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 St 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, for example, 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 5cm. 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 2.5cm, whatever its state.
Viel keeps some of the fat in his fridge for top-ups, in case it is reabsorbed. The whole procedure, which takes about 90 minutes and is performed under local anaesthetic, costs about $A8000.
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 about $1.6million a year in revenue. The twins are accomplished self-publicists, and have appeared in dozens of magazines and newspapers. Viel estimates he has performed 3000 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, which accounts for about 40% 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 also says he offers counselling before and after surgery. "I say no if they want something I can't give them," he said.
"When they want it longer when erect - I can't do that."
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