Phalloplasty is a surgery that entails creating a full sized adult male penis through grafting tissues from other areas of the body. The most common donor sites are the forearm, the groin area, and the lower abdomen, although the thigh and back are also used. Many surgeons perform urethral lengthening as part of the phalloplasty, allowing the ability to stand to pee. A vaginectomy (removal/closure of the vagina) is often part of the procedure, and a few surgeons will even simultaneously perform a hysterectomy if the patient hasn’t had one prior.
With all types of phalloplasty, the labia are united to form a scrotum, where prosthetic testicles are inserted. An erectile prosthesis can be inserted into the phallus to enable sexual penetration, which is usually done in a separate surgery. There are several types of erectile protheses, ranging from simple rods to elaborate pumping systems. These are the same prostheses that are used for men with erectile dysfunction. However, many men do not opt for erectile implants, as they carry a risk for rejection, and they find other methods (such as self-adhesive wrap with a condom) to be adequate for achieving sexual penetration.
Phalloplasties vary in their cosmetic outcome, with some remaining the same shape and circumference along the entire length (giving more of a “tube” like appearance), while other surgeons are able to create a convincing looking head by creating a glans and coronal ridge. Some patients will pursue electrolysis or laser hair removal either before or after surgery in order to have a hairless penis. Most men who have received phalloplasties would say that they pass the “locker room test” but their penises are able to be distinguished from non-trans male penises when looked at up close.
The major advantage to having a phalloplasty is the result of having a full sized adult male penis, which can be anywhere from 4 to 9 inches long, and 5+ inches in circumference. Erotic sensation in the length of the phallus is variable, depending on the type of phalloplasty performed. However, despite many rumors to the contrary, practically all patients retain the ability to orgasm. The major disadvantages to phalloplasty are the large scars that occur on donor sites, the high cost, and the intensity of the surgery and recovery.
Complications most often occur from urethral lengthening, and they most often include either a fistula (hole in the urethra) or a stricture (blockage of the urethra). Sometimes these complications can resolve on their own, but they commonly require surgery to correct. Other complications include infection, tissue death (either parts of the phallus or the entire phallus itself), unsatisfactory aesthetic result, testicular or erectile implant extrusion, failure to regain sensation, and complications associated with the donor site; all of which can often require further surgery.
written by jakedgreenbeer
- Radial Forearm Free Flap
This technique involves using a graft of tissue that is taken from most of the circumference of the non-dominant forearm. The tissue is rolled up to form a “tube within a tube,” with the inner part of the forearm forming the new urethra, and the outer forearm forming the outside of the phalloplasty. The forearm donor site is then covered with a skin graft from the upper thigh.
The grafted urethra is connected to the native urethra using tissue from the vaginal wall and/or the inner labia. This is usually done as part of the initial procedure. This technique involves microsurgery, where grafted nerves are connected to the existing clitoris, which results in erotic sensation throughout the length of the entire phallus. It may take up to a year for nerve sensation to regenerate; however, sensation from the buried clitoris is always retained.
The major disadvantage to this procedure is the scar that results on the forearm, which is a deal-breaker for many transmen. It should be noted that one study found no long term functional damage to the forearm in any of the 125 participants who received radial forearm phalloplasties. However, this is the only procedure where one does not have to compromise on full adult size nor erotic sensation. This is usually a two stage surgery; one stage for the creation of the phallus, urethral hook up, vaginectomy, and initial scrotoplasty, and a second stage for the erection implant and permanent testicular implants.
Recently, some radial forearm phalloplasty surgeons have combined forearm flaps with flaps from other areas (such as the thigh or groin) in order to retain erotic sensation while trying to minimize the area of the forearm scar.
written by jakedgreenbeer
- Pedicle Pubic/Groin/Abdominal Flap
This procedure creates a tube out of either the suprapubic lower abdominal area, or the hip/flank area adjacent to the native genitals (usually running from the groin to the edge of the pelvic bone). The exact location of the donor site as well as name of procedure varies. However, the main difference between this method and the radial forearm method is that the tissue used to create this type of phallus is never completely detached from the body. A flap of skin and tissue is raised to create a tube that is initially attached on both ends (this procedure was formerly referred to as the “suitcase handle” technique for this reason). This procedure may also utilize grafted skin from the thigh area to wrap around the outside of the pedicle flap, mimicking the loose outer skin of the penis. One end of the flap is detached, swung down and connected to the clitoral area, and finally the other end is detached in order to allow the phallus to hang freely.
A urethral extension may by created using tissue from the labia or vaginal wall, or simply from creating an "inside-out" inner tube from the donor area. The clitoris is left intact, either buried in the base of the phallus, or just below it. This operation is performed in anywhere from one to twelve stages (the latter of which takes over a year to complete).
This method produces a penis that retains tactile, but not erotic sensation, as no microsurgery is performed. The aesthetic appearance of the penis is also sometimes less realistic than radial forearm phalloplasties, however, this varies among surgeons and individual patients, and many pedicle flap phallos are exceedingly good looking. The major advantage to this procedure is an adult sized penis without any major visible scarring, as the scar most often left is usually just a line that is easily hidden below clothing.
written by jakedgreenbeer
- Musculocutaneous Latissimus Dorsi (MLD) Flap
This is a relatively new type of phalloplasty, currently performed by only two surgeons. As noted on one of the surgeon’s websites, “The latissimus dorsi used in this phalloplasty is the broadest muscle of the back comprised of a pair of flat, triangular-shaped muscles across the middle and lower back.” This procedure involves a free tissue flap transfer, leaving a long, linear scar which runs from the underarm down to the lower back, which is considered preferable and less conspicuous to many transmen. Microsurgery is performed to connect nerves, and the erotic sensation is generally better than with pedicle flaps, but less than with radial forearm flaps.
written by jakedgreenbeer