Understanding Phalloplasty: Surgical Techniques, Complications, Recovery

A phalloplasty surgery has become popular in recent years as an option for many transgenders and non-binary people who are interested in gender confirmation surgery. A phalloplasty involves the construction or reconstruction of a penis. It is also used for penile reconstruction in cases of cancer, trauma or congenital defect. The phalloplasty surgery is aimed at building a penis that is cosmetically appealing and also of a sufficient size so that it is capable of releasing urine from an upright position and also feel sensation. Phalloplasty is known as a complex procedure and more than one surgery is involved in this procedure.

The techniques of phalloplasty have continued to evolve as the fields of urology and plastic surgery continue to make advances. As of today, the gold standard in any phalloplasty is considered to be the radial forearm free-flap (RFF) phalloplasty technique, where the surgeons make use of a skin flap taken from our forearm to build the penile shaft.

Some of the criteria for people to qualify for phalloplasty include:

• The patient needs to be taking the male hormone for at least one year or more.
• The patient needs to be at least 20 years old and if below 20 years, then an authorization is required from the legal parents or guardians to go ahead with the phalloplasty surgery.
• The patient should be leading a man’s life for at least a year or more.
• Patient has to be in good overall physical health.
• A mental test needs to be undertaken and the patient has to be certified by a psychiatrist showing that the patient is in a normal mental state.
• For at least six months, the patient should have had undergone mastectomy and total hysterectomy-oophorectomy.

A phalloplasty simply refers to a flap of skin being turned into a phallus. When you choose to undergo a phalloplasty, it begins by doctors removing a skin flap from a part of your body, usually from the forearm. This flap is either removed entirely or left partially attached. The tissue is then used for making both a urethra and the penile shaft. It is made in a tube-within-a-tube sort of a structure. This larger tube is literally rolled up and put around the inside tube. After this, skin grafts are taking from an inconspicuous part of the body in order to minimize scarring and then grafted on to the penis donation site.

The tricky part comes in the urethra as a female urethra is shorter than a male urethra, therefore, surgeons have to first lengthen the urethra in order to attach it to the female urethra to allow urine to flow from the tip of the penis. The clitoris is left in place itself, and it becomes located somewhere near the base of the penis. It can still continue to be stimulated. The surgery makes no difference to achieving orgasms, and patients can continue to do so even after their surgery.

Apart from penile construction/reconstruction, a phalloplasty can also comprise of a number of other procedures that are performed in tandem. These include:

• Hysterectomy – a procedure where the doctors remove the uterus.
• Oophorectomy – this procedure removes the ovaries.
• Vaginectomy or vaginal mucosal ablation – a procedure to remove or partially remove the vagina.
• Scrotectomy – a procedure to turn the labia majora into a scrotum.
• Glansplasty – a procedure that sculpts the appearance of the uncircumcised tip of the penis.
• Urethroplasty – a procedure to lengthen the urethra and connect it to the inside of the new phallus
• A penile implant for allowing erection

These procedures are not done in any particular order and no timeline is followed. Some people choose not to get all of them done, while some choose to do some of these procedures at the same time. Others even spread out each procedure over a couple of years. Plastic surgery, gynecology and urology are the three specialties from which surgeons are chosen to perform these procedures along with phalloplasty.

There are many different phalloplasty techniques that surgeons use for performing the surgery. The difference amongst these phalloplasty techniques is the location from where the donor skin is taken to create the flap and also the manner in which this skin flap is removed and then reattached. Some of the common donor sites in phalloplasty include: lower abdomen, groin, torso, thigh and forearm. The forearm is the most preferred site for most surgeons for phalloplasty.

Let us take a look at the four most common phalloplasty techniques.

This is one of the most recent techniques to be used in phalloplasty. The radial forearm free-flap (RFF/RFFF) phalloplasty technique uses a free flap procedure in which the donor tissue is removed completely from the forearm, keeping the flap’s blood vessels and nerves intact. These very blood vessels and nerves are then reattached, thus allowing natural blood flow to the newly created phallus. RFF is one of the preferred phalloplasty techniques as it provides extra sensitivity and the aesthetic results are good. The urethra in this phalloplasty technique is constructed in a tube-within-a-tube manner, thus allowing the person to urinate while standing upright. The surgeon also leaves room for a later implantation of an inflatable pump or erection rod.

Another reason RFF phalloplasty is preferred over other procedures is that there are very low chances of mobility damage in this technique, though the skin grafts taken from the forearm does leave moderate to severe scarring in this scenario. For people worried about visible scars, this phalloplasty technique is not recommended.

Also known as supra-pubic phalloplasty, this procedure is usually a choice for trans-men who do not additionally require a restructured urethra or a vaginectomy. In this is phalloplasty technique, the urethra does not go through to the tip of the penis and urination is not possible in a standing position. The individual will need to urinate in a seated position. There is no microsurgery involved in this phalloplasty technique and this makes the procedure less expensive as well.

An abdominal phalloplasty does not allow erotic sensation, though the newly constructed phallus will have tactile sensation. Instead of this, the preserved clitoris can still continue to be stimulated. A penile implant can allow penetration. Scarring is easily hidden as the scar occurs from hip to hip and is horizontal in nature, allowing it to be hidden by clothing. There are also fewer complications associated with an abdominal phalloplasty as it does not involve the urethra.

The ALT technique is not usually the preferred choice of surgeons as it leads to a lower than expected level of physical sensitivity in the newly constructed penis. In this procedure, the skin flap/tissue is separated from the blood vessels and nerves and the urethra has to be restructured for allowing upright urination. There is also ample space left for a penile implant. While people undergoing an ALT procedure tend to be satisfied, but they generally report lower levels of sensitivity and satisfaction during sexual intercourse. Another drawback to this procedure is that there is a higher risk of urinary and other complications with ALT, as compared to RFF. While there is also significant scarring left over from the skin graft in this technique, but the scars are left in a more discrete place.

The technique of MLD involves taking the donor skin from the back muscles, just under the arm. This phalloplasty technique uses a large tissue flap to allow surgeons to create a larger penis. This phalloplasty technique is equally well-suited for restructuring the urethra and addition of an erective device as well. The donor skin flap is taken with the blood vessels and nerve tissues, though it is less erotically sensitive as compared to the nerves that are connected in the RFF procedure. The site from where the skin flap is taken heals well with minimal scarring.

Like all surgeries, phalloplasty also comes with a risk of infection, tissue damage, bleeding, and pain. Furthermore, phalloplasty carries a high risk of complications. Most of these involve the urethra and include:

• Urethral fistulas.
• Narrowing of the urethra leading to obstruction of urinary flow.
• Death of the transferred skin flap.
• Ruptures along the surgical incision lines.
• Pain in the pelvic region.
• Pelvic bleeding.
• Rectal or bladder injury.
• Loss of sensation.
• Discharge and fluid from the wound site requiring drainage and regular dressings.

The site from where the skin flap has been removed also carries a risk of complications, including:

• Wound breakdown.
• Bruising.
• Pain.
• Decreased sensation.
• Unsightly scarring or discoloration of the tissue.
• Red and bumpy skin at the wound site.
• Decreased mobility in rare cases.

It takes four to six weeks to resume work after a phalloplasty. If you have a strenuous job, then you will be recommended to wait for at least eight weeks before resuming work. You also need to avoid exercising and heavy lifting during first few weeks post phalloplasty surgery. A catheter will be inserted for few weeks and after two to three weeks, you can begin to urinate through the new phallus.

While there are several stages in your phalloplasty, for the final stage that involves the penile implant, you will have to wait for a year between any other surgical procedures. It is important that you get a full feeling in the new phallus before you get the implant. Full healing from a phalloplasty can take up to two years.

General post-surgical care in phalloplasty includes:

• Avoid putting pressure on the new penis.
• Do not apply ice to the area.
• Keep the phallus elevated to reduce swelling and improve circulation.
• Keep the surgery site clean and dry.
• Avoid taking a shower for the first two weeks.
• Do not pull out the catheter as it can cause damage to your bladder.
• Urine bag needs to be emptied at least three to four times a day.
• Do not try to urinate from the penis before your doctor gives you the go ahead.
• Proper aftercare will ensure a speedy and safe recovery from a phalloplasty.