There are qualified and experienced surgeons performing successful penile enlargement surgeries in the world today, but sometimes men do not manage to select such a person for their penis enlargement surgery. When a man has had the misfortune to join the thousands of men who have experienced an outmoded or failed phalloplasty surgery, he is often faced with problems ranging from disfigurement to dysfunction. When these unhappy situations occur, reconstruction surgery provides a way back toward normalcy.

Reconstruction of penile enlargement surgery can be necessary due to a number of different complications from previous surgeries. Sometimes these complications are the result of more than one procedure performed incorrectly, or even of use of outdated procedures. For example, the injection of fat to increase the girth of the penis is a technique still practiced by a few physicians. They defend this outdated technique, even though it risks an enormous number of complications, ranging from perforation of the bowel during fat harvesting to multiple lumps and bumps on the shaft of the penis. This penile enlargement technique is still practiced in the United States even though it has never been approved by the FDA, and despite the fact that a few physicians have lost their medical license as a result of using this technique.

Dr. Alexander Krakovsky does not offer fat transfer or injection for penile augmentation and he does not recommend using the fat transfer technique (Free Fat Transfer, or FFT) for penile augmentation. As mentioned, this technique can result in multiple complications that are not obvious immediately after surgery because of post-surgical swelling. After the swelling subsides and fat is reabsorbed, it becomes clear that there is almost no enlargement; multiple lumps and bumps appear; and the surgeon recommends that more fat be injected. The cost effectiveness of this technique is also very questionable, since it requires many years of maintenance to retain the desired girth enhancement. This is because injected fat is not anchored, and tends to be absorbed into the body, unlike the fat attached to skin grafts or dermal grafts.

Injected free fat can also move around and create bumps and clumps that give an uneven appearance or an unnatural shape to the penis. Other complications can occur as a result of the FFT technique, such as penile retraction, curvature of the penis, and infection.  Despite the fact that new technologies have been developed for fat harvesting and preparation, the old technique of injecting fat into the shaft of the penis continues to create penile deformities that require full and extensive reconstruction surgeries. Dr. Krakovsky has performed a significant number of reconstruction surgeries for men who have experienced the FFT technique. He removes the fat (because it deforms the penis) and substitutes a permanent graft.

Of course, even the best techniques can be performed incorrectly if the surgeon is not qualified or experienced. For example, although both dermal fat grafts (skin grafts with the fat attached, or DFGs) and AlloDerm (R) grafts are state-of-the-art methods for increasing penile girth, these surgeries can be practiced incorrectly. (For more information about AlloDerm, see the AlloDerm section on this website.) Incorrect stitching can cause these graft(s) to move from their original location and concentrate on the side of the penis and/or at the base of the penis. Other complaints can include a curving or shortening of the penis that can make the erect penis shorter, an unbalanced or unnatural appearance, and areas that feel hard to the touch. These complications can be eliminated using more modern graft positioning techniques, such as penile degloving and uniform side stitching.

One outdated technique for penile girth augmentation with grafts involves stitching the graft(s) in only two places: on the penis head and at the base of the penis. This type of approach runs a number of risks. The graft can be displaced and moved to unpredictable locations, such as the base of the penis. This can create situations where the penis appears deformed or misshapen. The graft can also shift laterally, causing the middle section of the front of the penis to become empty, while increasing the size of the side of the penis. The result is a crater-like effect along the front of the penis. Several phalloplasty surgeons, who have never undergone the appropriate training, still practice this old stitching technique, and therefore patients continue to develop these complications. Modern techniques avoid these problems by adding stitching on the sides and in the middle of the graft(s), in addition to the stitches on the penis head and at the base of the penis. This eliminates the problem of grafts migrating from their original location.

Another outdated technique for girth and glanular enhancement with grafts uses grafts that are too small, thin, narrow, or insufficient in quantity. The old technique for use of DFGs implements a skin graft that is two or even three times smaller (thinner, shorter, and narrower) than the graft used in current up-to-date techniques. The old technique for use of AlloDerm uses grafts of much smaller dimensions, and also uses an insufficient number of AlloDerm layers. As a result, the grafts cannot fill the space between the skin and the tunica albuginea. This is not obvious to the patient immediately after surgery, due to post-surgical swelling. However, once the swelling subsides, it becomes clear that there has been very little enlargement of the penis. In addition, the graft can become dislodged because of this extra empty space, and the absorption rate is higher, quicker, and faster than with modern techniques, Modern techniques have eliminated all of these complications. The size of the DFGs has been increased to three times what it was, allowing them to completely fill the space between the skin and the tunica albuginea; the quantity of AlloDerm sheets used for penile enlargement has also been increased in size and in quantity. Finally, modern phalloplasty techniques have eliminated the problem of graft dislodgement.  

Despite its lack of approval by the FDA, as well as the inherent disadvantages, risks, and relative ineffectiveness of FFT (absorption by the body, uneven distribution, and unpredictable shifting and displacement), the technique for inserting it into the body is still practiced by several surgeons in the United States. This is because this technique is less invasive, resulting in a much lower infection rate than for permanent grafts; This does not in any way outweigh its liabilities. FFT involves injections, while grafts require incisions that, as with any surgical incision, must heal. Of the two types of graft, AlloDerm (R) tends to have a higher rate of infection than DFGs. However, with proper technique and follow-up care, infections should not occur. Follow-up care includes the patent’s compliance with post-surgical instructions and guidelines provided. Even should an infection or wound opening occur, these complications are treatable, whereas the complications associated with FFT require complete penile reconstruction, including removal of the injected fat.

As with complications due to girth and glanular enhancement surgeries performed incorrectly or with outmoded techniques, complications can occur as a result of penile lengthening surgery performed incorrectly or because of use of questionable surgical techniques. Incorrect performance of penile lengthening surgery does not necessarily refer to post-operative loss of the penile length achieved during surgery. Maintenance of penile length following penile lengthening surgery depends greatly on the patient’s compliance with the one-year follow up stretching program necessary to maintain length gain. It also does not refer to the amount of length gained, since this varies, and is something that cannot be predicted before surgery. However, some surgeons use lengthening techniques that tend to produce complications for the patient. These can be both cosmetic, such as unusually large scars or permanent loss of pubic hair, and functional, such as a loss of sensation in the penis, or even, in extreme cases, chronic pain, or impotence. Many of these complications occur as a result of use of the very old incision technique known as the VY flap, still used by inexperienced surgeons, when combined with the recommended and accepted practice of releasing the fundiform and suspensory (and collateral) ligaments.

Again, it is important to remember that some complications can occur as a result of not following the recommended pre- and post-operative guidelines for penile enhancement surgeries. However, these complications tend to be of a different nature than those requiring reconstruction. For example, if washing and wound care are not done properly, infection can occur. The treatment for these types of complications from penile enlargement surgery does not normally involve reconstruction surgery. Rather, it can involve antibiotics, repair, or in rare instances, temporary insertion of a drain and/or repetition of the original surgery with removal of grafts.

Besides the physical complications the patient brings to reconstruction surgery, he also brings psychological complications. After any traumatic experience, people tend to be less trusting and more cautious and fearful. They tend to have their own theories about what happened, which may or may not be correct, or they tend to be anxious because they do not understand what happened. The patient may already have worsened his situation by seeking help from another unqualified surgeon, increasing the existing complications. The patient may be in pain, or he may be very concerned about the effects the situation is having on his relationships, his self-image, and/or his ability to perform daily bodily functions.

Obviously, in these situations, a great deal of exchange of information and education of the patient is required. The patient must be thoroughly examined both physically and through taking a history of what has occurred. Next, the patient must thoroughly understand what has created his current situation, and what options exist for improvement through reconstruction. The patient must get to know the surgeon well enough to trust in his integrity, knowledge, and ability to help him. Only then can the patient, with the guidance of the surgeon, make choices about the types of reconstruction surgery or surgeries he wants to undertake.

It is important to note that many patients have unrealistic expectations when undergoing this surgery. Despite what is written above, they think that their penis will be reconstructed exactly as it was before, and that there will be no restrictions regarding augmentation. These expectations are absolutely unrealistic and can create tremendous dissatisfaction for the patient. This dissatisfaction can, in turn, compromise the reputation of the surgeon and his techniques. The patient must have realistic expectations when undergoing this surgery. The surgeon will explain what can be fixed and what cannot. He will also inform the patient of the minimum and maximum positive outcomes he can expect from the surgery. The patient should understand that sometimes the minimum is all that can be attained.

Dr. Krakovsky is a very compassionate and caring surgeon, and these qualities are important for men seeking reconstruction. Dr. Krakovsky takes as much time as necessary to be sure that the patient is provided with the answers he needs to make the right choice. Dr. Krakovsky has also developed a number of tools to help his patients to be fully informed and feel confident about their surgery, what is going to happen during the surgery, and what the patient must do to help make the surgery successful. Dr. Krakovsky’s patients who have undergone reconstruction surgery are very grateful for the improvements this surgery provides. They feel much better about themselves and their future, and report that they feel more confident in their appearance and their ability to lead their lives.

Dr. Krakovsky requires that the patient arrive in San Diego the day before surgery for a final pre-surgical appointment and final preparations for the surgery. The success of this surgery requires complete bed rest after the surgery and overnight. Usually, the patient must stay in the area for three to four days after the surgery, so that Dr. Krakovsky can guide, reassure, and tend to the patient during this time. Regular follow up with Dr. Krakovsky, either in person, or by phone or email is also critical to ensure that the healing process is proceeding as it should.

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