Phalloplasty is the construction or reconstruction of the Penis. These surgeries typically involve a plastic surgeon, gynecologist (for Trans-men) and urologist. Phalloplasty is performed on Transgender men as part of their surgical transition, it can, therefore, be referred to as Gender Affirmation Surgery.
Cisgender men who have lost their penis due to disease or accidents or who have congenital anomalies such as but not limited to epispadias, hypospadias, and micro-penis.
The first reconstruction of a Phallus was done by Russian doctor Nikolaj Bogoraz in 1936, using rib cage cartilage. While the first gender reassignment phalloplasty was performed by Sir Harold Gillies in 1946.
There are different ways to perform a phalloplasty, and it in some instances takes more than one surgery.
A phalloplasty begins with the retrieval of skin grafts from a selected part of the body, the tissue is then used to make the shaft; the outside of the phallus which is surgically attached to the pelvis and the urethra; the structure with which cisgender men use to urinate and ejaculate.
The reconstructed urethra is then attached to the existing urethra, in Gender reassignment surgery for transgender men, the urethra is elongated and the clitoris remains at the base of the Neo-Phallus where it can still be stimulated.
For a successful phalloplasty certain goals should be met, these goals include:
- Aesthetically pleasing phallus with normal appearance and adequate length and girth suitable for penetrative sex ( with a penile prosthesis in place)
- The ability of the owner to void/urinate while standing.
- Adequate erogenous/tactile sensation.
- Minimum scarring and disfigurement from the donor site
- Phalloplasty for Transgender men contains a number of procedures performed in tandem,
- Hysterectomy- the removal of the uterus.
- Oophorectomy- the removal of the ovaries.
- Vaginectomy-the removal or partial removal of the vagina.
- Scrotectomy- turning the labia majora (vulva) into a scrotum with or without prosthetics.
- Urethroplasty where the urethra is lengthened and attached to the existing urethra.
- Glansplasty where the neo-phallus is scalped to appear like an un-circumcised tip.
- Penile implant to facilitate erectile functions.
- Phalloplasty requires for an implanted erectile prosthesis for erectile functions and penetrative sex.
Phalloplasty techniques vary due to the area with which the skin/tissue commonly known as flaps is removed, how it is reused and reattached. Some of the more common types are;
Radical Forearm Free-Flap (RFF or RFFF)
RFF is the gold standard in Phalloplasty. The free flap tissue is removed from the forearm together with the veins and the nerves, it is then attached to some of the existing veins going to the patient’s groin to allow for easier merging of the graft with some of the pre-existing tissue. The blood supplies from the graft are merged with the vein leading to the femoral artery using microsurgical precision, this allows the blood to flow naturally to the neo-phallus.
This technique is preferred to the others because, it has proven to have great sensitivity as well as aesthetic appeal, the urethra forms well in the tube in tube fashion allowing for standing urination. The flap retrieved is also rather large and easy to harvest. It also has proven to have sensitivity in most cases and conducive for penetrative sex with a penile Prosthesis.
The main advantage of this flap however is consistent arterial anatomy and a long vascular pedicle with vessels of a large diameter which facilitates microsurgical anastomoses.
Some of the disadvantages of this procedure are; the harvesting area is pretty exposed and usually results in the harvesting of more skin grafts to cover it up which leaves visible scarring in two areas of the body. Another major disadvantage is that the colour of the skin from the forearm might differ with the colour of the skin around the genital area. RFF also requires a surgeon that is skilled at microsurgery.
Musculocutaneous Latissimus Dorsi flap (MLD)
MLD Phalloplasty is a surgery that uses tissue from a back muscle underneath the arm on the less dominant side, to create a good-sized phallus that enables standing-to-pee, as well as erectile function with a penile implant.
According to Marco Bumbasirevic from the University of Belgrade, The MLD flap is mobilized on a subscapular artery and vein, and a thoracodorsal nerve. The neo-phallus is created on-site and after dividing the neurovascular pedicle, transferred to the pubic region, where it is anastomosed with the femoral artery, saphenous vein, and ilioinguinal nerve.
MLD phalloplasty enables the individual to create a large phallus from the skin grafted. And also makes it easier for the penile prosthetic to be added.
Pre Phalloplasty advice includes the patient not working out as the build of muscles can create problems with the vascularization of the grafted skin for phalloplasty.
Anterolateral Thigh flap (ALT)
The ALT flap is a skin, fat and fascia flap that is usually supplied by the descending branch of the lateral circumflex femoral vessels and the lateral femoral cutaneous nerve.
According to In the pedicled surgical procedure, neurovascular supply is left partly attached to the donor site (“pedicle”) and simply transposed to the perineum, keeping the pedicle intact as a conduit to supply the tissue with blood and innervation.
ALT flap offers clinical advantages of less obvious donor site concealable with clothing, decreased surgical time, preservation of erogenous sensation and vascular supply of the flap without microsurgical anastomosis of nerves and vessels, and good potential for urethroplasty.
The disadvantage to this is it might be difficult for patients with a thick skin or more subcutaneous thigh fat.
Some of the other areas for harvesting skin graft include;
Free fibula osteoseptocutaneous Flap- where the skin is harvested from the leg area between the ankle and the knee. The obvious disadvantage is the scarring will be visible and large.
Abdominal Phalloplasty- skin graft is harvested from the abdomen running from one pelvic bone area to the other. A disadvantage of this type is the skin has a less natural appearance.
A penile prosthesis is required if the man wants to have penetrative sex with their partner. It is therefore not a compulsory step for all men who undergo phalloplasty.
A penile prosthesis is sometimes put during the initial surgery or after the phalloplasty. There are two kinds of prosthesis used, the semi-rigid devices that can be bent and used for penetrative sex, the inflatable prosthesis is pumped with a fluid from a reservoir placed in the abdomen. The pump is placed in the scrotum in order to stiffen and deflate.
Some of the advantages of a penile prosthesis are;
- The pump can be activated discreetly,
- The psychological and emotional well-being of the patient and the erection can be maintained long-term.
Disadvantages of the penile implant/prosthesis include;
- The penis may not be completely flaccid this is especially in the case of the semi-rigid devices
- Neo-phallus may not be as rigid as a natural phallus.
- Manual stimulation may be painful
- Risk of complications such as; excessive bleeding, scarring, and erosion of the tissues
Differences between Transgender Phalloplasty and Cisgender Phalloplasty
One of the biggest differences and one of the largest cause for infection is the lengthening of the urethra for transgender men. For cismen, the urethra is perfectly connected to the base of the penis while for transmen the urethra has to be surgically created and connected to the base of the phallus.
The second difference is the incorporation of the clitoris to the neophallus. For transmen, the retention of sensitivity has to be incorporated into the formation of the neophallus and hence the placement of the clitoris at the bottom of the neophallus or connecting the nerves from the grafted skin to those of the clitoris to allow for sensitivity during sexual intercourse and/or penetrative sex.
Risks and Complications
Some of the risks and complications associated with a phalloplasty include;
- Urethra Fistula
- Arterial Ischemia- Shortage of blood to the Neo-phallus
- Hematoma- Bruising
- Distal limited necrosis- The dying of certain parts of the Neo-phallus. This can also be called flap failure
- Lack of sensation
- Wound breakdown or ruptures along the incision line
- Urethra stricture/stenosis- Narrowing of the urethra
- Testicular implant Failure.
- Injury to the bladder/rectum
Complications associated with the donor site include;
Discoloration or excessive scarring
Numbness, stiffening and swelling of the surrounding area.
Before a phalloplasty can be done there are certain requirement both physical and psychological one is expected to have. In some cases, surgeons and doctors have required a psychological evaluation done by a licensed psychiatrist or psychologist. This is because some elements of phalloplasty are irreversible.
Physical examinations may include; diet, BMI level, lifestyle (smoking, alcohol intake, etc.) It is also required that the patient complete at least 12 months or more of hormonal therapy before a phalloplasty.
After the surgery has been approved. In some cases hair removal is considered an option, permanent hair removal techniques such as laser are to be done.
Doctors will also require your medical history as well as monitor aspects of your body such as body blood flow, skin coloration, any genetic diseases such as hemophilia and allergies.
Post Phalloplasty Care and Recovery
After phalloplasty surgery, you will be required to stay at the hospital for a few days to check; the blood flow to the neophallus, bleeding, general patient health, nausea, appetite, etc.
This period is also the most crucial for the emotional and physical well-being. It is important to have frequent monitoring in order to stay ahead of any issues and complications that might arise.
You will be provided with a sequential compression device (SCD) on your legs to prevent any blood clots. Your neophallus will be dressed in an elevated position to ensure uninterrupted blood flow.
A catheter will be attached to your urinal bladder and one in your penis to open up the urethra. The latter will be taken out when discharged.
You will have to keep your penis elevated and avoid strenuous activity for at least six weeks after the phalloplasty.
For faster healing, a nutritionally balanced diet should be ascribed to you after the surgery chewing, and swallowing of some foods may prove to be a difficulty after, it is therefore important to adhere to the food by either your doctor or a nutritionist or any medication and supplements provided.
Keep your incision clean and dry to avoid infection. Keep the catheter on until removed by the doctor.
Sensations may not be felt for a while after the surgery. Keep the area clean and dry, apply an antibacterial ointment on the area as specified.
For the Donor site. Keep the gauze on until for the recommended time by the surgeon.
Do not apply any water or any substance to the site. Avoid disturbance of the site and any strenuous activity.
Postoperative therapy will also help a person cope with their new body, understand and share some of the anxieties and concerns they may have for the future. Understand and feel support as they embark into their new life. Gage the patient’s sense of self-esteem and body acceptance after phalloplasty. Asses the patient’s quality of life, happiness and deal with any antagonistic feelings that may arise.
Questions to ask before Choosing a Phalloplasty technique and Surgeon
- A compressive understanding of each technique, its limitation and what to expect.
- Photographs of successful phalloplasty and the techniques used.
- How Many surgeries has the surgeon done?
- Fertility, be honest about any fertility desires you may have in both the short term and the long-term.
- Recovery time
- In-patient and outpatient support from the hospital
- Discuss how many surgeries you would ideally like to have. Some people choose to spread them over a long period of time, others choose to have them done in a short time.
- Depending on the technique, the number of surgeries your surgeon has done.
While there is limited resources on comparison of surgical techniques. Studies have found that ALT has a higher risk of urethra fistula and stricture that RFF.
RFF also had significantly lower partial or total neophallus loss than those who had ALT phalloplasty.
Quality of Life for men who have undergone Phalloplasty was significantly high although a lot of men show that erogenous sensation was less than they had previously hoped for. Sexual quality of life among men who have undergone phalloplasty improved significantly over a period of time. Most men indicated improvements in penetrative sex and/or masturbation.
For Transmen, research has shown increased sexual awareness, esteem and body satisfaction. Men with a penile implant showed especially higher satisfactory rates due to the penetrative aspects associated with masculinity.
They, however, had lower orgasmic rates compared to pre-phalloplasty.
This is due to the decrease in phallus sensitivity and the lack of understanding for stimulation of the incorporated clitoris at the base of the phallus for erogenous sensation. Penile Prosthesis placement was not associated with decreased erogenous sensation or orgasm.
A small number of men did show dissatisfaction with the neophallus, mostly attributed to the conflict between the expectation and the reality of phalloplasty.
While progress has been made in surgical and research about phalloplasty, its limitations and the quality of life thereafter. There is still a need for more targeted research to be conducted to incorporate different surgical techniques and the quality of life among a larger number of participants conducted over a longer time frame.