Phalloplasty is a complex set of surgical procedures that create a penis. It’s often part of a gender affirmation process for transgender men and nonbinary people. This is a major step, and it requires a lot of planning and care.
Typically, phalloplasty surgery involves multiple stages and several different procedures. There are many different options for how to create the phallus, depending on your goals and the donor tissue available.
In this article, we’ll explore the different types of phalloplasty, what the surgical process looks like, and some of the things you’ll want to consider as you research your options.
Types of Phalloplasty and Donor Sites
Phalloplasty is a complex surgery, and there are several different techniques surgeons can use. The best option for you will depend on your individual anatomy, goals, and surgeon’s expertise.
Radial Forearm Free Flap (RFFF)
RFFF is a frequently used technique that uses skin from the forearm to create the new penis. Surgeons often choose this method because the skin on the forearm is thin and pliable, which can lead to a more natural-looking result. It also allows for the potential to reconstruct the urethra in a single stage.
During the procedure, the radial artery and associated nerves are also transferred to the new penis to provide blood supply and sensation.
Anterolateral Thigh (ALT) Flap
The ALT flap uses skin, fat, and fascia from the anterolateral thigh (the front and side of your thigh). The thickness of the tissue on your thigh is a crucial consideration to determine if the ALT flap is a good option for you. If a larger amount of tissue is needed, the ALT flap can be a great choice.
Musculocutaneous Latissimus Dorsi (MLD) Flap
The MLD flap uses skin and muscle from the back. This flap can provide a larger amount of tissue than RFFF or ALT, but it may result in a bulkier penis.
The Phalloplasty Surgical Process
Phalloplasty is often performed in multiple stages, spaced out over time to allow for healing and to manage the complexity of the procedures. Here’s a general overview of what to expect:
Stage 1: Phallus Creation and Urethral Lengthening
In the first stage, the surgical team creates the phallus using the tissue flap you and your surgeon chose. This is intricate work! The team uses microsurgery to connect blood vessels and nerves in the donor tissue to those in your groin area. This connection is essential for sensation and function in the new phallus.
Urethral lengthening is also usually done during this first stage. The goal is to allow you to urinate through the tip of the new penis. According to the University of California San Francisco’s Gender Affirming Surgery Center, if you want urethral lengthening, it must be done during stage 1.
Stage 2: Scrotoplasty and Testicular Implants
Scrotoplasty refers to the creation of the scrotum. Surgeons typically use tissue from the labia majora to create the scrotal sac.
If desired, testicular implants can be placed during this stage. These implants give the scrotum a more natural look and feel.
Additional Procedures
Depending on your individual goals, other procedures may be performed at the same time as or before phalloplasty. These can include:
- Vaginectomy (removal of the vagina)
- Hysterectomy (removal of the uterus)
- Clitoral burying (repositioning the clitoris beneath the base of the neophallus)
Considerations Before and After Phalloplasty
Phalloplasty is a complex surgery, and it’s important to fully understand the process before committing to it. Here are some things to keep in mind:
Personalized Surgical Planning
Phalloplasty isn’t a one-size-fits-all procedure. The surgical plan should be carefully tailored to your individual needs, anatomy, and desired outcomes. It’s crucial to have open and honest conversations with your surgical team to discuss your priorities and develop a plan that aligns with your goals.
Recovery and Potential Complications
The recovery period after phalloplasty is significant and requires patience and commitment. It’s also essential to be aware of the potential complications that can arise. These may include infections, implant rejection (if you choose to have a penile implant), and urethral issues like strictures or fistulas. Many patients require a suprapubic tube (SPT) for temporary urine drainage during the initial healing phase.
Penile Function and Sensation
One of the key considerations for many individuals undergoing phalloplasty is the potential for nerve regeneration and the return of sensation in the newly constructed phallus. Nerve regeneration can begin as early as three weeks after surgery, but it can take a year or even longer to achieve meaningful sensation.
If the ability to achieve erections is a priority, a penile implant can be inserted after the surgical site has fully healed. However, it’s important to note that as of September 2022, there were no FDA-approved implantable prosthetic devices specifically designed for phalloplasty. The implants used are typically designed for cisgender men experiencing erectile dysfunction, and their use in phalloplasty is considered “off-label.”
Metoidioplasty: Another option for masculinization
Metoidioplasty is another type of surgery that can create a penis. It involves releasing the clitoris, which has already grown larger under the influence of testosterone, to create a smaller penis.
Metoidioplasty may be a good option for people who want a smaller penis and are not as concerned with lengthening the urethra so they can stand to urinate. Some people opt for metoidioplasty as a first step before a phalloplasty, while others are satisfied with the results of a metoidioplasty alone.
Frequently Asked Questions
Are phalloplasty scars permanent?
Yes, phalloplasty surgery will result in permanent scars. The extent and appearance of the scars depend on the specific surgical techniques used and individual healing factors. Scar revision procedures may be an option to improve the appearance of some scars, but they won’t eliminate them entirely.
Are there erectile devices for phalloplasty?
Yes, most phalloplasty procedures don’t naturally create erections. To achieve an erection, an erectile device, typically an inflatable penile prosthesis, is implanted. This allows the individual to achieve an erection on demand.
Does a phalloplasty look real?
The appearance of a phalloplasty varies depending on the surgical technique used, the individual’s anatomy, and the healing process. Modern techniques aim to create a phallus that looks as natural as possible, but it’s important to have realistic expectations and discuss this thoroughly with your surgeon.
Do you feel pleasure with phalloplasty?
The ability to experience sensation after phalloplasty varies. Surgeons aim to connect nerves during the procedure to allow for tactile sensation. While some individuals report experiencing erogenous sensation and orgasm, others may have limited or no sensation. Sensation depends on individual factors and surgical success.
Do people regret phalloplasty?
While the majority of individuals who undergo phalloplasty report satisfaction with their results, some may experience regret due to complications, unmet expectations, or psychological factors. Careful patient selection, realistic expectations, and thorough pre-operative counseling are crucial to minimizing the risk of regret.
Key Takeaways
Phalloplasty is a complex process that requires a lot of thought and planning. It’s a big surgical step in gender affirmation.
Learning about the different types of phalloplasty, the surgery itself, and the good and bad things that might happen can help you make good decisions about your own gender journey.
Talking with surgeons and other health professionals who know a lot about this kind of surgery is essential for getting the best results.