In order to compare the men who have responded to this questionnaire and the average public the researcher investigated numerous studies that took penile measurements. Contradictions dealing with penis size were endless. Past and present surgical techniques that are used to enlarge a penis will be explained in detail. The wide use of dermal and fat transplantations are expanding the many fields they influence. A few doctors who currently perform penile augmentation surgeries have questioned some of their patients and have compiled their basic characteristics and their surgical results. This is the only comparison data the researcher has found that relates directly to this investigation.
The Cry for Objective Research
The ultimate question is whether or not penile augmentation surgeries should be performed in the first place. The current techniques used by doctors around the world vary widely and have not been scientifically investigated. Robert Goldwyn, M.D. (1988) wrote a brilliant editorial addressing these issues. His article cries out for methodological research done by "objective persons" who will investigate the field of plastic and reconstructive surgery. Goldwyn requests research about surgeries that are "patently unnecessary" for the patient's physical survival. There is little scientific research conducted on the results of penile augmentation surgeries. Penile augmentation and lengthening surgeries fall into the "unnecessary" category. The editorial focuses on whose responsibility it is to make sure that these surgeries are beneficial to the patients.
Hennie Roos, M.D. and Irving Lissoos, M.D. (1994) clearly state that "orgasm in the female is not dependent on deep penetration" and that "the increased length will not lead to more stimulation in the female partner." There is "no logic behind penis lengthening ... it is the visual perception," claims Gary Griffin (1995), the author of "Penis Power Quarterly." These are important factors in evaluating the beneficial or detrimental effects of genital surgery.
Opponents of the surgical practice of penile enlargement have surfaced and voiced their opinions. Doctors who perform these surgeries are often alienated, so Griffin set up biannual private meetings to allow doctors who perform enlargements a platform to share their techniques, best results and much more. These meetings increase the uniformity of the different surgical procedures. The group met twice in 1994 in Southern California.
The surgical enlargement and elongation of the penis has been compared to breast enlargement because the latter also has no beneficial purpose other than aesthetics. Many studies have been done on women who have had breast enlargements. One such study (Schlebush & Mahrt, 1993) revealed a significant rise in their self-esteem ratings and reduced levels of anxiety and depression after surgery.
Meanwhile, very few studies have been conducted using penile augmentation patients as subjects. Some of the findings in those studies revealed low complication/infection rates and undiminished erectile capabilities or penile sensations after surgery. Overall patient satisfaction was considered high. However, considering that these studies were conducted by the doctors who also performed the surgeries, there is an inherent bias. This points to a strong need for unbiased research on this subject by objective researchers.
Throughout history there have been a variety of references to penile enhancement. The Indian Sadhus and Peruvian Cholomecs used weights, similar to the Penile Tissue Expander, to attain increased lengths of 12 to 18 inches. Their penises were not usable; they were altered simply for the sake of aesthetics. The Dayaks of Borneo (Talalaj & Talalaj, 1994) mutilated their penises for their partner's pleasure. They would stick needles through their glans and leave them there until a hole had formed. The next step was to find items to stick in the holes that would stimulate his partner. The man with the most decorations was said to be the best lover and all the women then pursued him.
The Topinama of Brazil (Talalaj & Talalaj, 1994) in the sixteenth century would significantly enlarge their penis by encouraging poisonous snakes to bite their penis. They were in pain for approximately six months but the men felt the pain was worth the sacrifice. At the end of the six months the men had a monstrous sized penis that delighted their women.
In the Kama Sutra of Vatsyayana (Burton, 1962), men are encouraged to use Apadravyas which "are put on or around the lingam to supplement its length or its thickness, so as to fit it to the yoni." There are quite a few sexual rites that originate in India. There is a principal Hindu god named Siva who is always represented by an erect phallus. Siva is worshipped by the phallic representation that can "be as small as a fist or as tall as a tree" (Talalaj & Talalaj, 1994).
In order for penis augmentation to become a booming business there has to be a high demand. The perceived need for such a surgery has reached a wide range of men. Men often feel a need to enlarge their penis in order to satisfy their partners more successfully. No matter how many sexual myths sexologists repeatedly knock down about penis size it will continue to be an issue. Dolores E. Keller, Ph.D., wrote a short article regarding women's attitudes on penis size. She conducted interviews with 57 sexually active women with an average of 4.2 partners over a period of two years. The women ranged in age from 17 to 52 years old. All but six of the women reported being "more stimulated either by the physical presence of, or fantasized pleasure of, the bigger penis". In the same article, Maj-Britt T. Rosenbaum, M.D. wrote her opinion on the importance of penis size to women. She believes that "penis size ranks fairly low on most women's lists of physical attributes important to sexual attraction" (Rosenbaum & Keller, 1976). Some women attach more importance to penis size than others, often equating the size of the penis to a man's masculinity.
The contradictory information uncovered throughout the many scientific articles is simply amazing. The mean and standard deviation of adult penis sizes differed in each journal article. According to William A. Schonfeld and Gilbert W. Beebe, (1942), it has long been evident that there is a clinical need "for more thorough knowledge of normal variation in the size of male genitalia." In their study, they refer to the erect length of the penis as its length when it is fully stretched. The measurement was taken from the mons veneris to the tip of the glans. The erect circumference of the penis was estimated by means of a regression equation. The age group from 20 to 25 years old included 54 subjects whose mean erect penis length was 13.02 cm. (5.13 in.). The flaccid circumference measured 8.55 cm. (3.37 in.) and the equated erect circumference of 11.39 cm. (4.48 in.).
The "phallic fallacy" is the belief that a larger flaccid penis increases more in size during erection than a smaller flaccid penis does. William Masters, M.D. and Virginia Johnson's (1963) data found contradicting results. Alfred C. Kinsey and his associates (1948) collected data concerning penis sizes from 3,500 males. These measurements were used by Paul L. Jamieson and Paul H. Gebhard (1988) to test the phallic fallacy. Taking the average of both Kinsey's larger and smaller penis groups, he found the mean flaccid penis length was 3.89 inches with a standard deviation of .73 inches. The mean erect length was 6.21 inches with a standard deviation of .77. The volunteers also measured flaccid and erect penile circumferences. The mean flaccid circumference was 3.75 inches with a .65 standard deviation. The mean erect circumference measured 4.85 inches with a .71 standard deviation. The researchers found that the average penis length increases 63.4% upon erection and the circumference increases by 32%. Jamieson and Gebhard were quite aware that "the variability in penis size will be likely to continue to intrigue ... specialists in the study of human sexuality, as well as the general public." This is the only data set that includes standard deviation of the measures.
According to A Descriptive Dictionary and Atlas of Sexology (Francoeur et al., 1991), the human penis in a flaccid state on average is between 3 and 4 inches in length and 1 inch in diameter. In an erect state, the penis, on average, is between 5 to 7 inches in length and 1.5 inches in diameter. The dictionary also defines "phallic identity" as "the tendency of males to seek their identity in their penis with an emphasis on the belief that ‘bigger is better'." "Phallocentrism" is an explanation of sexual development in which the penis is central and symbolically powered.
In his article on The ‘Small' Penis Syndrome, John Murtagh, M.D. (1989) included average penile sizes. He found the average length to be 3 to 4 inched flaccid and 5 to 7 inches erect. The average circumferences were 2.5 to 4 inches flaccid and 4 to 6 inched erect. Murtagh has found that males often visit their doctors for counseling about their anxiety relating to the size of their penis. Some males become preoccupied with the size of their penis when they enter a more sexually active lifestyle. "It is a manifestation of abnormal body image".
Body Image/ Self Esteem
Roos and Lissoos' (1994) patients were asked why they wished to obtain a penis elongation. Seventy-nine percent answered "self-image" whereas 14% said "functional", 6% said "congenital" and 1% said it was because of trauma. Their article on penis lengthening emphasizes that "a man's self-image is severely affected whether he is just under endowed or has a true micropenis." "The psychological importance of penis lengthening is underlined by the fact that the operation does not necessarily improve sexual function or performance." According to the article, the size of a man's penis is less important during sexual intercourse than in the changing rooms where machismo and self-image are at stake. "Small Penis Syndrome" is described as anxiety over the size of a man's own penis. Roos and Lissoos believe that "some men may even harbour pathological tendencies (attempted suicide) because they believe that their penises are undersized whether this is in actual fact true or not." Some patients may benefit from counseling while others have had their self-image beaten so badly that only surgery can correct their concerns. According to this South African study (Roos & Lissoos, 1994), "most heterosexual patients confessed that their fears and anxieties concerning their penis size had sprung not from the reaction of women during sexual relationships, but from the denigrating behaviour of other males."
History of Surgical Techniques
The first known human adipose tissue transplantation was attempted in 1893 by G.A. Neuber, M.D. (Billings & May, 1989). Each study concerning adipose tissue transplantation obtained different results leaving researchers confused. The studies were performed on many different mammals including humans, pigs, and rabbits. James May, Jr., M.D. (Billings & May, 1989) of Massachusetts General Hospital has concluded that the "results of free fat autotransplantation were found to be quite unpredictable." He also said that "this subject appears ripe for investigation."
F. Schorcher, M.D. (1957) reported his results using fat grafts on 200 mammaplasties. He found that the fat shrinkage was down one fourth of its original size by 6 to 9 months. Lyndon Peer, M.D. (Peer, 1977) found that adipose tissue grafts lost approximately 50 percent of their weight and volume one year or more following transplantation. He also claims that the survival of the adipocytes is directly related to early revascularization.
The procedure of fat removal is very delicate. According to Abram Nguyen, M.D. (Nguyen, Pasyk, Bouvier, Hassett, & Argenta, 1990), after a suction procedure, only 10 percent of the fat cells remain intact. A significant number of adipocytes are ruptured.
A dermal fat graft (photos 7.1 - 7.9) is a free graft "consisting of all the layers of skin and underlying subcutaneous fat remaining after the removal of the epidermis" (Sawhney, Banerjee & Chakravarti, 1969). It is thought that by placing the rich surface of the dermis against the receptor site that early revascularization will increase the chances of survival. It has been found (Billing & May, 1989) that this method makes the "graft easier to manipulate, stronger, and very stable and allow it to survive and ‘heal in' rapidly." Sawhney et al. found that dermal grafts will have lost approximately 33 percent of their bulk after the first 8 weeks. The dermal tissue sustains its bulk while the fat is slowly but completely replaced by fibrous tissue. Sawhney's pig studies found after one week after transplantation that the consistency of the dermal graft was soft with 70 to 90 percent of the fat preserved in all sections. There was some evidence of fibrosis around the edges of the graft. After two weeks, they found that there was a 9 percent reduction in the volume of the transplant. Four weeks after transplantation the bulk of the graft had decreased by 20 percent. Eight weeks after transplantation there was a "decrease in the bulk of the graft by 33.3 percent (Sawhney et al., 1969)." At this point, very little fat was observed because most had already been replaced by fibrotic (scar) tissue. In conclusion, Sawhney et. al. found that dermal grafts take best when provided with a complete absence of germs and a quick and atraumatic transfer.
Penile elongation was performed in more than 260 cases in less than one year by Drs. Roos and Lissoos in South Africa. The surgical procedure includes an extensive dissection of the suspensory ligament by the urologist while the plastic surgeon designs a skin flap. They believe that "the suspensory ligament of the penis is of the utmost importance in penis lengthening surgery" (Roos & Lissoos, 1994). The skin flap can take the shape of a "Y" (photo 12.1), "Z" or an "M" which will release the skin at the pubis symphysis. The Y-plasty, Z-plasty or M-plasty supplies skin for coverage of the new penile length. The penis is reattached to the lateral skin flaps to ensure the formation of the suspensory ligament in its new forward position. This also adds stability to the new penis during erection. This procedure, which Roos and Lissoos currently use, ensures that the angle of erection will not change as it did with their old technique, a technique adopted from Professor Long Dao Chou (Long, 1990) of China.
Severing of the suspensory ligament enables the penis to extend closer to its erect length while flaccid. But this is not a guaranteed result. Some men will not gain any length or will experience a shortening due to fibrosis (shrinkage and toughening of tissues). Many doctors who perform penile enlargement and lengthening suggest that their patients buy a "Penile Tissue Expander" (Ken Jons, undated). The Expander "promotes the healing of the penis in the most outward position." The device consists of a weight system taped onto the penis to be worn six to eight hours daily. The patients are advised to start using the Expander five days post-op and continue indefinitely. One man wrote Ken Jons and asked why his penis seems more flexible at the base. Other questions involving sexual activities were also printed in the "Penile Tissue Expander" article. This implies that there are pertinent sexological issues that need to be investigated thoroughly.
Past Patient Characteristics
The age distribution of Roos and Lissoos' patients (1994) was 10.4% under 30 years old, 14.5% between 30.1 and 35 years old, 23.6% between 35.1 and 40 years old, 15.5% between 40.1 and 45 years old, 19.4% between 45.1 and 50 years old and 15.3% over 50 years old. The majority of cases (59.3 %) fell between 35 and 50 years old. A follow up time of 4 months for this study was insured only by contacting patient number 70 to patient number 170.
Successful surgical results of penile elongation is also dependent on a patient's general health and surgical history. Roos and Lissoos mention cigarette smoking, medication and scar tissue from previous operations as possible endangerments to skin flap survival.
Murtagh (1989) discusses the fact that "the size and shape of a man's penis are not related to other aspects of body build." When a man increases the size of his body with fat, muscle or both, his penis stays the same size. Visually, this makes the penis look smaller than before the gain. According to Dr. A and Dr. C, a good proportion of their clientele are body builders. These men can increase the size of any muscle in their body except their penis. With the help of urologists, plastic surgeons and a few thousand dollars, these men can now conquer nature.
Past Surgical Results
Roos and Lissoos (1994) found that the average increase in length was 1.57 inches or 4 centimeters. No patients reported a change in the angle of their erection or their ability for erections. Out of the 260 cases, serious infection was treated in four patients. They received close to one hundred percent positive responses to their surgical results of penile elongation.
Gary Rheinschild, M.D. (1995) studied ten patients who underwent a dermal fat graft procedure for girth enhancement and a releasing of the suspensory ligament for increased length. At four months post operation, the average increase in length was 1.25 inches and the average girth enhancement was 1.3 inches. All patients maintained their pre-operative erectile abilities and their were no complications resulting from the gluteal fold graft sites. Rheinschild felt that his study revealed good patient satisfaction.
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