Phalloplasty Results: Key Outcomes and Surgical Insights

Phalloplasty is a complex surgical procedure designed to create a neophallus for individuals seeking gender-affirming surgery or reconstruction after trauma. Advances in microsurgery and tissue engineering have improved both functional and aesthetic outcomes, but the procedure remains intricate, involving multiple stages and potential complications.

Surgical techniques, donor tissue selection, and post-operative healing influence the final results. Key considerations include physical appearance, sensation, urinary function, and sexual capability. Understanding these factors helps individuals make informed decisions about their options and expected outcomes.

Tissue Sources

The choice of donor tissue affects vascular integrity, nerve preservation, and overall aesthetics. Several donor sites are commonly used, each with distinct advantages and limitations. Selection is based on patient anatomy, functional goals, and the surgeon’s expertise.

Forearm Flap

The radial forearm free flap (RFFF) is widely used due to its reliable vascular supply and potential for nerve coaptation, enhancing sensory restoration. This technique involves harvesting skin, subcutaneous tissue, and blood vessels from the forearm, ensuring adequate pliability for neophallus construction. A key advantage is the ability to incorporate the antebrachial cutaneous nerve, which can be connected to the pudendal nerve to facilitate erogenous sensation.

A study in Plastic and Reconstructive Surgery (2021) reported that over 80% of RFFF phalloplasty patients regained some degree of tactile and erogenous sensation within two years. However, this technique results in a conspicuous donor site scar, often requiring a skin graft, which may raise aesthetic concerns. Some individuals experience reduced grip strength or delayed healing at the donor site, necessitating post-operative physical therapy.

Thigh Flap

The anterolateral thigh (ALT) flap minimizes visible scarring by using tissue from the upper leg. It benefits individuals who prefer to avoid forearm scarring or have contraindications for forearm tissue harvesting, such as vascular insufficiency. The ALT flap provides thicker tissue, contributing to a more natural girth, though additional contouring procedures may be needed.

A systematic review in The Journal of Sexual Medicine (2022) found that ALT phalloplasty had fewer donor site complications than RFFF but was associated with prolonged post-surgical swelling. While the lateral femoral cutaneous nerve can be integrated to enhance sensation, the return of erogenous sensation is less predictable than with the forearm approach. Due to the flap’s bulkier nature, secondary debulking surgeries may be necessary to improve aesthetics and comfort.

Abdominal Flap

The abdominal phalloplasty technique, also known as the suprapubic or lower abdominal flap, is less common but remains an option for individuals with limited donor site availability. This method uses skin and subcutaneous fat from the lower abdomen, creating a neophallus with a uniform texture and minimal donor site morbidity.

A retrospective analysis in Annals of Plastic Surgery (2020) found that abdominal-based phalloplasty carried a higher risk of flap contraction over time, potentially affecting aesthetics. Additionally, the lack of a well-defined vascular pedicle makes it less suitable for individuals seeking optimal sensation or future erectile prosthesis implantation. While appropriate for select cases, this technique is generally reserved for those unable to undergo free flap procedures due to medical or anatomical constraints.

Construction Methods

Phalloplasty relies on microsurgical techniques, vascular anastomosis, and nerve coaptation to achieve a functional and aesthetically cohesive result. Each stage of construction optimizes structural integrity, durability, and long-term viability while balancing sensation and prosthetic compatibility.

A key aspect is forming a tubularized structure with sufficient vascularity to support tissue survival. This is achieved through a multi-layered approach, where donor tissue is shaped and sutured into a cylindrical form with an internal vascular pedicle. Microsurgical techniques maintain arterial inflow and venous drainage, preventing ischemic complications. Studies in The Journal of Plastic, Reconstructive & Aesthetic Surgery (2021) report that vascular anastomosis patency directly correlates with flap survival, with success rates exceeding 95% when performed by experienced microsurgeons.

Nerve coaptation plays a critical role in sensory restoration and functional outcomes. Surgeons connect donor site nerves to recipient sensory pathways, such as the ilioinguinal or pudendal nerve, to facilitate neural regeneration. Electrophysiological studies document progressive neural ingrowth over 12 to 24 months, with some individuals regaining protective and erogenous sensation within two years.

To enhance rigidity for future prosthetic implantation, internal structural reinforcement may be incorporated during the initial procedure. This can involve dermal grafts, fascial support layers, or acellular matrices to provide additional tensile strength. Some surgical teams preemptively create space within the neophallus to accommodate erectile devices, reducing the need for extensive modifications in later stages. A meta-analysis in Plastic and Reconstructive Surgery Global Open (2022) found that staged approaches with early structural reinforcement led to fewer complications related to prosthesis insertion.

Physical Appearance

Achieving a natural and proportionate aesthetic outcome depends on donor tissue selection, surgical technique, and healing. Surgeons strive to create a neophallus that aligns with the patient’s body proportions while maintaining symmetry and contour. Skin texture, pigmentation, and hair-bearing tissue also influence the final appearance.

Different donor sites yield variations in texture and thickness. Radial forearm flaps produce a smoother surface, while anterolateral thigh flaps result in a thicker, more cylindrical shape that may require refinement. Surgeons often use liposuction or secondary contouring to enhance definition and proportion.

Skin tone matching can be challenging, especially when donor tissue differs in pigmentation from the recipient area. Medical tattooing or staged skin grafting can address this issue. Additionally, hair presence depends on the donor site, and some patients opt for preoperative laser hair removal to improve hygiene and aesthetics.

Sensory Restoration

Sensation return after phalloplasty is a gradual process influenced by nerve coaptation, healing, and neuroplasticity. Surgeons reconnect nerves from the donor tissue to sensory pathways in the recipient site, allowing for protective and erogenous sensation recovery. Axonal regeneration enables nerve fibers to reestablish functional connections.

The donor site impacts sensory outcomes. The radial forearm free flap allows for direct nerve coaptation, increasing the likelihood of erogenous sensation. In contrast, thicker donor flaps, such as those from the thigh, present more challenges in nerve integration, sometimes leading to less consistent results. Post-operative nerve testing helps track progress and assess neural recovery.

Urethral Reconstruction

Creating a functional neourethra is one of the most intricate aspects of phalloplasty, requiring precise surgical techniques to ensure structural integrity and long-term urinary function. The goal is to extend the native urethra through the neophallus, enabling standing urination while minimizing complications like strictures or fistulas.

One of the primary challenges is maintaining adequate blood supply while ensuring urethral patency. A two-stage urethroplasty approach can reduce complications by allowing tissue to heal before full integration with the urinary tract. Studies in The Journal of Urology (2022) report that strictures occur in approximately 30-50% of cases, often requiring secondary interventions. Advances in tissue engineering, including acellular dermal matrices and buccal mucosa grafts, show promise in improving long-term outcomes.

Sexual Function

Satisfactory sexual function after phalloplasty depends on structural considerations, nerve integration, and prosthetic compatibility. Since the neophallus does not develop spontaneous erections, individuals seeking penetrative function may opt for an erectile prosthesis, typically implanted in a later stage.

The choice of prosthesis impacts functional outcomes. Malleable implants provide a simpler mechanism for rigidity, while inflatable prostheses offer a more dynamic experience but require more complex placement. A review in Sexual Medicine Reviews (2021) found prosthesis implantation success rates ranging from 70-85%, though complications such as mechanical failure or extrusion remain concerns. Psychological well-being and body confidence also influence overall sexual satisfaction.

Donor Site Scarring

Donor site scarring varies by tissue source, affecting healing and cosmetic outcomes. While functional success is the priority, the aesthetic impact of scarring can influence patient satisfaction. Postoperative scar management, including laser therapy and silicone gel application, can improve appearance and minimize discomfort.

Radial forearm flap phalloplasty results in a prominent forearm scar, often requiring a skin graft. This area is prone to hypertrophic scarring, and some individuals report lingering hypersensitivity or tightness. The anterolateral thigh flap leaves a less conspicuous scar, though healing times may be prolonged. Abdominal flap phalloplasty has the least visible donor site scarring, but the harvested tissue’s characteristics may result in a more rigid neophallus.