Phalloplasty constructs a penis using tissue transplanted from another part of the body, most commonly the forearm or thigh. The surgery involves multiple stages over 12 to 18 months, with each phase building a different functional component: the shaft, the urethra, the nerve connections, and eventually an erectile implant. It is one of the most complex reconstructive procedures in surgery, typically requiring around six separate operations to reach its final result.
Where the Tissue Comes From
The core of a phalloplasty is a “flap,” a section of skin, fat, blood vessels, and nerves harvested from a donor site on the body. Surgeons shape this tissue into a cylindrical shaft and microsurgically connect its blood vessels and nerves to those in the groin. The two most common donor sites are the forearm and the outer thigh.
The radial forearm free flap, taken from the inner forearm, is the most widely studied technique and has been used since the mid-1980s. It produces a phallus with thinner, more pliable tissue that tends to have better sensory outcomes because the forearm’s nerves are relatively large and well-suited for reconnection. The tradeoff is a visible scar on the forearm, which is typically covered with a skin graft. In a study of 56 patients who underwent forearm flap phalloplasty, 95% retained a surviving neophallus after a mean of six surgical procedures. Flap complications occurred in 25% of patients, but complete flap loss was rare at 5%, caused by issues like blood clots or infection.
The anterolateral thigh (ALT) flap, taken from the outer thigh, leaves its scar in a less conspicuous location and provides bulkier tissue. It can be performed either as a free flap (fully detached and microsurgically reconnected) or as a pedicled flap (kept partially attached to its original blood supply and tunneled into position). The thigh flap’s greater bulk can be an advantage for patients who want more girth, but may require later revision to reduce excess tissue.
Less common donor sites include the abdomen, groin, lower leg, and upper back, each with different tradeoffs in scar placement, tissue thickness, and sensory potential.
How the Urethra Is Extended
For patients who want to urinate while standing, the urethra must be lengthened from its original position all the way to the tip of the new phallus. This is one of the most technically demanding parts of the procedure and carries the highest complication risk.
The extended urethra has distinct segments. The first is the fixed portion, created from local tissue near the original urethral opening. Surgeons mobilize flaps of nearby mucosal tissue, bring them together at the midline, and roll them into a tube. This bridges the gap between the native urethra and the base of the new shaft. The second segment, the pendulous urethra, runs through the length of the phallus itself. It is typically formed from a strip of the donor flap’s skin that is rolled into a tube within the shaft during the initial flap construction. The two segments are then connected, and a new urethral opening is created at the tip.
Because this involves joining different tissue types and creating a long, narrow channel, urethral complications like narrowing (strictures) and abnormal openings (fistulas) are relatively common. Many patients need at least one additional procedure to address these issues. Some people choose to skip urethral lengthening entirely to avoid these complications, which means urination continues from the original position.
Restoring Sensation Through Nerve Transfers
Sensation is restored through microsurgical nerve connections performed during the initial flap surgery. The principle is similar to a nerve transfer: sensory nerves from the donor flap are carefully joined to nerves in the groin and genital area, allowing nerve fibers to slowly grow into the transplanted tissue over many months.
In a forearm flap procedure, two nerve connections are typically made. One pairs a nerve from the forearm flap with a nerve that supplies the clitoris, preserving the pathway for erogenous sensation. The other connects a second forearm nerve to a nerve in the groin area, providing general touch sensation to the shaft. These connections are matched based on nerve size and the number of nerve fibers to give the best chance of functional recovery.
Sensation does not return immediately. Nerve fibers regenerate slowly, and it typically takes several months before any feeling develops in the new phallus. The transplanted skin contains only about 10% of the sensory receptor density found in native genital tissue, which creates a natural ceiling on how much objective sensation is possible. However, outcomes are more nuanced than that number suggests. Studies show a gap between what clinical tests can measure and what patients actually experience: even when standardized sensory testing shows limited results, the majority of patients report meaningful tactile and erogenous sensation. Many are able to achieve orgasm. Some centers now use targeted nerve therapy and electrical stimulation during surgery to improve these outcomes further.
Shaping the Glans
The tip of the phallus is sculpted to resemble a natural glans through a technique called glansplasty or coronaplasty. Several methods exist, but they share a common goal: creating a visible ridge (the corona) that separates the head from the shaft, giving the phallus a more natural contour.
One common approach involves making a circumferential incision near the tip of the shaft, raising a small flap of skin, and folding it back on itself to form the coronal ridge. The exposed area is then covered with a thin skin graft. Sutures placed through the graft and beneath the folded skin flap create definition in the ridge and sulcus, the groove just behind the head. Another technique uses an angled incision to create a flap with a longer dorsal surface, mimicking the natural asymmetry of the glans. The dressing is removed about five days after the procedure.
Glansplasty is sometimes performed during the initial surgery but is often done as a separate, later stage to allow the shaft to heal fully first.
Erectile Implants
Because transplanted tissue cannot become erect on its own, an erectile device is implanted in a later stage, typically after the phallus has fully healed and sensation has begun to develop. Two main types are used.
Semi-rigid (malleable) implants are rods placed inside the shaft that keep it in a permanently firm state. You bend the phallus upward for sexual activity and downward to conceal it under clothing. These devices are simpler, less expensive, easier to implant, and have fewer mechanical failures. They are the more commonly used option in phalloplasty, and specific models have been designed for use in a neophallus.
Inflatable implants use a hydraulic system with a fluid reservoir and a pump, typically placed in the scrotum. Squeezing the pump transfers fluid into cylinders within the shaft, creating an erection that can be deflated afterward. These feel more natural in terms of transitioning between flaccid and erect states, but they are mechanically more complex and carry a higher risk of device failure or complications. In some cases, a patient starts with a semi-rigid implant and later upgrades to an inflatable one, potentially with larger cylinders for improved results.
Surgical Stages and Timeline
Phalloplasty is almost never a single operation. The full process, from initial flap transfer to final revisions, typically spans 12 to 18 months and involves multiple surgeries spaced several months apart to allow healing between stages.
The first and most significant stage is the flap harvest, shaft construction, and microsurgical connection of blood vessels and nerves. If urethral lengthening is included, part or all of it may happen during this stage. Subsequent stages may include connecting the urethra, implanting an erectile device, creating a scrotum with testicular implants, performing glansplasty, and revising the shape or addressing complications. The exact number and order of stages varies by surgical team and the patient’s goals.
Before surgery begins, patients typically undergo hair removal on the donor site. Because the transplanted skin will form the outer surface of the phallus (and in some cases, the inner urethral lining), removing hair follicles beforehand prevents hair growth inside the urethra or on the shaft. This process usually involves electrolysis or laser treatments and can take many months to complete.
Recovery and What to Expect
The initial recovery from the first stage is the most intensive. Hospital stays typically last about a week, and patients have a catheter in place while the urethral connections heal. The donor site, whether forearm or thigh, requires its own healing period and wound care.
Full functional recovery takes a year or longer. Nerve sensation develops gradually over months. Each subsequent surgery adds its own recovery period, though later stages are generally shorter and less physically demanding than the first. Throughout the process, patients work closely with their surgical team to monitor blood flow to the flap, track returning sensation, and address any complications as they arise.