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Autologous Fat Injection (AFI) — Penile Girth Enhancement

Autologous fat injection (AFI) for penile girth enhancement is one of the older penile-augmentation techniques, popularized in the early 1990s. Fat is harvested by liposuction from a donor site and injected subcutaneously around the penile shaft. The fat is autologous, but resorption is unpredictable (20–80% of injected volume in fat-grafting series)[13], and referral-center reports describe irregular nodules and penile deformity. These problems have made it one of the more controversial techniques in genital cosmetic surgery.[1][2][3][4]

For the broader male cosmetic-genital-surgery decision framework see the Male Cosmetic Genital Surgery atlas page. For the related dermal-fat-graft variant and ADM wraps see Dermal Fat Grafts & AlloDerm Wraps. For the reversible alternative see Hyaluronic Acid Filler.

I. Definition and Concept​

Autologous fat injection (autologous fat transfer, lipofilling, fat grafting) for penile girth enhancement involves three sequential steps.[1][5][6]

  1. Harvesting. Fat aspirated from a donor site (abdomen, flanks, thighs) via liposuction.
  2. Processing. Lipoaspirate refined (centrifugation, decanting, or filtration) to separate viable adipocytes from blood, oil, and debris.
  3. Injection. Purified fat injected into the subcutaneous tissue of the penile shaft (between skin / dartos fascia and Buck's fascia) to increase circumference.

Autologous fat is biocompatible, readily available and natural-feeling. The penis is a challenging recipient site because of its mobile, thin-skinned, cylindrical anatomy with a limited vascular bed for graft revascularization, and the mechanical stress of erection / detumescence cycles.[1][3]

II. Historical Context​

  • Early 1990s. Penile fat injection popularized alongside SLD as a combined "penile enlargement" procedure, heavily marketed.[2][3]
  • 1994. Trockman and colleagues reported a case of complications (two painful inflammatory nodules requiring excision).[8]
  • 1996. Wessells, Lue and McAninch reported 12 men who presented to one referral center over 16 months with complications of penile augmentation performed elsewhere. All 12 had suspensory ligament release and 10 had also received autologous fat injection. Irregular residual fat nodules were the chief complaint in 7, skin deformity and scarring in 4, and scrotalization in 4. Reoperation was needed in 6, wound complications occurred in 6 and sexual dysfunction was reported by 4. The authors concluded that the techniques "should be regarded as experimental."[2]
  • 1997. Alter reported reconstruction of deformities after penile enlargement surgery performed elsewhere. He listed "disappearance of fat, penile lumps and nodules, and shaft deformities" as the complications of fat injection.[3]
  • 2000s–present. Refined techniques (multi-layer injection, smaller volumes, Coleman principles) have been reported with fewer complications in small series, but unpredictable fat resorption persists.[1][9][10]

III. Surgical Technique​

A. Fat harvesting​

Donor sites.[1][5][6]

  • Abdomen. Commonly used; convenient; large volume.
  • Flanks / love handles. Good fat quality.
  • Inner thighs. When abdominal fat is insufficient.
  • Buttocks. Less commonly used.

Harvesting method.[5][6][11]

  • Suction-assisted liposuction (SAL). Standard; tumescent solution (lidocaine and epinephrine in saline) infiltrated, then aspirated through a blunt-tipped cannula.
  • Syringe aspiration (Coleman technique). Manual aspiration via 10 mL syringes attached to a blunt cannula; gentler on adipocytes.[6]
  • Cannula size. A technical review recommends a 4-mm harvesting cannula, based largely on laboratory and animal-model comparisons.[5]
  • Low negative pressure. Excessive suction damages adipocytes, and gentle controlled aspiration is preferred.[5]

B. Fat processing[5][6][11]​

  1. Centrifugation (Coleman). 1,200g × 3 min; three layers (oil top / concentrated fat middle / blood-fluid bottom). The middle layer is used for injection. This is the most widely standardized method.[6][11]
  2. Decanting / gravity sedimentation. Simpler but less consistent.[5]
  3. Cotton-pad filtration. May preserve adipocyte structure better than centrifugation.[11]
  4. Soft centrifugation. 400g × 1 min; compromise between concentration and viability.[11]

Principle. In He 2022 (human lipoaspirate; in vitro and in vivo comparison of three processing methods), Coleman centrifugation caused more cell-structure destruction and viability loss than cotton-pad filtration or soft centrifugation, and volume retention rates were similar in the three groups.[11]

C. Injection technique (penile-specific)​

Kang 2012 (n = 52). This series gives the most detailed published technique for penile fat injection. Fat was injected into the superficial, middle and deep layers of Colles' fascia; the remaining details below are from the full paper.[1]

  • Injection plane. Colles' fascia (dartos fascia), the subcutaneous layer between penile skin and Buck's fascia.
  • Multi-layer injection. Superficial, middle, and deep layers of Colles' fascia for even distribution.
  • Entry points. 2–4 small stab incisions at the penile base or along the shaft.
  • Injection volume. Mean 38.54 mL (range 25–49 mL) in Kang’s penile fat-injection cohort.[1]
  • Technique. Small aliquots in a retrograde, fanning pattern with a blunt-tipped cannula; penis held in traction.
  • Fat distribution. Place small aliquots evenly in the selected subcutaneous shaft planes; Salem’s 30-patient AFI cohort used smaller volumes dorsally near the neurovascular bundle and avoided ventral injection along the urethra.[10]
  • Operative time. Mean 44 minutes (range 37–49 min).

Technical principles (general fat-grafting literature).[5]

  • Small aliquots distribute grafted fat through recipient tissue.[5]
  • Avoid pooling. Large bolus deposits undergo central necrosis from inadequate diffusion.
  • Slow injection speed limits shearing.
  • Blunt-tipped cannulas lower the risk of intravascular injection.[5]
  • Avoid injection into Buck's fascia or tunica albuginea, to avoid the risk of ED, Peyronie's-like fibrosis or corporal injury.
  • Postoperative care in Littara’s series. A cohesive elastic shaft bandage was applied; patients were advised to avoid intense physical activity for 30 days and sexual or masturbatory activity for 60 days.[40]

IV. Outcomes​

StudynVolume injectedGirth gainLength effectComplicationsFollow-up
Kang 2012[1]5238.5 mL (25–49)+2.28 cm proximal; +2.28 cm distalNo changeNodular fat 1.92%6 mo
Littara 2019 (mixed procedures)[40]355 total (334 received AFI: 33 girth only, 301 with lengthening)Injected volume not reportedPooled flaccid midshaft girth +2.76 cm in the pooled 355Lengthening combined in 301>30% fat loss in 21/334 fat recipients; fat nodules in 2/33412 mo
Deskoulidi & Caminer 2023[9]75Not specified~ 1 cmCombined with SLD (2–4 cm flaccid length)3 fat-injection revisions (4%)Not stated; revisions at 6–12 mo
Salem 2019[10]30 (15 with a prior semi-rigid implant; 15 potent controls)Median 55 mL (implant group), 45 mL (controls)Group median girth rose 2.2 cm (implant group) and 2.7 cm (flaccid controls) at 6 moN/AGirth declined between 3 and 6 mo in both groups; fat irregularities/nodules in 2/15 per group6 mo
Excluded: Spyropoulos 2005 (free dermal-fat graft for shaft thickening, not AFI)[12]11 mixed procedures (3 grafts)N/ANo AFI girth outcomeNo AFI length outcomeSee thedermal-fat-graft pageNot stated
Wessells 1996 (referral complications; all had SLD release, 10 had fat injection)[2]12Not specified—Only 1/12 reported length gainNodules 7/12, skin deformity 4/12, reoperation 6/12, sexual dysfunction 4/1216-month enrollment
Alter 1997 (reconstruction; complications of enlargement done elsewhere)[3]19———Fat disappearance, lumps, nodules, shaft deformities—

V. The Central Problem — Unpredictable Fat Resorption​

The fundamental limitation of AFI, in the penis and at all body sites, is unpredictable and often substantial graft resorption.[4][7][13][14]

General fat-grafting resorption data​

  • Reported resorption is 20–80% of injected volume, depending on technique, recipient site, and patient factors.[7][13]
  • Pooled facial-fat-graft retention 47% (95% CI 41–53%) at 3–24 months (meta-analysis, 27 studies, 1,011 patients).[4]
  • Conventional fat-grafting survival approximately 44% (versus approximately 64% with cell-assisted lipotransfer).[13]

Penile-specific resorption concerns​

  • The penis is a uniquely hostile recipient site because of:
    • Thin subcutaneous tissue with limited vascular bed.
    • Constant mechanical stress from erection / detumescence cycles.
    • Mobile anatomy: significant dimensional changes with erection.
    • Gravity-dependent position: fat may migrate or redistribute unevenly.
  • Salem 2019 reported lower median girth at 6 months than at 3 months in both fat-injection groups; group outcomes were reported through 6 months.[10]
  • Alter 1997 listed "disappearance of fat" among the three complications of penile fat injection.[3]
  • Non-uniform resorption, with some areas resorbing more than others, is the presumed basis of the irregular nodularity and asymmetry described in referral series.[2][3]

VI. Complications​

A. Irregular fat nodules and lumps — the hallmark complication[1][2][3][8]​

  • Wessells 1996. Irregular residual fat nodules were the chief complaint in 7 of 12 men (10 of the 12 had received fat injection).[2]
  • Alter 1997. Described "penile lumps and nodules" as a primary indication for reconstructive surgery.[3]
  • Trockman 1994. Case report of a 36-year-old man with 2 painful inflammatory nodules requiring surgical excision 3 months after injection.[8]
  • Kang 2012. Nodular fat occurred in 1/52 (1.92%) at 6 months. The lower rate may reflect multi-layer injection technique or patient selection.[1]

Mechanism. Non-uniform fat resorption leaves islands of surviving fat interspersed with areas of complete resorption, creating palpable and visible irregularities. Large bolus deposits undergo central necrosis, forming oil cysts and calcified nodules.[3][5]

B. Penile deformity and poor cosmetic appearance​

  • Wessells: poor cosmetic appearance was the chief complaint in the 12 referral patients.[2]
  • In the Wessells referral series, skin deformity and scarring were chief complaints in 4 of 12 men with complications; all had ligament release and 10 had fat injection.[2]
  • Scrotalization occurred in 4 of 12 Wessells complication referrals.[2]
  • Shaft deformities: asymmetric thickening, irregular contour, "sausage-like" or "lumpy" appearance.[3]

C. Fat disappearance / resorption​

  • Complete or near-complete resorption can leave the patient with no girth gain and possibly worse cosmesis than baseline (from scarring and fibrosis).[3]

D. Sexual dysfunction​

  • Wessells: 4/12 (33%) patients reported sexual dysfunction.[2]
  • Proposed mechanisms include pain from nodules during intercourse, altered penile sensation, psychological distress from deformity, and rarely ED from deep injection injury.

E. Wound complications​

  • Wessells: 6/12 (50%) wound complications.[2]
  • Infection, hematoma, seroma at injection sites or donor sites.

F. Need for reoperation​

  • Wessells: 6/12 (50%) required reoperation.[2]
  • Deskoulidi: 3/75 (4%) returned for revision of fat injections 6–12 months after surgery.[9]
  • Alter: 19 patients underwent 24 reconstructive operations for deformities from penile-enlargement surgery.[3]

G. Fat necrosis and oil cysts​

  • Large deposits of injected fat that fail to revascularize undergo liquefactive necrosis, forming oil cysts (sterile collections of liquefied fat).
  • May calcify over time into palpable hard nodules.
  • Can be confused with malignancy on imaging.

H. Fat embolism​

One case report describes fatal fat embolism after penile autologous fat injection performed following penile lengthening.[34]

I. Infection​

  • Rare but reported; superficial cellulitis to deep abscess. Risk increased with non-sterile technique or excessive tissue trauma.

VII. Reconstruction of Fat-Injection Complications​

Alter 1997 described the repairs in 19 men (24 operations).[3]

  • Fat-nodule excision through small incisions.
  • Asymmetrical fat-deposit removal (debulking).
  • Scar revision for injection-site scars.
  • Limitations. Complete correction not always possible; some residual deformity may persist.
  • Penile appearance and function were reported improved; complications were 1 hematoma requiring drainage, minor wound complications and 1 inadequately reversed V-Y flap.

Furr 2018 referral-center series: 11 patients with severe complications from genital-enlargement surgery (including AFI), with adverse changes including "sexually disabling penile deformity and severe shortening, curvature, edema, subcutaneous masses, infection, non-healing wounds, and sexual dysfunction." 10/11 underwent corrective surgery, 3 with split-thickness skin grafting.[15]

For the operative atlas of these reconstructions see Penile Skin / Shaft Reconstruction (04e).

VIII. Strategies to Improve Fat-Graft Survival​

Several enrichment strategies have been investigated. One 2026 retrospective, nonrandomized penile study compared mechanically isolated SVF-enriched fat grafting with conventional Coleman fat grafting (50 versus 38 men) through 12 months.[36]

A. Platelet-rich plasma (PRP)​

  • Wu 2021 meta-analysis (11 studies, 1,125 patients): PRP and fat grafting showed significantly higher fat-survival rate and lower recovery time versus conventional fat grafting; no difference in patient satisfaction.[16]
  • Across studies with 3–24 months of follow-up, fat survival was 20.5–54.8% (FG alone) versus 24.1–89.2% (PRP and FG).[16]
  • A 2025 systematic review (27 studies, 15 of them animal studies) judged SVF / ADSC-based methods and PRP the "most promising approaches" for fat-graft enrichment, with substantial heterogeneity in protocols and outcome measures.[17]

B. Stromal vascular fraction (SVF)​

  • Jefri 2026 reviewed 18 studies (893 patients), of which 16 contributed to the retention meta-analysis. SVF-assisted grafting had 17.20 percentage points higher pooled retention (95% CI 11.26–23.15; p < 0.001; I² = 98%); the breast subgroup was not statistically significant (p = 0.06).[18]
  • In Jefri’s nonpenile SVF-preparation subgroup analysis, automated enzymatic systems had the largest pooled retention difference versus conventional grafting (+22.82 percentage points; 95% CI 16.53–29.10; I² = 89%).[18]
  • No major complications were reported, and cyst / fat-necrosis rates were comparable (RR 1.15, 95% CI 0.57–2.33).[18]

C. Cell-assisted lipotransfer (CAL) / adipose-derived stem cells (ADSCs)​

  • Laloze 2018 systematic review (25 studies, 696 patients; 16 studies in the efficacy meta-analysis): CAL showed significantly higher fat survival than conventional grafting at breast and face sites (64% versus 44%, p < 0.0001).[13]
  • The benefit was significant only for injection volumes < 100 mL.[13]
  • CAL was associated with more complications (8.4% versus 1.5%, p = 0.0019) and did not reduce the number of procedures needed.[13]

D. Technical optimization (Nemir 2021)[5]​

  • Larger harvesting and grafting cannulas: reduce shearing.
  • Slow injection speeds: minimize cell damage.
  • Dispersion technique: small aliquots distributed throughout tissue, avoiding pooling.
  • Minimize environmental exposure during processing.
  • Blunt-tipped cannulas: avoid intravascular injection.
  • Gentle processing (soft centrifugation or filtration) may preserve adipocyte structure better than standard Coleman centrifugation.[11]

One single-center, nonrandomized penile study reported retention of 81.6% of 1-month flaccid-girth gain at 12 months with SVF-enriched fat versus 50.5% with Coleman fat; longer-term and randomized evidence is needed.[36]

IX. Comparison With Other Girth-Enhancement Techniques​

EAU 2026 weakly recommends HA and AFI for penile girth enhancement after extensive counseling, but strongly recommends against grafts and the Penuma subcutaneous implant as experimental.[32]

FeatureAutologous fat injectionHA fillerDermal fat graftPenuma silicone implant
MaterialPatient's own fatCross-linked HAPatient's dermal-fat stripMedical-grade silicone (cured)
BiocompatibilityAutologousGood (biodegradable)AutologousGood (inert)
Girth gain+2.28 cm proximal and distal at 6 months (Kang AFI, n = 52)[1]+2.44 cm flaccid at 12 months (Zhang HA, n = 38)[27]+1.67 cm flaccid at 6 months after combined lengthening and dermal-fat grafting (Xu, n = 23)[26]+4.9 cm midshaft circumference (+56.7%) at 30–90 days among 400 consenting Penuma patients (Elist)[25]
DurabilityGeneral fat-grafting resorption 20–80%; penile-specific retention uncertain[13]Among 41 of 50 enrolled HA patients followed to 18 months, mean midshaft girth remained above baseline (11.26 vs 7.48 cm; Kwak)[28]Dermal-fat graft shrinkage was inconspicuous at 6 months in Xu’s combined-surgery cohort[26]Penuma is an implanted device; 3% required removal in Elist’s 400 consenting patients[25]
ReversibilityFocal fat deposits can be excised or debulked; complete reversal is not established[3]Yes (hyaluronidase)Partially (surgical removal)Implant removal is possible, but curvature or shortening may persist in selected complication referrals[35]
Nodule / irregularity rateOne nodule in 52 Kang AFI patients[1]; irregular residual fat nodules were the chief complaint in 7 of 12 Wessells complication referrals (10 had AFI; all had ligament release)[2]No comparable estimate in cited studiesNo comparable estimate in cited studiesNo comparable estimate in cited studies
Repeat procedure or device removal (different endpoints)3/75 returned for fat-injection revision after combined surgery; 6/12 complication referrals required reoperation after ligament release, with AFI in 10/12[9][2]Oates and Sharp describe HA top-up injections without a surgical reoperation estimate[20]Xu's 23-patient dermal-fat abstract gives no reoperation estimate[26]Device removal: 3% among 400 consenting Elist patients; up to 10% in reports summarized by Ramazan[25][19]
InvasivenessModerate (liposuction + injection)Minimally invasive (office)Surgical (donor site + penile)Surgical (implant placement)
FDA statusSame-procedure autologous fat transfer may qualify after rinsing, cleansing, sizing, shaping or centrifugation solely to remove debris and extracellular fluid; processing to isolate SVF generally does not qualify for that exception[29]No FDA-approved penile indication for HA filler[30]Same-procedure autologous dermal-fat grafting may qualify for the FDA tissue exception[29]FDA 510(k) cleared for cosmetic penile augmentation (Penuma)[31]

X. Special Application — Fat Injection With Penile Prosthesis ("Girth Supersizing")​

Salem 2019 described autologous fat injection in patients with semi-rigid penile implants for "girth supersizing" (prospective case-control study, Egypt).[10]

  • Thirty married participants received fat injection: 15 had a semi-rigid implant placed at least 3 months earlier and remained dissatisfied with girth, and 15 were potent controls.[10]
  • Median penile girth increased significantly in both groups.
  • Median girth fell between the 3- and 6-month group visits in both groups.[10]
  • In the controls, the volume injected correlated positively with the change in girth at 6 months.
  • The authors concluded that fat transfer is "simple and safe" for augmenting girth in patients whose girth is less than 11.5 cm after prosthesis insertion.

XI. Patient Selection and Contraindications​

Appropriate candidates (based on published series).[1][12]

  • Men with objectively thin penises (Kang selected patients whose proximal and distal penile thirds each had mean circumference ≤ 7.4 cm).[1]
  • Men with normal penile dimensions seeking augmentation should be referred for psychological evaluation for possible dysmorphophobic disorder, and any surgical proposal requires extensive counseling about limited evidence.[24] Spyropoulos selected psychosomatically normal men for augmentation procedures.[12]
  • Adequate donor-site fat for harvesting.
  • Psychosomatically normal individuals (Spyropoulos excluded patients with psychiatric disorders).[12]

Society guidance and patient-selection considerations. The 2026 EAU guideline weakly recommends autologous fat injection for girth enhancement with extensive counseling, but strongly recommends against it in men with penile dysmorphic disorder.[32] The AUA/Urology Care Foundation position statement (reaffirmed 2018) says subcutaneous fat injection has not been shown safe or efficacious.[33] For adults without structural or functional penile abnormalities, BAUS/AGUS 2026 recommends against absorbable cosmetic penile injectables, a group in which it reviews autologous fat, because high-quality evidence is lacking.[37] The Fifth ICSM consultation (published 2026) gives a weak recommendation based on low-quality evidence describing AFI and HA as relatively safe, while noting that additional procedures will likely be needed over time.[38]

  • Unrealistic expectations: patients expecting large, permanent girth increase.
  • Body dysmorphic disorder (BDD). A multidisciplinary approach including psychological evaluation is advised for men requesting augmentation.[19]
  • Insufficient donor-site fat: very lean patients.
  • Active penile infection or skin disease.
  • Coagulopathy or anticoagulant use (relative, for liposuction component).
  • Prior penile surgery with significant scarring (may limit injection plane).

Psychological screening. Multiple authors emphasize that "most men seeking these interventions have penile dimensions within the normal range" and recommend a multidisciplinary approach including psychological evaluation.[12][19] Spyropoulos used a structured questionnaire to select only 11 of 28 presenting patients (39%) for surgery.[12]

XII. Evidence Quality and Limitations​

The evidence base for penile AFI is limited and of low quality.[21][22][23]

  • No randomized controlled trials for penile fat injection.
  • Kang's uncontrolled 52-patient series reported 6-month outcomes.[1]
  • Most informative data come from referral-center complication series (Wessells, Alter, Furr), which inherently overrepresent complications but provide safety data.[2][3][15]
  • In a narrative review of 29 penile-girth-enhancement studies, 26 (89.7%) were not randomized controlled trials, with "overall low quality and limited level of evidence."[21]
  • Romero-Otero 2021 BJU Int SR: "the quality of studies on penile-enhancement procedures is still low" and "prevents us from establishing recommendations based on scientific evidence."[22]
  • Vyas 2020 SR: "poor" study quality regarding methodology for patient selection and outcomes reporting; pooled complication rate 14.6% across all augmentation techniques, highest with combined augmentation.[23]
  • Adverse events are probably largely under-reported across all penile-augmentation studies.[21]

XIII. Clinical Summary​

Autologous fat injection for penile girth enhancement is an older technique with unpredictable results. The fat is autologous, and the donor site is contoured at the same time. General fat-grafting studies report 20–80% resorption; penile-specific long-term volume retention is not established.[13] Referral-center series document irregular nodularity, penile deformity and reoperation.[2][3] In the Wessells series, 7 of 12 men had irregular nodules and 6 needed reoperation. Referral series over-represent complications, and denominators for the procedure are unknown.[2][3][15]

A more recent series using multi-layer injection (Kang, n = 52, single center, 6-month follow-up, no comparator) reported a 1.92% nodule rate and a +2.28 cm girth gain at 6 months.[1] Deskoulidi and Caminer (n = 75, 15 years of experience) reported a 4% revision rate for fat injection as part of combined augmentation.[9] These results may reflect technique or patient selection. Small, nonrandomized comparisons of AFI with historical Macrolane HA and of SVF-enriched with conventional fat exist.[39][36]

Kang and Salem reported group outcomes through 6 months.[1][10] Littara’s mixed-procedure cohort (355 men, 334 receiving AFI) reported flaccid midshaft circumference of 11.50 cm at 2 months and 11.06 cm at 12 months, without isolated-AFI outcomes.[40] Meta-analyses report higher fat-graft retention with enrichment at non-penile sites.[13][16][17][18] A 2026 penile SVF comparison reported greater retained girth gain at 12 months than conventional fat grafting, but it was nonrandomized and requires independent confirmation.[36]

Fat injection requires donor-site liposuction and has uncertain long-term volume retention; the cited AFI and HA reports differ in design and follow-up.[1][2][20][21] Sito’s historical same-center retrospective comparison of 27 AFI and 56 Macrolane HA patients reported more local adverse events after AFI, but conflicting event counts prevent a reliable numerical rate comparison; the paper also reports a manufacturer warning against penile Macrolane use.[39] HA fillers are reversible with hyaluronidase; Oates and Sharp reported that results from their experience-based penile HA protocol generally lasted beyond 24 months and encouraged patients to return after that for top-up injections.[20][21] The choice between techniques depends on patient anatomy, expectations, and tolerance for the respective risk profiles.

See Also​

References​

1. Kang DH, Chung JH, Kim YJ, et al. Efficacy and safety of penile-girth enhancement by autologous fat injection for patients with thin penises. Aesthet Plast Surg. 2012;36(4):813–818. doi:10.1007/s00266-012-9891-4

2. Wessells H, Lue TF, McAninch JW. Complications of penile lengthening and augmentation seen at one referral center. J Urol. 1996;155(5):1617–1620. doi:10.1016/s0022-5347(01)66144-5. PMID 8627836

3. Alter GJ. Reconstruction of deformities resulting from penile-enlargement surgery. J Urol. 1997;158(6):2153–2157. doi:10.1016/s0022-5347(01)68185-0

4. Lv Q, Li X, Qi Y, et al. Volume retention after facial fat grafting and relevant factors: a systematic review and meta-analysis. Aesthet Plast Surg. 2021;45(2):506–520. doi:10.1007/s00266-020-01612-6

5. Nemir S, Hanson SE, Chu CK. Surgical decision-making in autologous fat grafting: an evidence-based review of techniques to maximize fat survival. Aesthet Surg J. 2021;41(Suppl 1):S3–S15. doi:10.1093/asj/sjab080

6. Egro FM, Roy E, Rubin JP, Coleman SR. Evolution of the Coleman technique. Plast Reconstr Surg. 2022;150(2):329e–336e. doi:10.1097/PRS.0000000000009355

7. Kølle SF, Fischer-Nielsen A, Mathiasen AB, et al. Enrichment of autologous fat grafts with ex-vivo expanded adipose-tissue-derived stem cells for graft survival: a randomised placebo-controlled trial. Lancet. 2013;382(9898):1113–1120. doi:10.1016/S0140-6736(13)61410-5

8. Trockman BA, Berman CJ, Sendelbach K, Canning JR. Complication of penile injection of autologous fat. J Urol. 1994;151(2):429–430. doi:10.1016/s0022-5347(17)34972-8

9. Deskoulidi PI, Caminer D. Lengthening phalloplasty with division of the suspensory ligament and distally based fat flaps in penis-enlargement operations. Plast Reconstr Surg. 2023;152(3):434e–437e. doi:10.1097/PRS.0000000000010313

10. Salem AM, Osman IAL, Zaghloul AS, et al. Effect of girth supersizing on patient satisfaction after semi-rigid penile-implant insertion: a prospective case-control study. Aesthet Surg J. 2019;39(7):NP259–NP265. doi:10.1093/asj/sjz072

11. He Y, Zhang X, Han X, Li F. The importance of protecting the structure and viability of adipose tissue for fat grafting. Plast Reconstr Surg. 2022;149(6):1357–1368. doi:10.1097/PRS.0000000000009139

12. Spyropoulos E, Christoforidis C, Borousas D, et al. Augmentation phalloplasty surgery for penile dysmorphophobia in young adults: considerations regarding patient selection, outcome evaluation and techniques applied. Eur Urol. 2005;48(1):121–127. doi:10.1016/j.eururo.2005.02.021

13. Laloze J, Varin A, Gilhodes J, et al. Cell-assisted lipotransfer: friend or foe in fat grafting? Systematic review and meta-analysis. J Tissue Eng Regen Med. 2018;12(2):e1237–e1250. doi:10.1002/term.2524

14. Trotzier C, Sequeira I, Auxenfans C, Mojallal AA. Fat-graft retention: adipose tissue, adipose-derived stem cells, and aging. Plast Reconstr Surg. 2023;151(3):420e–431e. doi:10.1097/PRS.0000000000009918

15. Furr J, Hebert K, Wisenbaugh E, Gelman J. Complications of genital-enlargement surgery. J Sex Med. 2018;15(12):1811–1817. doi:10.1016/j.jsxm.2018.10.007

16. Wu M, Karvar M, Liu Q, Orgill DP, Panayi AC. Comparison of conventional and platelet-rich-plasma-assisted fat grafting: a systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2021;74(11):2821–2830. doi:10.1016/j.bjps.2021.05.046

17. Hasiba-Pappas S, Opriessnig E, Nischwitz SP, et al. Optimizing autologous fat grafting: a systematic review of enhancement strategies and graft survival. Aesthet Surg J. 2025. doi:10.1093/asj/sjaf242

18. Jefri ZE, Alashjaee RH, Almarri AK, et al. Stromal-vascular-fraction-assisted fat grafting: a systematic review and meta-analysis of clinical outcomes. Aesthet Plast Surg. 2026;50(2):677–691. doi:10.1007/s00266-025-05511-6

19. Ramazan M, Øbro LF, Wiborg MH, et al. Complications of penile augmentation: a narrative review of injectables, implants, and surgical grafts. Int J Impot Res. 2026;38(3):238–246. doi:10.1038/s41443-025-01190-8

20. Oates J, Sharp G. Nonsurgical medical penile-girth augmentation: experience-based recommendations. Aesthet Surg J. 2017;37(9):1032–1038. doi:10.1093/asj/sjx068

21. Manfredi C, Romero Otero J, Djinovic R. Penile-girth-enhancement procedures for aesthetic purposes. Int J Impot Res. 2022;34(4):337–342. doi:10.1038/s41443-021-00459-y

22. Romero-Otero J, Manfredi C, Ralph D, et al. Non-invasive and surgical penile-enhancement interventions for aesthetic or therapeutic purposes: a systematic review. BJU Int. 2021;127(3):269–291. doi:10.1111/bju.15145

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