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Dr Oates

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Reply with quote  #1 
I am going to move a few posts from my original thread HA injectable Phalloplasty - for safety to this as it is nearly 500 posts and over 30 pages. Hopefully this will help new guys coming to the forum to see what we have discussed over the past 18 months or so.

Maybe it will be best to keep most discussion on the original thread.

For more information on the CALIBRE procedure, before and after pictures, my blog go to  - 
http://www.calibreclinic.com.au

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Dr Oates

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My original Post - 

 
 #1 
Skeptical One and members,

I am a doctor providing injectable penis augmentation with HA in Australia. So remember to take anything I say with the understanding that I will probably write to support what I do. But I will try and explain why i do it and why I don't think there is anything better available at the moment. When I find something better, then we will look to change.

I have been working in the area of cosmetic surgery for 17 years after originally training in ENT surgery. Yes this is a significant career change. I mostly did facial plastic surgery for 15 years but had occasional requests for phalloplasty. After seeing how the surgery was done I did not really want to take it up - I did not think I would want it myself. But there were a number of articles published in the medical literature using HA's that interested me.

I began injecting cosmetic fillers (Collagen and Hylaform) back in 2000. I have seen a number of permanent fillers come and go. I have seen some significant complications of permanent fillers. I have also seen complications of temporary fillers - but the complications were temporary as well.

For any cosmetic surgery safety is the most important thing. It is not like cancer surgery where scars or significant issues are accepted. This is why I have avoided the permanent fillers. I have also avoided stimulatory fillers (Newfil, Elanse, Radiesse). Stimulatory fillers may be fine - but the risks are somewhat increased and not acceptable when we were starting a new procedure.

The issues to overcome were making sure it was painless, did not risk obstructing the penile artery or urethra, being smooth and even and minimal down time. 

We are happy that we can get the penis nice and numb. Without needles.

The injecting layer (essentially just below the skin, between the Dartos and Buck's fascia) is easy to get into and stay in using blunt cannula. By using blunt cannula and staying in the right layer there is no risk of blocking a vital structure.

Getting it even is usually not difficult. The advantage of a cosmetic doctor over a urologist for this procedure is that we are experienced and skilled in performing cosmetic injectables. We know how to get it nice and smooth. But even then there is the occasional penis with (circumfential) bands which can be difficult to even out completely.

Injectable phalloplasty is a walk-in/walk-out procedure. We ask guys to give it a rest for a few days - but guys love to come back and tell us how they put it to use that night. Preferably give him a rest.

One of the great advantages of HA's is that they are completely reversible with a medication called Hyalase which is an enzyme to dissolve HA. This is one reason why it is our main injectable filler anywhere - you can get rid of it if you need to. In the penis the great thing is that if, for any reason, you were not happy we could do a few small injections and get rid of it all in a few minutes.

Obviously the main problem with HA's is that they are not permanent. We use Voluma (part of the Juvederm range) made by Allergan (now trialling Ultimate by Teoxane, very similar but we hope will have some advantages - Aug '17). This is the world number 1 HA by the biggest company in the business with the most research to back it up. They(Allergan) are intrigued by its use in injectable phalloplasty but it is strictly off-label. That means the company has not researched it and had it approved for this use in Australia.

After reading all I could, trying to get in contact with the Korean doctors (but failing), we tried our first patient in 2014. With just 5 ml of a different HA (initially tried a different HA because HA's are really expensive in Australia and the other company was willing to let me have some at a discounted price for the trial). He was happy - as was his wife. We did another 5ml.

Then I honed the technique on number of friends (quite an unusual experience, handling your friends penis's - and sticking a needle into it). We gradually improved the early results and waited to see how it would last. The Korean's had 90% retention after 18 months with what I feel is an inferior HA. Even in the last 6 months we have made further refinements to technique to improve results.

To improve longevity we have switched to Voluma. I have it in my face and it has lasted over 2 years. Voluma has the best researched longevity of any HA. HA's always last longer when injected in large amounts. HA's should have good tissue integration when injected correctly. That is it should not be injected in 1 big blob. With correct technique there are lots of fine collagen bundles around and it will not move. There are places in the face, such as the tear trough, where HA's last much longer (routinely years). It is hoped the penis will be another of these locations where there is less local, natural hyaluronidase (the dissolving enzyme) so it will last a decent time.

So yes we do have clinics on the east and west coast of Australia. I believe we do more injectable phalloplasties than anyone else in the country - but we have really only been doing it a relatively short time. We focus on safety first.

Free fat transfer can give good results. But I have also seen infections, resorption, unevenness. PMMA/Megafil/Silicone/Articol etc are too great a risk. I am sure there are guys with great results they are very happy with. The question to ask yourself is "If I get one of these minor/major problems how am I going to cope?". Surgery with lengthening and dermal fat grafts can be successful, with the right surgeon. But is major surgery, very expensive (>$30K in Australia) and has protracted down time.

I am happy to answer questions - but remember again - I have a commercial interest in this. But that commercial interest requires happy patients.

The Effects of Penile Girth Enhancement using Injectable Hyaluronic Acid Gel, a FillerTae Il Kwak MD1, MiMi Oh MD1, Je Jong Kim MD2 and Du Geon Moon MD2,
The Journal of Sexual Medicine Volume 8, Issue 12,  3407–3413, December 2011

Use of Macrolane VRF 30 in Emicircumferential Penis Enlargement
Giuseppe Sito, MD,Sergio Marlino, MD,Adriano Santorelli, MD
Aesthetic Surgery Journal February 2013 vol. 33 no. 2 258-264

Human glans penis augmentation using injectable
hyaluronic acid gel
JJ Kim1, TI Kwak1, BG Jeon1, J Cheon1 and DG Moon1
International Journal of Impotence Research (2003) 15, 439 - 443

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Dr Oates

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Reply with quote  #3 
Quote:
Originally Posted by hunkydory
Hi Dr. Oates, thanks for posting. I see that you referenced and article on Macrolane. What are your thoughts on that, as I know people who are happy with it - but have also heard by members on this board that it is not a good choice. Thanks in advance.

Hunkydory,

Macrolane has never been approved for use in Australia so I don't have much personal experience with it. But it did help start me on the journey. I knew someone who had it done for breast augmentation in Singapore. Which interested me that she would have a temporary solution when there is a common surgery with quite good permanent results. She had problems with lumps - which is something which is just not acceptable in the breast (cancer worry). So I had to dissolve it with Hyalase.

Macrolane seems to be getting withdrawn from countries rather than expand - which does not fill me with confidence. The Italian Urologist who published using Macrolane have a Youtube video. It looked like someone who is not a cosmetic injector, not how I would inject. But I imagine that done sympathetically it could give a good result - it is a lumpy HA rather than a smooth consistencey and is made to inject deep. It is produced by a very reputable HA company with plenty of experience. And it comes in 10ml syringes and is a lot cheaper than the 1 ml syringes we have to use in Australia. I would want to see/feel it under the thin skin of the penis before using it myself.


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Dr Oates

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Reply with quote  #4 
   #68 
Quote:
Originally Posted by hoddle10
@ Dr Oates,

Could you briefly outline some of the possible complications that could occur with HA, even when using a micro cannula? Basically what are the risks, other than a poor aesthetic outcome? Having actually felt a micro cannula, I'm struggling to really see what could go wrong, but at the same time, I'm aware there are usually possible complications that we as potential patients don't really think of.

Thanks

Hi Hoodle10,

The most common is to get a small temporary bruise. We have had 1 guy who had swelling and movement of the product and have had to dissolve some of the HA.

The advantage off the microcannula (it is still 70 - 90mm long, just thin) is reduced chance to get obstruction of a vital structure. Those being the dorsal penile artery and the urethra. Both of these are deeper structures so difficult (but maybe not impossible) structures to get too with a cannula.

There are occasional inflammatory reactions to even HA fillers. More common in people with autoimmune diseases - which are more common in women.

Again the big advantage of HA is the ability to dissolve it if you need too, so even if it is a rare problem there is a quick way of dealing with it.
 
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Dr Oates

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   #145 

Where we inject - yes between the superficial (Dartos) fascia and the deeper bucks fascia. From the Androfil video it looks to be exactly the same plane as that needle - we are not injecting deeper than that. The person posting from Androfil (a practice manager when I PMed) said it was rediculous to think that a 27G needle could cause a blockage to these vessels - sorry totally wrong. In fact most arterial blockage has been caused by 27G needles. As Androfil said - that is what comes in the box. Arterial blockage is caused by being in the wrong plane - which is one of the reasons the cheek filling video gave me the shivers. Plus injecting without gloves. And then posting the video.

The Angular Artery runs across the face at an angle from just out from the corner of the mouth to the corner of the nose and up to the corner of the eye. Is tends to have lots of bends in it so it can stretch out when you tun your face. It is one of the most commonly occluded arteries and leading cause of blindness. Most blindness comes from fat - presumably injected with cannula (this is not fully documented not the size if the cannula). The area of the face being injected needs to be done down at the bone - well below the artery and you know you are there because you can feel it. Or very superficial with a needle into the skin itself well above the artery. If you really want to inject at a more medium depth like they appear to be doing then you better be using a cannula, and actually keeping it moving is safer than keeping still( hopefully you come out of the vessel before injecting too much rather than nice and slowly injecting a big blob carefully into the artery) - but still no guarantee.

On Hyalase not being effective (ie Hunky) - surprising. Maybe what was left was either granulation or scar? My concern with a blockage in the dorsal artery was getting the hyalase down through the deep fascia. But it has been well shown that it penetrates well through a thick arterial wall. In the case of this happening they hyalase is injected with a needle. When people ask me how much - till the problem if totally fixed or you run out of Hyalase. Amazingly Hyalase is not an approved medicine in France and they have to purchase it elsewhere and 'smuggle' it in.

On getting rid of injected blobs of fat. Lipodissolve often/usually causes lots of redness/swelling/pain and i dont think you would like it. I use injected steroid and usually find it gets rid of lumps and bumps in lips and around eyes - so that would be my first choice.

Stem cells. Quite possibly a big part of the future of medicine. I banked cord blood when my 2 kids were born to store the stem cells. But currently it is research and conjecture. Yes there are stem cells in fat and we have been injecting them with fat transfer for decades. Maybe it was always the stem cells that were responsible for a lot of the benefits we saw. But...I dont think any of the kits available now have been demonstrated to really get you that much more or that it then does that much more. Unfortunately we have just had a death of an elderly woman having it for dementia. Not directly related to the actual stem cells (I think) but the procedure and being on blood thinning medications and the doctor not knowing that.

I will try and post some histology pictures to show exactly where things are. First thing to notice is the dorsal artery does not necessarily run in the midline and can be/usually paired. The superficial facia and skin are intimately applied. It is also called the Dartos fascia - the dartos muscle is the muscle 'in' the skin of the scrotum and why it can contract (the cremaster muscle is the one that actually retracts the ball). There there is a loose space between the superficial and deep fascia. You will all be aware of what this loose space does (think of a single man before he goes to sleep). The deep fascia and Tunia are quite thick. It could be punctured by a cannula. But less likely. And a lot less likely than a needle - especially one going in and out as rapidly as it the Androfil video.

I have had 4 PM's while writing this post - will check after inserting some pictures.

If these pictures dont make it clear I am sure you will let me know. The subcutaneous layer is the loose space - where the product goes with the cannula (and the needle). There should be a second image (pink) which is a microscopic close up - if it does not come up I will repost. cadaverpenis.jpg

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smacks

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Reply with quote  #6 
Hello,

I had HA injections earlier this year on two separate visits.  First time 6ml and second time 8ml.  I am happy with the results of the Juvederm Voluma.  Too ba d it wasnt permanent...though i hear unsubstantiated claims that it can stimulate the production of new tissue giving some permanent though smaller long term effects?

Also wondering if anyone offers HA injection with PRP injections and if this shows any promising Long Term results.
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chester

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Reply with quote  #7 
Quote:
Originally Posted by smacks
Hello,

I had HA injections earlier this year on two separate visits.  First time 6ml and second time 8ml.  I am happy with the results of the Juvederm Voluma.  Too ba d it wasnt permanent...though i hear unsubstantiated claims that it can stimulate the production of new tissue giving some permanent though smaller long term effects?

Also wondering if anyone offers HA injection with PRP injections and if this shows any promising Long Term results.

Voluma is not a bio-stimulatory filler, so it won't create permanent, long-term results. For that, you should look into Ellanse.

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Dr Oates

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Reply with quote  #8 
I was trying to have a more limited thread here without general discussion but will comment here.
HA is great because it can be reversed and complications don't have to be permanent. But no it is not forever. But we seem to be getting a few years.
There have, however, been multiple studies (see my blog on calibreclinic.com.au) that show stimulation of collagen production and other 'ground substance' (HA is part of a group of molecules that exist between the cells) from the the injection of HA. We see that in repeated injections into lips that you need less filler, less frequently after multiple injections.
I don't think at this stage we are going to see HA like Voluma give us long term enlargement. PRP in addition or alone is interesting - but I am reserving my judgment on that. Ellanse stimulating long term (beyond the 4 yr product) maybe - at this stage still have to wait and see..

For more comments could we go back to the HA for safety thread? Thanks.

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Reply with quote  #9 
Dr. Oates

Any news regarding how your Ellanse with patients?
Any new thoughts on any upcoming HA fillers?
Can you speak to other HA's that you offer as a viable alternative to Voluma and what their advantages/disadvantages are?
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chester

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Reply with quote  #10 
Quote:
Originally Posted by randomword1234
Dr. Oates

Any news regarding how your Ellanse with patients?
Any new thoughts on any upcoming HA fillers?
Can you speak to other HA's that you offer as a viable alternative to Voluma and what their advantages/disadvantages are?

Check out the thread called "Ellanse Procedure." Subtle77 is Dr. Oates' Ellanse patient.

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Dr Oates

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Reply with quote  #11 
Quote:
Originally Posted by randomword1234
Dr. Oates

Any news regarding how your Ellanse with patients?
Any new thoughts on any upcoming HA fillers?
Can you speak to other HA's that you offer as a viable alternative to Voluma and what their advantages/disadvantages are?


Hi Random,

I have recently had one develop granuloma lumps/hardness. I was quite concerned, injected A40 Triamcinolone(steroid). Within 1 week they had almost totally settled. Still injected a bit more - now waiting....

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Dr Oates

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Reply with quote  #12 
Also using Ultimate (Teosyal HA - seems just the same as voluma. Teosyal have just released in Australia the Resilient HA with is more flexible - so now going to trial that as well as Belotero....
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sexy beast

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Reply with quote  #13 
hey there dr oates, does ellanse inject similar to voluma, do u notice more movement w/ ellanse than w/ voluma? if you had a choice which would you choose, the reason i'm asking is that as much as i like the voluma the squishiness bothers me a little. i like my results w/ the voluma but i would like it better if it were a bit firmer.
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randomword1234

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Reply with quote  #14 
To add to sexy beasts question, are there other HA's that are firmer than Voluma that are viable options?
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