Even the penile enlargement fad has to be measured against the Web...

Rohit Khare (khare@pest.w3.org)
Thu, 6 Jun 96 15:25:17 -0400

> Fortuitously, the World Wide Web was exploding at just this time, allowing
> the California surgeons to tout their expertise all over the world.

> "I go out on a limb more than I did before with business," he says.
> "Now [when] I go into business meetings, I'm thinking, 'If you guys
> had just half of what I have.' "

How a Risky Surgery Became Profit Center in Los Angeles


LOS ANGELES -- A sleek promotional video from Cosmetic Surgery International
here stars satisfied customers offering up breathless testimonials. "This,"
says a man in his 40s, "is absolutely the best thing that ever happened to
me." Adds another, "I can't believe I waited so long."

Just like braces for crooked teeth, the video explains, this cosmetic surgery
is "simple, safe and effective." But this is no orthodontia. For $5,900 and a
mere 55 minutes of time, the surgeon in the video promises to substantially
lengthen and widen a patient's penis.

Like the beginning of breast augmentation in the 1970s, penile enlargement
has become a hot new cosmetic specialty -- and nowhere is it more prevalent
than here in the nation's plastic-surgery capital. Popularized only during the
past few years, penile enlargement is now a major profit center for some
enterprising urologists and plastic surgeons whose incomes have fallen with
managed care. The fledgling industry has grown quickly even though the
procedure is unregulated, isn't taught by any university, can be dangerous --
and doesn't always work.

Toll-Free Advice

Cosmetic Surgery International says its two surgeons together perform 30 to
45 enlargements each week and are booked through July. One Southern California
clinic reported revenue averaging more than $1 million a month. Several
medical groups advertise toll-free numbers, like 1-800-SURGEON in Beverly
Hills, which accepts Visa and MasterCard and has operators ready to explain
the $7,000 procedure to callers in Thai, German, Vietnamese, Swedish or
French. "I cannot physically talk to everyone with interest out there," says
Rodney Barron, a Beverly Hills urologist who has opened sales offices in San
Francisco, San Diego, Orange County and Los Angeles and says he has performed
more than 3,000 enlargements.

Nationwide, some 20 to 30 surgeons now practice phalloplasty, as the
procedure is known; about half are clustered in Southern California. Based on
individual surgeons' estimates of their patient caseloads, the industry brings
in at least $24 million a year -- a fraction of the estimated $350 million a
year breast-implant business, but a fast-growing industry nonetheless.

All this despite the fact that the American Urological Association and the
American Society for Aesthetic Plastic Surgery both say the surgery has "not
been shown to be safe or efficacious." To the extent that the public hears
about the usually hush-hush procedure at all, it is because of terrifying news
reports of botched jobs and complications, ranging from scarring and
lumpiness to impotence and even death. A high-profile surgeon in Los Angeles
has been slapped with dozens of malpractice suits, while another in Miami is
in prison for the death of a patient.

New 'Outlook on Life'

Yet especially here in Southern California, where a culture of vanity
prevails, new recruits to the surgery are easy to find. Cosmetic surgery in
general is more popular here than anywhere else in the country. In 1994, the
latest year figures are available, 84,300 cosmetic surgeries were performed in
California -- 21% of all U.S. cosmetic surgeries, and more than double the
number performed in second-place Florida, according to the American Society of
Plastic and Reconstructive Surgeons.

"I never felt comfortable or confident about myself before," says Frank
Whitehead, a Los Angeles entrepreneur who had an operation to both lengthen
and widen his penis last year. Sitting in the office of his printing shop in
the San Fernando Valley, Mr. Whitehead, a tall, affable man with a black
mustache and tufts of black hair peeking through a plaid shirt unbuttoned to
his navel, says that the procedure "has changed my whole outlook on life."

"I go out on a limb more than I did before with business," he says. "Now
[when] I go into business meetings, I'm thinking, 'If you guys had just half
of what I have.' "

Southern Origins

How penile enlargement became so popular here is a tale more of marketing
than medicine. In the late 1980s, a Miami physician named Ricardo Samitier,
who had created a niche for himself by performing silicone lip enlargements,
decided to apply his trade to penises. The result was a penis-widening
operation in which he injected fat extracted from the abdomen or other parts
of the body.

Meanwhile, half a world away in China, a surgeon named Long Daochao had
invented a procedure to lengthen the penis; his new technique was brought to
the U.S. in 1991 by another Miami physician, urologist Harold Reed. The
lengthening procedure involves severing a ligament that attaches the penis to
the pubic bone, allowing the internal portion of the organ to drop to the

For a while, Dr. Samitier dominated the fledgling field. But his reign was
cut short after one of his patients, a 47-year-old lounge singer who had been
on blood-thinning medication, died following the operation in 1992. Dr.
Samitier is now serving a five-year prison sentence for manslaughter.

That's when Los Angeles urologist Melvyn Rosenstein stepped in. Dr.
Rosenstein, now 57, had performed a handful of enlargements in 1993 when he
teamed up with marketing expert Ed Tilden, who had promoted a Beverly Hills
hair-transplant center and who saw a marketing gold mine in penile surgery.

Together, the two men opened the Men's Institute of Cosmetic Surgery. It
advertised penile enlargements heavily in national magazines like GQ and
Penthouse as well as in local newspaper sports pages, with this slogan:
"Dreams do come true." Dr. Rosenstein, tall and garrulous, appeared in the ads
as well as in his own promotional video. He eagerly offered up quotes to
reporters, telling them that his clients included "a major movie star," two
famous singers, and "CEOs you read about in Forbes." He declined to comment
for this piece.

The marketing machine worked, spectacularly. Soon, the two men set up
satellite offices in more than a dozen cities, including Phoenix, Houston,
Baltimore and New York. The offices were staffed by young men who, former
associates say, frequently had no medical background and who were paid $4,000
a month to explain the procedure to prospective patients. The patients were
then referred to Dr. Rosenstein's Culver City, Calif., clinic, where he
performed six to 14 surgeries a day. In Los Angeles County Superior Court
papers, he reported that the clinic's revenue totaled $7.4 million for the
first six months of 1994. Dr. Rosenstein and Mr. Tilden have since had a
falling out and are in litigation.

Dr. Rosenstein's business was such a success that other surgeons quickly
joined in. Many simply read or heard about the procedure and then set up shop
with no experience. They had little choice; there were few physicians they
could turn to who would teach them. "Most of those guys don't want to teach
anybody else because it means giving up business," says Gary Alter, a Beverly
Hills urologist and plastic surgeon who performs the procedure.

For some surgeons feeling the pinch of managed care, the procedure was a
godsend. "Unfortunately, many doctors have target incomes, and when they see
their incomes dropping down, they start elective surgery," says Miami's Dr.
Reed, who believes some of the surgeons aren't performing the operation
properly. "So a cottage industry starts to develop."

Soon, Los Angeles sports pages were filled with ads for the likes of
1-800-SURGEON, Surgery Center for Men, the Barron Centers, 1-800-680-MALE and
the Southern California Specialists in Sexual Medicine. Some ads promised as
much as a 30% to 50% increase in width and a two-inch increase in length.
Fortuitously, the World Wide Web was exploding at just this time, allowing the
California surgeons to tout their expertise all over the world.

Little Oversight

The surgeons were able to ply their new trade with little oversight. While
other new medical procedures are backed up by extensive research and
scientific studies, no comprehensive studies have yet been completed on penile
enlargement. The Food and Drug Administration, which oversees breast
implants, doesn't monitor the surgery because no implant or drug is involved.
Hospitals must approve new procedures, but most phalloplasty surgeons perform
the operations in their offices or in private clinics.

Nor do state authorities get involved unless they receive complaints about
individual surgeons, says California Deputy Attorney General Elisa Wolfe.
"We're not looking at the procedure itself," she says. "Experimental surgery
is not illegal. We cannot take on an industry."

Free from regulation, the industry exploded into a marketing phenomenon.
Currently, there are well over 30 web sites devoted to penile enlargement.
While no official figures exist, surgeons estimate that 10,000 to 15,000
widening or lengthening surgeries have been performed in the U.S. since the
early 1990s. Surgeons try to outdo one another with slick promotional
materials, including, on the web sites, impressive before-and-after pictures.

Complaints Pile Up

One thing most of the promotional literature doesn't mention: the dangers of
the surgery. Soon after Dr. Rosenstein began performing phalloplasty,
complaints began piling up against him and his center.

Ron Nance, 47, a carpenter from Monterey, Calif., says that following 1994
surgery performed by one of Dr. Rosenstein's associates, he got a severe
infection. He says he had to fly back to Los Angeles, and that Dr. Rosenstein
opened up the incision without giving him an anesthetic. On the plane back
home that afternoon, Mr. Nance says he noticed the stitches were coming out
again. The complications persisted, and Mr. Nance says he flew to Los Angeles
a total of nine times for repairs before turning to other surgeons for help.
His girlfriend left him, he says: "She couldn't take it anymore."

Nearly two years later, with $20,000 invested in the operation and repairs,
Mr. Nance says he remains not only permanently scarred but impotent. "This
procedure preys on men with little self esteem," he says. "You feel like this
is your ticket to happiness." He has sued Dr. Rosenstein and the other surgeon
involved in Los Angeles County Superior Court, alleging sexual dysfunction,
deformity and fraud and deceit, among other things. Dr. Rosenstein has denied
the charges, and an attorney for the other surgeon says the charges are
without merit.

More than 50 other lawsuits have been filed by 18 different attorneys against
Dr. Rosenstein in Los Angeles County Superior Court. Dennis Grant, an Orange
County resident, alleges that he "suffered disfigurement, shortening and loss
of use of his penis," while Gary Cates, another former patient, claims he
suffered "pain, swelling" and "excessive scarring." Other complaints allege
complications ranging from "lumpiness" and "shrinkage" to "uneven surface with
what appears to be cysts," and "impotence." In court papers, Dr. Rosenstein
has denied the charges.

'Getting Out'

The California Medical Board intervened in January, and Dr. Rosenstein's
medical license has been temporarily suspended pending a disciplinary hearing.
The surgeon's attorney, Thomas P. Brown, says his client "vigorously
contested" the allegations, though he says Dr. Rosenstein won't attempt to
re-enter the penile-enlargement business in any case.

"Given the volume of litigation and aggravation associated with it, Dr.
Rosenstein is getting out of the business and staying out of it," Mr. Brown
says. "But he still maintains he didn't do anything wrong."

Some complaints also began surfacing about at least four other surgeons, who
face a growing stack of malpractice suits in California, New Jersey and
Illinois courts.

Malpractice insurers sometimes cover physicians who perform the lengthening
procedure, but rarely cover them for the fat-injection widening. Mark Gorney,
an executive vice president of Napa, Calif., insurer Doctors Co., calls the
fat injections "a totally ineffective procedure and nothing short of fraud."

Critics, including some professors of urology, say there is no indication
that the lengthening surgery works for everyone, and that fat injections
result in too high a degree of deformities. "I challenge them to stop for a
minute and show us the results based on preoperative and postoperative
measurements," says Harin Padma-Nathan, assistant professor of urology at the
University of Southern California. The lengthening operation "appears to be a
sham operation to date."

A New Mop-Up Business

Indeed, the industry is so riddled with problems that it is now spawning a
mop-up business of its own: An Internet support group for disgruntled patients
provides information about surgeons, reconstructions and malpractice suits.
At least two California attorneys now specialize in penile malpractice cases.
San Francisco attorney Steven Fabbro says he has 30 clients, mostly former
patients of Dr. Rosenstein, while Camarillo, Calif., attorney Keith Schulner
says he has 35 clients and spends the bulk of his time on the Rosenstein

"This could be the fantastic break that every attorney has ever wanted," Mr.
Schulner says. "Or it could be a disappointment. We're going to be clogging up
the courthouse for a while."

Repairing allegedly bungled surgeries has also become the main livelihood of
Gary Rheinschild, a urologist who operates the Potency Management Center in
Anaheim, Calif. His business has nearly doubled this year, he says, to between
five and six surgeries a week. About 80% are reconstructions costing $4,500
and the balance are enlargements, costing $7,300 for the lengthening and
widening. Beverly Hills urologist Dr. Alter and San Francisco urologist Jack
McAninch, the new president of the American Urological Association, also work
on botched enlargements.

"A lot of doctors are appalled by this and don't want to talk about it," says
Dr. Rheinschild as he pulls on his surgical gown, preparing for a lengthening
operation on a 32-year-old aerobics instructor. "But a lot of people are
jumping in because of the big money. People shouldn't be doing this unless
they know what they're doing."

Dr. Rheinschild says he has seen a lot of complications during the past few
years, most of which he says are avoidable. For example, he won't perform fat
injections because they often result in "concave areas, nodules and
asymmetrical looking penises." He advocates dermal grafts, a different
procedure in which two strips of fat are removed from the patient's gluteal
folds, where the thighs meet the buttocks, and implanted on either side of the

Hoping for Legitimacy

Hoping to legitimize phalloplasty, several surgeons last year created the
American Academy of Phalloplasty Surgeons. But so far only about a dozen
surgeons have joined, and the academy hasn't yet published any scientific
studies. One member, E. Douglas Whitehead, has received approval to begin a
study at Beth Israel Medical Center in New York.

Despite the horror stories, though, the business shows no signs of slowing.
Even Dr. Rosenstein's colleagues are already back in the saddle. It turns out
that Cosmetic Surgery International, the outfit that uses the slick
promotional videotape and is booked through July, is co-owned by Dr.
Rosenstein's stepson, Jonathan Yaker, along with Christopher Solton, who is
Dr. Rosenstein's former marketing director. Promotional literature CSI
recently mailed out displays the name "Rosenstein Medical Group" and features
flattering newspaper articles about the surgeon.

Mr. Solton, the co-owner, insists that Dr. Rosenstein has nothing to do with
CSI. "It must have been an old folder," he says. "It was a mistake." Dr.
Rosenstein's attorney, Mr. Brown, says he has notified CSI that the surgeon
can no longer be referred to in the clinic's materials.

Other phalloplasty practitioners say the procedure isn't going away because,
quite simply, the time is right for it. The surgery ties into the American
male psyche, they say, making for possibilities that aren't only lucrative but

"You've had a few people who have done large numbers with bad results," Dr.
Alter in Beverly Hills says. "But in 10 years, as improvements are made,
you'll see this surgery becoming mainstream. It's a vain society out here."