffold.

If that is accurate, does that mean the dartos fascia is also cut and retracted to the base as well as the skin during penis enlargement surgery phalloplasty?

Correct.

If during penile augmentation the PLGA biodegradable scaffolds are placed on the penis when stretched, what happens when it is no longer stretched? Could the scaffold buckle?

No, scaffolds do not buckle. They soften soon and slightly adapt, but also hold the penis in a slightly stretched position until they resolve.

Is there a gap between the end of the scaffold and the glans after Perovic penis girth enlargement surgery using tissue engineering with biodegradable PLGA scaffolds?

No, we put scaffold up to the glans.

Is the polylacti-co-glycolic acid (PLGA) scaffold tapered towards the glans during Perovic penile enlargement surgery?

No, it is not.

Is there a medication to stop painful erections for a few weeks after Perovic penile enhancement surgery?

Yes, but we do not want to have healing and tissue modeling in flaccid state. Erections are painful in the beginning, but very welcome.

Should antibiotics be taken before arrival in Belgrade for surgery and after the procedure has been completed?

Antibiotics should be given intravenously immediately before surgical incision so their level in blood and tissues is sufficient at the beginning of surgery. It happens within a few minutes after IV injection.

(Patients do not need to medicate themselves in preparation.)

Does Dr Djinovic do penile lengthening using 'rib cartilage in the space between the glans cap and tips of the corpora cavernosa' as per the article in the British Journal of Urology International 2000; 86:1028-33 (ISSN: 1464-4096)?

We DO NOT perform lengthening with cartilage any more.

(He also does not do penile enhancement using fat or silicone.)

Can Dr Djinovic do penile curvature correction at the same time he does penile enhancement surgery on a patient?

We can perform both curvature correction and penile widening procedures at the same time.

If the scaffold is placed in a flaccid penis during penile augmentation, how can it be long enough to cover the entire penile shaft when erect?

It is placed in a stretched flaccid penis.

Why are scrotal dermal cells no longer required to seed the scaffolds during penis enlargement surgery?

Because the results are equal and only serum treatment method is much simpler and patients do not need to come to Belgrade twice.

Are the scaffolds used for penis enlargement placed between the penis skin and the buck's fascia?

Yes.

During penis girth enlargement are the biodegradable scaffolds placed on top of or underneath the colles fascia?

Colles fascia is in the perineum and is not in contact with scaffolds.

Does the new tissue created from phalloplasty scaffolds to achieve penile augmentation attach to the skin or the fascia?

It is attached to the fascia.

Where is the penile skin cut during Perovic penile enlargement surgery in order to deglove the penis for an uncircumcised patient who wants to retain his foreskin?

A circumcoronal incision is done 6-7 mm under the glans.

What is the difference between “compliant” and “non-compliant” penile skin when referring to penile enhancements?

Compliant skin is loose and abundant providing enough space for scaffolds placement while non-compliant is tight, especially in erection and does not provide enough space for scaffolds expansion.

What scaffold thicknesses are available for penis girth enlargement patients to choose?

3 and 4 mm thicknesses.

Can penis girth enlargement be performed under a local anesthesia?

Yes, if a patient insists and he is compliant with that kind of anesthesia.

Does penile length become shorter after penis girth enlargement?

Yes, but only temporarily until scaffolds start to reabsorb and become soft, usually 1-2 months.

What are the possible complications of penis girth enlargement and what is done to remedy them?

Seroma formation is the main complication and it can be hardly predicted. It usually forms in patients who do not follow advice for abstinence from masturbation and sexual intercourse (for avoiding friction).

Of course, the remedy is for the patient to STOP HAVING SEX until fully healed.

In some cases, anti-inflammation and/or antibiotics need to be taken.

What are the details and specifics of the Perovic-Djinovic variation of ligamentolysis penile lengthening?

For penile lengthening, in most cases we use ligamentolysis which gives penile lengthening in flaccid state. Also in obese patients we do liposuction of the pubic region, as well as penile skin reconstruction where indicated in order to expose and in this way lengthen the penis in flaccid state. Autologous tissue culture is used for penis girth enlargement, not lengthening. The results are permanent. Presently in the world, there is no good and reliable technique for glans enhancement. We can do male breast reduction (gynecomastia) simultaneously as well as nipple reduction.

Is it true that the secret to gaining the most from penile lengthening surgery is to make certain that the surgeon you choose does NOT re-attach ANY of the web or ligament structures but instead builds a flap behind those structures to prevent re-attachment and that this has the downside of changing erectile angle but the upside of allowing far greater length gains?

Correct.

Would Foundation surgeons perform a girth enhancement procedure on an individual who has HIV but is in excellent health?

The answer is no. No one from our staff will take this risk. This is aesthetic surgery, not necessary surgery.

What happens to the veins that are prominent on a natural erect penis after tissue engineered scaffold surgery by Dr Sava Perovic? Are they still visible?

Scaffolds have nothing to do with the prominence of veins — it is simply normal variety. They are visible after surgery like before.

Do you perform surgery to divert a vein or other source of blood flow into the penis so it has a greater amount of blood which makes the penis grow to hold the volume?

No, it didn't’t show any good long-term results.

What is the risk of damage or numbness to a penis as a result of adding length or girth using Sava Perovic's tissue engineering with PLGA scaffolds?

Very low risk of temporary numbness. It is more often seen in some other penile surgeries where the neurovascular bundle is mobilized and stretched, but not in our technique for penile enlargement.

Does Perovic tissue engineering penis enlargement have any other advantages over dermal grafting,

Not cutting any pieces out of you is a BIG advantage over any procedure that does. It is cut-and-paste vs. hi-tech regenerative medicine.

Tissue engineering is extremely complex and requires a very high level of surgical skill and a good support team.

Perhaps that is why more doctors don't use tissue engineering which is far superior to any other method.

In addition, patients who get their penis enlargement from Dr Djinovic experience no complications except for the 3% of guys who have sex just a week after the surgery instead of the recommended four weeks.

Those minor complications can be treated with moderate amounts of common antibiotics.

The hi-tech polylacti-co-glycolic acid scaffold (PLGA) was made by Regen Biotech Inc., Sungnam, Korea, which has 108 patents for tissue engineering and regenerative medicine. They got the raw PLGA material from Alkermes, Inc. of Cambridge, Massachusetts.

This technology and surgery has been around more than a decade and works better than anything else.

There are no sheets of tissue used.

In the early years, fibroblast cells harvested from just 1 cc of biopsied scrotal dermal tissue were cultured and then seeded on the biodegradable, pretreated PLGA scaffolds. Later, blood serum was used instead.

A patient's body gradually replaces them over a four-month period with your own tissue in a natural way.

The result is 100% the patient's tissue with no foreign substance around the penis.

Only penis — no fat, no Alloderm, nothing synthetic.

The disadvantages of other surgeries are risks of serious complications, such as penile deformities (from lipofilling and dermofetal grafting), fibrosis, penile shortening (Alloderm), skin injury and necrosis (various liquid implants).

What kind of length gain have you seen typically from Perovic penis enlargement surgery?

Penile “enlargement” includes both the lengthening and widening procedures.

Dr Djinovic uses ligamentolysis for penile lengthening which is the only way to safely increase length.

Length increase in flaccid state tends to be one inch and less than that in erect state because the suspension system is reworked but the actual penis is not augmented to make it longer.

In obese patients, surgeons could do “wet” liposuction of the pubic region, as well as penile skin reconstruction where indicated in order to expose and in that way lengthen the penis in flaccid state.

The increase in length:

… depends on the local findings and patient’s constitution (such as penile skin distribution, pubic fat, tissue characteristics) but the gain ranges from 1-4 cm (0.4 to 1.6 inches). In some cases there is no increase in length. The final result is visible after 4-6 months usually and it is lifelong.

Increase in circumference (girth) was approximately 30% in the initial pilot study done a decade ago [mean value of flaccid girth gain 3.15 cm (±0.42, range 1.9  to 4.1 cm) | mean value erect girth gain was 2.47 cm (±0.49, range 1.8 to 3.0 cm)].

Significant but not massive size increase is the trade off for the safety, success, permanency, and few, minor complications of tissue engineering by Dr Djinovic.

The procedure could be repeated a year later for additional gains and some patients are considering their third girth enhancement.

It was possible to calculate the approximate immediate increase in girth after surgery using the formulas:

[Circumference = pi x Diameter] and

[Diameter = Circumference / pi]

… because the scaffolds were exactly 4mm thick which meant an instant 8mm increase in diameter

[(original penile diameter + 8 mm) x 3.14].

How that morphed over the subsequent months varied from person to person.

Penile diameter can be calculated using circumference.

What's the the effect of penis enhancement surgery on sensations, pleasure, orgasms, stiffness of the erection, and effect on ability to penetrate?

The surgery does not injure any nerves or other important structures, so all of the above mentioned are fully preserved.

Does penile lengthening (ligamentolysis) result in the penis pointing downwards and a hairy base of the penis and slipping and shifting during intercourse?

There is some downward penile pointing, but the other two problems — no. After ligamentolysis the angle goes down a little, but it does not affect penile stability.

Hasn't anyone developed a method for re-anchoring the penis after ligamentolysis penile lengthening to avoid the reported problems of slipping and shifting during intercourse?

It is not a problem to perform, but it would nullify the effect of ligamentolysis.

What post-operative procedures must patients follow to get maximum results from the penis enlargement surgery? Pumps? Weights? What?

Vacuum device is advised for all patients, a stretching device for most.

Where will the incision for the penile lengthening be done during penile enlargement surgery? Or is it done during degloving?

We use the same subcoronal circumcising incision made during penile degloving.

Why not do penis enlargement surgery by putting an Allograft (see AlloDerm® below) dermal matrix graft under the proximal glans cap for glans enhancement?

It gives only temporary glanular widening. There is no real possibility of enlarging glanular spongiosal tissue.

Why not use AlloDerm® for penis enlargement?

You may find some well-known surgeons touting AlloDerm® and even bragging that they use ONLY AlloDerm®.

The biotechnology company that manufactures AlloDerm® and Cymetra® (an injectable form of AlloDerm®), LifeCell Corporation, will not and does not recommend their product for penis enlargement phalloplasty.

In fact, the USA Food and Drug Administration (FDA) regulates it's use and has specifically NOT approved Alloderm® as a “void filler” nor for “cosmetic augmentation”.

LifeCell warns phalloplasty surgeons that it is “important to clarify” that: “cosmetic augmentation phalloplasty does not fall within approved procedures for which LifeCell can promote AlloDerm®”.

So even though some plastic surgeons still use this biological material for penile girth enhancement regardless (they prefer to call it a "sheet of collagen created from deceased humans"), Sava Perovic Foundation considers it inadvisable and warns:

AlloDerm® is not resorbable and gives serious scarring. It is very dangerous with possible disastrous results such as risk of fibrosis and penile shortening. Tissue culture is safe. After scaffold reabsorption there is no residual foreign tissue around the penis. The shape after surgery is excellent.

Why shouldn't I get 1-hour glans penile enhancement using hyaluronic-acid gel injected over the entire glans penis using a 30 gauge needle and local anesthesia which gives a 20% increase in girth for about 12 months?

It has only temporary and short-term effect and cannot convert into sponge-like glans tissue.

Why doesn't Sava Perovic Foundation do autograft dermal fat grafts or porcine dermal matrix grafts?

With dermal grafts there is risk of penile deformities and with porcine dermal matrix grafts there's very high risk of serious fibrosis and permanent penile shortening.

(Fibrosis is the formation of excessive scar tissue in response to injury.)

Why is flaccid, not erect penis size, usually used when talking about the results of penis enlargement surgery?

Actual increases from penis enlargement (penile lengthening) surgery are less significant than with girth enhancement surgery and much less noticeable in the erect state.

Real penile lengthening (i.e.; lengthening of corporal bodies) is NOT a routine and safe procedure because of high risk of losing the ability to have an erection. It can be done safely only in patients with erectile dysfunction or Mb Peyronies concomitantly with implantation of penile prosthesis. We usually do only ligamentolysis, liposuction of pubic area and skin redistribution. All we (all surgeons) do is to expose the penis more outside body — it is especially visible in obese patients and in ones with different deformities of penile skin here the penis is covered.

Are penis enlargement exercises of the penis muscles effective?

No way! Because, except in the case of a Perovic Total Phalloplasty neophallus, the penis is not made of muscle but rather veins that produce an erection through congestion and vasodilatation. Penis exercises are useless and a lie with no medical basis.

Does Dr Perovic's penis enlargement surgery produce “permanent” results that will last a life time?

Yes.

What is the location and extent of scarring resulting from penis enlargement surgery by Sava Perovic Foundation?

There is a subcoronal circular scar, hardly visible in the majority of patients.

What stitching material does Dr Djinovic uses for penis enlargement surgery and do patients need to have it removed later by a doctor their local area? If so, when?

We always use very thin, resorbable sutures, so there is no need for their removal — the stitches fall off after 2-4 weeks.

I had a partial suspensory ligament cut done in the past but it failed. Can you redo it?

Yes, no problem.

I want buttocks liposuction when I get my penis enlargement phalloplasty. Can Dr Djinovic do that? And does he use wet or dry liposuction?

This can be done. We prefer 'wet' liposuction.

Exactly how many cases of penis enlargement surgery has Sava Perovic Foundation done?

As of October 2007, we had done more then 300 cases of penile enlargement using PLGA scaffolds. The results are nicely presented in the article on the Medical-Tourism-in-Thailand.COM web site. Complications are minor and all are treated without the need for more surgery.

(From 2008 the surgeons stopped keeping record of the number of times they have done this elective surgery.)

What happens to old fat injections when you do penis enlargement using PLGA scaffolds?

Autologous fat injections are compatible with our tissue engineering using biodegradable PLGA scaffolds for penis enlargement. If the result of the past fat injection is satisfactory to the patient we can preserve it and to add scaffolds under or over it. We usually remove it because of a lot of irregularities and uneven contour — bumps and lumps. But IF the result is acceptable and the patient wants that — we can also preserve it.

Do the Thai plastic surgeons who have studied Sava Perovic's "penile enhancements using tissue engineering with biodegradable scaffolds" procedure perform it in Bangkok?

They do not have scaffolds, nor the appropriate lab in which to prepare it as they should so they cannot have the same results. And of course, there are many tricks in this procedure …

(These Thai doctors do their own personal adaptation of Perovic techniques and procedures in a buffet-style manner. They do NOT do the exact same things in the exact same way as the Professor and have their own rates of success and complications.)

Are there any girth gains when the penis is erect through the tissue engineering with biodegradable PLGA scaffolds phalloplasty which Dr. Perovic performs? Is the penis circumference increased in both flaccid and erect state?

Yes, there is also girth gain in the erect state.