A vast painting covers the wall above a marble mantelpiece on which rests a human skull. It depicts Maurizio and Roberto Viel, who are twin plastic surgeons and a nude woman whose breasts they have augmented. The imposing work, called Creation, greets patients at the brothers' clinic on Harley Street in London. But increasingly these patients are men and, increasingly, they come in search of a larger penis.
As the exposure of crotches and more on billboards (think David Beckham's pants ads) as well as in magazines and pornography helps to fuel a rising sense of inadequacy among many men, penis enlargement has become, if you'll pardon the pun, a growth business. But penises, more than breasts, have evolved to withstand great stress and changes in size and they resist almost all attempts to make them permanently bigger.
Roberto Viel says he has overcome these challenges and performs about 200 penoplasty operations a year.
Sitting at his desk, he pulls out a gold-nibbed pen and draws a penis. It includes the suspensory ligament, which holds up the erect penis. By partially severing it, having accessed it by cutting away a flap of flesh covering the pubic bone, Viel causes the penis to drop, and hang lower by as many as two inches. The length of the erection is not increased, however, and its angle is lower. "If I cut too much it will be like that," Viel says, overlaying his drawing with a drooping outline, "and that's not the best for sex."
Viel also extracts fat, usually from the patient's stomach and injects it under the skin on the top side of the penis, increasing its circumference by more than an inch, whatever its state. Viel keeps some of the fat in his fridge for top-ups, in case it is reabsorbed. The procedure, which takes about 90 minutes and is performed under local anaesthetic, costs around £5,000.
Viel studied medicine in Milan and trained in France and America alongside his brother. They have worked for more than 20 years at their London Centre for Aesthetic Surgery.
Maurizio is now based at the clinic's other branch, in Dubai. In 1991, Roberto gave Maurizio a nose job, which made the twins look more alike. Ten years later, Roberto injected fat from Maurizio's tummy into his brother's face, with similar results.
Penis enlargements now make up half the Viels' work, bringing in around £1m a year. The twins are accomplished self-publicists and have appeared in dozens of magazines and newspapers. I learned about the growing demand for their procedure in a press release sent by his clinic's public relations agent. Viel estimates he has performed 3,000 penis enlargements since 1991. He is fully licensed to carry out his procedure, inspired in part by the pioneering work in the 1980s of Dr Long Daochao, a Chinese surgeon.
But it remains a niche technique. None of the 230 surgeons represented by the British Association of Aesthetic Plastic Surgeons (Baaps), which accounts for about 40 per cent of the industry, offers penoplasty. The Viels are not members. Nigel Mercer, a consultant plastic surgeon and former president of Baaps, says: "It's not something we say every surgeon should offer because there have been lots of unhappy patients."
Marcus Drake, a senior lecturer in urology who specialises in reconstruction surgery at the University of Bristol, says: "There is always a reason for a ligament and if you cut it the associated joint or structure wobbles around. A bit of introspection on any man's part will soon make him recognise this is borderline risky." Drake goes further, pointing out the lack of full clinical trials of penoplasty.
Viel says the limited availability of penis surgery is not due to risk but because "there is no formal training" for it. He adds: "I have developed and improved the technique using surgical techniques from different surgeries to put together a procedure I think is reliable and gives good results in a safe way. Nobody wants to take any risks and I would not be so naive or stupid to put my name to a procedure that was not safe."
Viel also says his success rate is high: "Of course sometimes there are cases when people are not completely happy because of a misunderstanding of expectations before the operation but the likelihood of this is very low."
He also says he offers counselling before and after surgery. "I say no if they want something I can't give them," he explains. "When they want it longer when erect – I can't do that. Or when I think they don't need it or they have underlying psychological issues." Figures collected by Baaps showed 4,300 cosmetic surgical procedures were performed on men last year, a rise of 6 per cent. Most popular was the nose job, with 1,000 incidences. Penis enlargement does not feature in the top ten, but writer Tracey Cox says she's not surprised that demand is growing. "I do an online clinic where men can ask anything about relationships or sex," she says. "They ask about two things – maintaining an erection and getting a bigger penis." Cox blames a growing obsession among both sexes with image, as well as the prevalence of porn. "What men fail to take on board is that men are picked as porn stars for a reason. The danger is porn is what boys are using as sex education."
Viel says his patients vary in age and profession. Steve (not his real name) is 35 and lives with his wife and two children. Four years ago, before Steve was married, Viel injected fat into his penis. Why? "Why not," he says on the phone from his home in Birmingham. "From a young age I thought it'd be brilliant. I wasn't worried about my size but I suppose in the end I didn't want to be Mr Average. I wanted it more for my inner confidence than for showing it."
Steve only had the fat graft, passing up on the ligament snip (90 per cent of Viel's patients have both). "When it was done I looked down pretty much straight away," he recalls. "You've got a small incision on your penis with one stitch. I thought, wow, that's amazing."
Viel says Steve's "why not" rationale is unusual and that the majority of his patients, none of whom would talk to i, seek not just a bigger penis, but a better life. "They don't feel comfortable," he says. "They don't want to go to the pool with their son, or to the beach or to play football because they don't want to change in the changing room. It's a very sensitive issue."
Some men become so fixated on size they resort to unlicensed surgeons. Baaps warned last year of an alarming rise in silicone implants advertised online for as little as £120. Jim Horton wanted a bigger scrotum. He visited a practitioner at his house and allowed him to inject silicone stored in a milk bottle into his scrotum using "what looked like a sealant gun from a DIY store". The silicone migrated, causing dramatic hardening and swelling. Horton was too embarrassed to seek help, eventually requiring emergency corrective surgery. Viel has seen patients who have visited unlicensed surgeons, usually abroad. "The results are unbelievable," he says.
But to what extent does he see himself part of an industry that profits from and fuels paranoia in men who may be vulnerable?
"I don't do that," he says. "Men are just taking more care about their health and looks in the same way more men are going to the gym. Why age in a way we're not happy with?"
Viel leaves his desk to pose for photographs in front of his portrait. He's on a tight schedule; a patient is on his way for a penis enlargement. Is it a procedure Viel has ever considered undergoing?
"I personally wouldn't have it at the moment," he says. "I feel comfortable with what nature gave me."