Phalloplasty

Overview

Phalloplasty is a complex surgical procedure primarily used for gender affirmation. It can also serve as a type of genital reconstructive surgery to create a neophallus for addressing congenital anomalies, severe penile injuries, or diseases. The goal of phalloplasty is to create a functional and aesthetically pleasing neophallus that meets the individual’s needs and enhances their quality of life.

The procedure aims to construct a natural-looking penis that allows for standing urination, provides sensation and pleasure, enables erection with a penile implant, and supports sexual intercourse. Typically, it involves using skin flaps to form the new penis, addressing both physical and emotional challenges, such as gender dysphoria.

The success and safety of phalloplasty are highly dependent on the surgeon’s expertise, with more experienced practitioners generally achieving better outcomes and reduced surgical risks. Recovery from phalloplasty can be lengthy, often requiring a month or more for full healing and optimal functional results.

Reasons for undergoing the procedure

Phalloplasty may be recommended to address congenital conditions, such as:

• Micropenis, or a very small penis
• Aphallia, or an undeveloped penis
• Epispadias, where the urethral opening (meatus) is located at the top of the penis rather than at the tip
• Hypospadias, where the meatus is situated below the tip of the penis
• Atypical genitalia, or genitalia that don’t appear normally male or female

Phalloplasty can also be performed on those who have experienced penile trauma from events like car accidents, complications from circumcision, or penile cancer.

Some people assigned female at birth (AFAB) also go through this surgery to align their physical bodies with their gender identity and help alleviate gender dysphoria.

Risks

Complications are common with phalloplasty. Early detection of issues can help reduce their impact on long-term outcomes. 

Complications of this major and complex surgery include:

• Anesthesia-related complications: Sore throat, nausea, vomiting, constipation, severe allergic reactions (anaphylaxis), and in rare cases, stroke, are its potential side effects.
• Partial phallic loss: Insufficient circulation can result in necrosis or tissue death. Adequate blood flow is essential for the neophallus.
• Urethral stricture: Narrowing or complete blockage of the urinary passage can occur when a scar tissue developed due to a reduced blood flow.
• Urinary fistula: An abnormal connection may form between the urinary tract and a nearby organ, such as the intestines. Additionally, a urinary fistula may form an opening to the outside of your body. 
• Urine dribbling: Postvoid dribbling may occur.
• Bacterial infection: Open wounds are susceptible to bacterial infections, which can progress to sepsis if not addressed promptly.

Before the procedure

Before the procedure, patients should provide a list of all allergies and medications, including herbal supplements, and stop taking blood-thinning medications if applicable. It is also important to avoid eating or drinking for 8 to 12 hours before the surgery, although essential medications may be taken with a small sip of water.

Individuals may also receive health recommendations, such as quitting smoking or achieving a BMI under 32, to minimize surgical risks.

For individuals undergoing gender-affirming phalloplasty, preparation typically spans at least a year. It usually involves:

• Physical examination to evaluate overall health and medical history.
• Mental health evaluation by a qualified professional, such as a therapist or psychiatrist, to assess the individual’s understanding and expectations of the surgery, with referral letters needed from two mental health providers.
• Comprehensive patient education to ensure a clear understanding of the procedure’s risks, benefits, and post-surgical care.
• Undergoing masculinizing hormone therapy for at least a year and living in accordance with one’s gender identity for the same duration.
• Hair removal (electrolysis or laser) from the donor site for tissue creation.

During the procedure

For phalloplasty, tissue flaps are usually taken from the forearm or thigh, and the donor site will need a skin graft, which can be done during or after the surgery.

The duration of the surgery typically ranges from eight to ten hours, though it may be longer if additional procedures are performed. 

The procedure is often done as follows:

• General anesthesia is administered to put the patient to sleep, ensuring they do not feel pain or sensations during the procedure.
• A large flap of skin is harvested from the patient’s forearm or thigh, which includes nerves, arteries, and veins, but lacks erectile tissue.
• The harvested flap is shaped into a shaft and attached to the groin, though it will not include a head (glans). 

Additional gender-affirming surgeries can be performed alongside phalloplasty or staged separately to allow for healing between procedures:

• Glansplasty, which involves creating a head for the penis
• Scrotoplasty, or creating a scrotum for testicular prostheses
• Urethroplasty, or lengthening the urethra to allow standing urination
• Placing a penile implant for erections
• Vaginectomy, or closure of the vagina
• Hysterectomy, or the removal of the uterus
• Oophorectomy, or the removal of the ovaries

In general, phalloplasty can take eight to ten hours or more to complete. If you opt for additional procedures in different stages, the overall process may take between 12 and 18 months to finish.

After the procedure

After phalloplasty, the patient will awaken from anesthesia, likely feeling groggy. Healthcare providers will monitor their health and manage pain as they fully regain consciousness. 

Phalloplasty is performed as an inpatient procedure. One will stay in the hospital for at least a week to ensure proper blood supply to the new penis.

Additional procedures are often scheduled several months after the initial operation, in cases of staged surgery.

Outcome

Generally, phalloplasty benefits include:

• Relieves physical and emotional challenges
• Provides a natural-looking penis capable of sexual function
• Supports achieving gender identity

Specific advantages include:

• Extended urethra: Allows urination while standing.
• Forearm flaps: Offer excellent cosmetic results and better sensation.
• Thigh flaps: Provide more penis length options and easier-to-hide scars.

A penile implant offers the ability to achieve an erection at will. Various implant options will be discussed and evaluated as needed.

After phalloplasty, rest is essential, and most individuals return to their normal activities only after at least six weeks. Regular follow-up appointments with the healthcare team are crucial for monitoring the healing process. Additionally, ongoing visits with a mental health professional experienced in transgender care are recommended to support recovery and adjustment during this period.

These may also be recommended during recovery period:

• Use a Foley or suprapubic catheter for urination
• Refrain from too much physical activity, including exercise and household chores
• Keep incisions clean and dry
• Change dressings on surgical wounds as needed
• To manage pain, prevent infection, and address constipation, take the prescribed medications

It is also important to monitor for potential complications during recovery. Seek immediate medical attention if any of the following is experienced:

• Infection symptoms, such as fever, chills, headaches, and swelling, discoloration, or pus
• Unusual skin changes in the new penis
• Pain or difficulty urinating
• Persistent pain
• Signs of blood clots, like swelling in the groin or lower leg
• Severe bleeding or bandages drenched in blood
• Throwing up and having trouble staying hydrated