This book covers all aspects of penile augmentation using injectable hyaluronic acid gel, including penile girth enhancement and glans penis augmentation for individuals with small glans or those seeking treatment for premature ejaculation.
Unlike other fillers, HA is considered the safest due to its low antigenicity and the ability to reverse its effects with hyaluronidase. The author, an expert in this field, shares valuable tips and tricks drawn from 25 years of experience, supported by detailed illustrations.

The book serves as a comprehensive guide to the evolving field of penile augmentation, with a specific focus on the use of hyaluronic acid gel as an injectable filler. It is structured to provide a deep understanding of the historical and cultural contexts that have influenced the practice of penile augmentation, as well as the anatomical and technological advancements that have made these procedures more popular and accessible.

Starting with an exploration of the history and anatomy of the penis, the text outlines the development of injectable fillers and the current guidelines governing their use, establishing a strong foundation for clinical applications.

Contents

Part I: General Perspectives
1. Introduction
1.1 Necessity of Hyaluronic Acid Fillers in Penile Augmentation: Toward a Safer and More Effective Approach
1.2 The Rise of Hyaluronic Acid Fillers in Aesthetic Medicine
1.3 Necessity of HA Fillers in Penile Augmentation
1.4 Purpose of This Book
1.5 Structure of the Book
1.6 Future Perspective
2. Anatomy of the Penis
2.1 Gross Structural Anatomy of the Penis
2.2 Microscopic Anatomy of the Penis
2.3 Vascular and Neural Supply of the Penis
2.4 Functional and Structural Roles of Buck’s and Dartos Fascia
2.4.1 Glans Penis Anatomy
2.4.2 The Special Epithelium of Glans
2.4.3 The Glans Contains a Large Number of Special Receptors
2.5 Conclusion
3. Development of Fillers
3.1 Historical Background
3.2 Timeline of Filler Development
3.3 Synthetic Fillers
3.4 Hyaluronic Acid Derivatives
4. Current Hyaluronic Acid Gel
4.1 Hyaluronic Acid Filler Market Overview
4.2 Properties of Hyaluronic Acid Gel
4.2.1 Cross-Linking
4.2.2 Particle Sizing
4.2.3 HA Concentration
4.3 Current FDA-Approved Hyaluronic Acid Fillers
4.4 KFDA-Approved Hyaluronic Acid Fillers for Penile Girth Enhancement
5. Current Guideline of Penile Augmentation
Part II: Penile Girth Enhancement
6. Historical Development of Penile Girth Enhancement (PGE)
6.1 Introduction
6.2 Evolution of Penile Girth Enhancement (PGE)
6.2.1 Early Materials and Techniques
6.2.2 Summary
6.3 Penile Girth Enhancement with Dermofat Graft
6.3.1 Introduction
6.3.2 Mechanism of Graft Survival
6.3.3 Surgical Technique (Figs. 6.1 and 6.2)
6.3.4 Clinical Outcomes
6.3.5 Complications and Management
6.3.6 Long-Term Results
6.3.7 Summary
6.4 Penile Girth Enhancement with Autologous Fat Transfer (AFT)
6.4.1 Introduction
6.4.2 Technique for AFT
6.4.3 Complications and Management
6.4.4 Long-Term Outcomes
6.4.5 Summary
6.5 Penile Girth Enhancement with Biograft (Allograft, Xenograft)
6.5.1 Introduction
6.5.2 Surgical Technique
6.5.3 Clinical Outcomes
6.5.4 Complications and Management
6.5.5 Late Complication
6.5.6 Summary and Future Directions
6.6 Hyaluronic Acid Fillers: The Modern Shift (Expanded Narrative)
6.6.1 Conclusion: Penile Girth Enhancement Techniques
6.7 Future Outlook
6.8 Final Recommendation
7. Current Publications for Penile Girth Enhancement (PGE) with HA Gel
7.1 Historical Evolution of Penile Augmentation: From Dangerous to Safe Techniques
7.2 The Search for Effective and Safe Penile Enhancement
7.3 Modern Advances: The Role of Injectable Fillers
7.4 The First Clinical Study on PGE with HA Gel: Kwak et al. [4]
7.4.1 Background and Justification
7.4.2 Study Design and Methodology
7.4.3 Results and Clinical Findings
7.4.4 Impact and Clinical Significance
7.5 Key Clinical Studies on PGE with HA (2011 Onward)
7.5.1 Key Clinical Studies on PGE with HA Gel
7.5.2 Pioneering Research and Clinical Evidence
7.5.3 Comparative and Meta-Analytical Studies
7.5.4 Safety and Complications
7.6 Guidelines and International Perspectives on PGE
7.6.1 Sexual Medicine Society of North America (SMSNA) Position Statement (2024)
7.6.2 International Consultation on Sexual Medicine (ICSM) 2025 Guideline (Pre-publication)
7.7 Conclusion and Future Perspectives
7.8 Future Directions in HA-Based PGE May Include
8. Development and Principles of Penile Girth Enhancement using Injectable Hyaluronic Acid Gel
8.1 Introduction: The Birth of a New Paradigm
8.2 Development and Initial Clinical Evaluation of HA-Based PGE
8.2.1 Study Design and Patient Cohort
8.2.2 Injection Technique and Procedural Details
8.2.3 Outcomes and Long-Term Results
8.2.4 Clinical Significance and Early Lessons
8.3 General Principles for Successful PGE
8.3.1 Patient Selection and Preoperative Planning
8.3.2 Injection Techniques and Advanced Refinements
8.3.2.1 Retrograde and Anterograde Injection Technique
8.3.2.2 Adaptation of Facial Aesthetic Techniques to Penile Augmentation
8.3.2.3 The Dual-Plane Concept for Volume and Contour Harmony
8.3.3 Postoperative Management and Long-Term Care
8.4 Clinical Outcomes and Lessons Learned
8.4.1 Long-Term Outcomes from Early Clinical Studies
8.4.2 Insights from the Phase III Multicenter Trial
8.4.3 Lessons Learned in Clinical Practice
8.5 Future Perspectives and Expanded Indications
8.5.1 Expanding Global Adoption and Regulatory Approvals
8.5.2 Secondary Benefits: Potential Role in Premature Ejaculation Management
8.5.3 Innovations in Filler Technology
8.5.4 Addressing Challenges and Building Consensus
8.6 Conclusion: Establishing HA Fillers as the Standard of Care
9. Tips and Tricks for Penile Girth Enhancement (PGE) with Hyaluronic Acid (HA)
9.1 Introduction
9.2 Why “Tips and Tricks” Are Essential for PGE with HA
9.3 Practical Considerations for Injection-Based PGE
9.4 Differentiating PGE with HA from Other Techniques
9.5 Positioning “Tips and Tricks” as Essential Knowledge
9.6 Key Considerations and Technical Challenges in PGE with HA Fillers
9.7 Key Technical Considerations
9.8 Misunderstandings from Publications of PGE: Insights from KFDA Approval Studies and Korean Clinical Data
9.8.1 The Role of Uro-Andrologists in PGE
9.8.2 The Future of HA Fillers in PGE
9.8.3 Conclusion: The Key to Success in PGE
10. Clinical Case Series in Hyaluronic Acid-Based Penile Girth Enhancement: Anatomical Considerations, Complications, and Corrective Strategies
10.1 Case 1: Physiologic Time-Dependent Distal Ventral Migration of HA Filler
10.2 Case 2: Managing Long-Term Distal Migration, Delayed Circumcision, and HA Remnant Removal in a 55-Year-Old Male
10.2.1 Part 1: Initial PGE and Early Distal Migration
10.2.2 Part 2: Minimal Circumcision and Staged Retouching
10.2.3 Part 3: Late-Stage Correction with Hyaluronidase and Reinjection as Case 14 (2024)
10.3 Case 3: Filler Displacement in a 67-Year-Old Male with Senile Atrophy and Retracted Preputial Ring
10.4 Case 4: Filler Distribution Challenges in a Patient with Previous Circumcision Scar and Adhesions
10.5 Case 5: Distal Ventral Migration After Large-Volume Initial Injection
10.6 Case 6: Delayed Aggravation of Distal Migration After Large-Volume Injection
10.7 Case 7: Postinjection Care and Long-Term Stability in a 54-Year-Old Male
10.8 Case 7.1: Postinjection Care and Long-Term Retouching in a 54-Year-Old Male
10.8.1 Proper Patient Communication: Aligning Expectations with Clinical Reality
10.9 Case 8: Photo Presentation of PGE with HA and HA Reinjection at 1-Year Follow-Up in a 39-Year-Old Male (Fig. 10.8)
10.10 Case 9: HA Injection Following Non-HA Filler for Long-Term Augmentation
10.10.1 Challenges of HA Injection After Non-HA Fillers
10.11 Case 10: Managing PLA History and HA Reinjection in a 42-Year-Old Male
10.11.1 Clinical Observations: Reinjection in Powerfill® Patients
10.12 Case 11: Remodeling HA Asymmetry Over Time in a 41-Year-Old Male
10.13 Case 12: Correction of a Superficial HA Lump 3.5 Years Postinjection
10.14 Case 12 (Continued): Staged Correction and Retouching for Optimal Outcome
10.15 Case 13: Long-Term HA Remnant Removal in a 54-Year-Old Male
10.16 Case 14: Long-Term HA Remnant Removal and Reinjection in a 53-Year-Old Male (Extension of Case 2, Part III)
10.16.1 The Role of Hyaluronidase in HA-Based PGE
10.17 Conclusion
Case Summary: Clinical Insights from 14 HA-Based Penile Girth Enhancement (PGE) Cases
Integrated Lessons from the Series
Part III: Glans Penis Augmentation
11. Premature Ejaculation: Integrating Pathophysiology with Current Treatment Modalities
11.1 Introduction
11.2 Pathophysiology of Premature Ejaculation
11.2.1 Central Nervous System Contributions
11.2.2 Neurotransmitter Systems
11.2.3 Hormonal and Endocrine Factors
11.2.4 Autonomic Dysregulation
11.3 Current Treatment Modalities and Their Pathophysiological Targets
11.3.1 Pharmacological Therapies
11.4 Behavioral Therapies
11.5 Surgical and Minimally Invasive Therapies
11.5.1 Integrating Pathophysiology with Treatment Selection
11.6 Positioning GPA with HA Filler as a Mechanism-Based Therapy
11.7 Take-Home Messages for Clinicians
11.8 Conclusion
12. Development and Clinical Applications of Glans Penis Augmentation with Injectable Hyaluronic Acid Gel
12.1 Introduction
12.2 Preclinical Studies: Establishing Feasibility
12.2.1 Technical Feasibility and Histological Potential Space
12.2.2 Long-Term Retention and Biocompatibility: Beagle Dog Model
12.3 Human Studies: Aesthetic Indications
12.3.1 Study Design and Patient Groups
12.3.2 Evolution of Injection Techniques
12.3.2.1 Injection Technique Evolution
12.3.3 Results and Patient Outcomes
12.4 Discussion
12.5 Conclusion
13. Glans Penis Augmentation for the Treatment of Premature Ejaculation
13.1 Introduction
13.2 Effects of Glans Penis Augmentation Using Hyaluronic Acid Gel for Premature Ejaculation
13.2.1 Patients
13.2.2 Procedures
13.2.3 Evaluation
13.2.4 Results
13.2.5 Discussion
13.3 Study Summary 1: Comparative Study (GPA Versus Dorsal Neurectomy)
13.4 Long-Term Effects of Glans Penis Augmentation Using Injectable HA Gel for Premature Ejaculation
13.4.1 Patients and Evaluation
13.4.2 Results
13.4.3 Discussion
13.5 Study Summary 2: Long-Term Follow-Up (5-Year Study)
13.6 Chapter Conclusion
14. Is There a Place for Surgical Treatment of Premature Ejaculation?
14.1 Introduction
14.2 Current Guidelines and Recommendation Status
14.3 Reported Efficacy of Selective Dorsal Neurectomy (SDN)
14.4 Establishment of a Standard SDN Procedure
14.5 Glans Penis Augmentation (GPA) Using HA Gel
14.6 Minimally Invasive Techniques
14.7 Conclusions
14.8 Future Directions
15. General Principle of GPA by Injectable HA Gel
15.1 Introduction
15.2 Glans Penis Anatomy
15.2.1 Feasibility in Human Application
15.2.1.1 Location
15.3 Preoperative Preparation
15.3.1 Patient Selection
15.3.2 Informed Consent
15.3.3 Preparations
15.4 Injection Techniques for Filler Procedures
15.5 Various Injection Method Adopted for GPA
15.5.1 Dr. Moon’s Initial Technique [11]
15.5.2 Current Moon’s Injection
15.6 Volume of Injection
15.7 Postoperative Care
15.7.1 Immediate Care
15.7.2 Retouch
15.8 Complication
15.9 Limitations
15.10 Conclusion
16. Current Publications on Glans Penis Augmentation (GPA)
16.1 Introduction
16.2 Key Highlights of Initial GPA Publication
16.3 Editorial Commentary by Seftel AD: J Urol. 2005 Jun;173(6):2077
16.4 Clinical Studies of GPA with HA for the Treatment of PE
16.4.1 Key Highlights of the 2012 Study by Abdallah H. et al.
16.4.2 Key Highlights of the Clinical Study by Littara A. et al.
16.4.3 Key Highlights of a Randomized Controlled Crossover Study by Alahwany A. et al.
16.4.4 Key Highlights of a Prospective, Controlled Study by Shebl SE et al.
16.4.5 Key Highlights of a Retrospective Observational Study by Chen et al.
16.5 Review Articles of GPA with HA for the Treatment of PE
16.5.1 A Narrative Review of Kosseifi F, et al. (2020) Narrative Review [11]
16.5.2 A Narrative Review of Ambusaidi H, et al. (2023) Narrative Review [12]
16.5.3 A Narrative Review of Zucchi A, et al. (2021) Narrative Review [13]
16.5.4 A Systematic Review and Meta-Analysis by Culha MG, et al. (2024)
16.5.5 Interventions to Treat Premature Ejaculation: A Systematic Review Short Report by Cooper K, et al. (2015)
16.6 Key Highlights of the 2024 Systematic Review and Meta-Analysis by Culha MG et al. (Table 16.2)
16.7 Progress from Other Studies
16.7.1 Initial Validation (2004–2013)
16.7.2 Expansion and Technique Refinement (2019–2023)
16.7.3 Systematic Evidence Base (2015–2024)
16.8 Summary of Reviews
16.8.1 Efficacy
16.8.2 Safety
16.8.3 Challenges
16.8.4 Position in the Treatment Landscape
16.9 Conclusion
17. Evolution of Guidelines for Premature Ejaculation (PE)
17.1 Introduction
17.2 Development of PE Guidelines
17.2.1 Early Guidelines and Pharmacotherapy
17.2.2 Evolving Perspectives on Surgical Treatments
17.2.3 Glans Penis Augmentation (GPA) Using Hyaluronic Acid (HA)
17.3 Advantages Over Selective Dorsal Neurectomy (SDN)
17.4 Clinical Efficacy
17.5 Guideline Evolution and Current Status
17.6 Expanding Evidence Base
17.7 Selective Dorsal Neurectomy (SDN)
17.8 Efficacy and Outcomes
17.9 Complications and Limitations
17.10 Comparing SDN and GPA
17.11 Current Guidelines and Recommendations
17.12 Future Directions and Recommendations
17.13 Conclusion
18. Complications of Glans Penis Augmentation (GPA)
18.1 Introduction
18.2 Glans Penis Augmentation Using Injectable Fillers
18.3 Complications of Glans Penis Augmentation Using Fillers
18.4 Technical Errors
18.5 Inflammation and Immune Responses
18.6 Vascular Complications
18.7 Permanent Fillers and Severe Complications
18.8 Significant Complications
18.9 Severe Complications
18.10 Complications of Other Fillers for GPA
18.11 Review of Referred Cases Presenting with Complications
18.12 Complications of Other Fillers: Bellagen and Rofilan
18.13 Complications of Mixed and Semipermanent Fillers
18.14 Complications Associated with Cross-Linked Dextran Gel (Lipen-D®)
18.15 Autologuous Fat Injection
18.15.1 Autologous Fat Injection for GPA
18.16 Case Report: Autologous Fat Injection for Glans Penis Augmentation
18.17 Case Report: Fatal Fat Embolism Following Penile Augmentation
18.18 Complication of Indirect Glans Penis Augmentation
18.19 Summary Table: Filler Types and Associated Complications
18.20 Conclusion
19. Indirect Glans Penis Augmentation (GPA)
19.1 Introduction
19.2 Historical Background
19.2.1 Penile Disassembly Technique by Perovic (1990s)
19.2.2 Introduction of Dermofat Grafts (2000s)
19.2.3 Shaeer’s Refinement of Indirect Glans Augmentation (2010s)
19.2.4 Advancements in Scaffold Technology (2010s to Present)
19.2.5 Integration of Lengthening Techniques
19.3 Objectives and Techniques
19.4 Indications, Advantages, Limitations, and Risks of Indirect GPA
19.5 Conclusion
20. Glans Penis Augmentation (GPA) with Distal Penile Girth Enhancement (PGE)
20.1 Introduction
20.2 Rationale for Combining GPA and Distal PGE Can Be Discussed in Three Aspects
20.3 Procedure Considerations
20.4 Pilot Study Results: GPA with Distal PGE
20.5 Discussion
20.6 Conclusion
21. Clinical Case Series of Glans Penis Augmentation (GPA)
21.1 Introduction and Background
21.2 Case 1. Correction of Glans Deformity Following Complication of Indirect GPA
21.3 Case 2. GPA with Frenulum HA Injection in a Patient with Intractable Premature Ejaculation
21.4 Case 3. GPA with Distal PGE in an International Patient
21.5 Case Summary Table
21.6 Conclusion