Phalloplasty is a series of operations designed to construct a penis, known as a neophallus. These complex procedures are pursued for various reasons, including gender affirmation for transgender men and reconstruction following trauma or for congenital conditions. The process is highly individualized, with outcomes depending on the patient’s anatomy, their specific surgical goals, and the techniques employed by the surgical team.
Aesthetic Outcomes
The visual appearance of the neophallus is determined by the tissue flap used for construction, harvested from a donor site on the patient’s body. Common donor sites include the radial forearm free flap (RFFF) and the anterolateral thigh (ALT) flap. The RFFF is favored for its thin, pliable tissue that can create a detailed aesthetic, while the ALT flap provides more bulk and girth.
Beyond the penile shaft, other procedures contribute to the overall aesthetic. Glansplasty is a surgery performed to create a distinct head, or glans, at the tip of the neophallus. Scrotoplasty involves the formation of a scrotum, into which testicular implants can later be placed to achieve a more natural look and feel.
Scarring at the donor site and on the neophallus is a permanent outcome. The extent and appearance of scars vary with the surgical technique and individual healing. An RFFF procedure leaves a scar on the forearm, while an ALT flap results in a scar on the thigh. Surgeons place incisions strategically to minimize visible scarring on the neophallus.
Urinary Function
A primary functional goal for many patients is the ability to urinate while standing (stand-to-pee). This is achieved through urethral lengthening, where the native urethra is extended through the neophallus. This reconstruction allows urine to exit from the tip of the new penis.
Creating a new urethra is complex and has a high rate of complications. The two most common issues are urethral fistulas, which are small holes causing urine to leak from the shaft, and urethral strictures, which are narrowings that can obstruct flow. Fistulas and strictures are observed in a notable percentage of patients who undergo urethral lengthening.
Correcting these complications involves revision surgeries. Because of the challenges associated with creating a functional neourethra, achieving reliable standing urination can be a lengthy process. It is not uncommon for individuals to need one or more additional operations to resolve these issues before they can consistently urinate from a standing position.
Sensation and Sexual Function
Sensation returns to the neophallus gradually through intricate microsurgery. Surgeons connect nerves from the donor flap to existing pelvic nerves to provide both tactile (touch) and erogenous (sexual) sensation. Nerve regeneration is slow, and it can take months or even years for sensation to fully develop.
The neophallus cannot become erect on its own. To achieve rigidity for penetrative intercourse, an erectile implant is surgically placed in a later stage. This is done after the initial construction has fully healed and the tissue is strong enough to support the device.
Two primary types of erectile implants are used. An inflatable penile prosthesis consists of cylinders inside the phallus, a pump in the scrotum, and a fluid reservoir in the abdomen; squeezing the pump creates an erection. A semi-rigid rod provides constant firmness that can be positioned for intercourse. The choice between devices depends on patient preference, anatomy, and surgeon recommendation.
The Staged Surgical Process and Long-Term Healing
Phalloplasty is a series of planned operations, not a single event. This multi-stage approach allows for proper healing between procedures and addresses different goals sequentially. The entire process can span one to two years or longer, depending on the surgical plan and the patient’s healing.
The initial stage involves creating the penile shaft and, if desired, urethral lengthening. This surgery requires a long recovery period for the tissue flap to heal and establish a new blood supply. Subsequent stages, scheduled after several months of healing, focus on aesthetic refinements and the placement of implants.
Final results are not realized until long after the last surgery. Long-term healing involves the body’s adjustment to implants as aesthetic and functional outcomes continue to evolve. Adherence to post-operative care instructions is necessary to support healing and achieve the best possible results.