Phalloplasty is a surgical procedure to construct or reconstruct a penis. It serves various purposes, most commonly for gender affirmation in transgender individuals, but also for reconstruction after trauma, cancer, or congenital differences. The procedure aims to create a phallus that aligns with the patient’s goals, encompassing appearance, function, and sensation.
Achieving Appearance and Function
A primary goal of phalloplasty is to achieve a satisfactory aesthetic outcome, including the size, shape, and appearance of the neophallus. Surgeons utilize different techniques, such as the radial forearm free flap (RFFF) or the anterolateral thigh (ALT) flap, each influencing the final look. For instance, the RFFF, a common standard, uses forearm tissue, resulting in a reliably shaped phallus but leaving a noticeable donor arm scar. Conversely, the ALT flap, while less common due to lower sensation outcomes, provides ample tissue for size. Some patients opt for additional aesthetic refinements, such as micropigmentation or fat grafting, to improve color, texture, and scar appearance.
Beyond aesthetics, functional capabilities are a significant focus, particularly the ability to urinate from a standing position. This involves urethral lengthening, a challenging part of the surgery. A systematic review from 2022 found that 92.2% (529 of 574) of patients achieved standing micturition after phalloplasty with urethral lengthening. For penetrative sexual activity, a penile implant is often a subsequent step, typically placed after the neophallus has healed and sensation has developed, usually around one year post-initial surgery. A study reported 54.5% of patients had an erectile prosthesis implanted.
Sensory Outcomes
Restoring sensation in the neophallus is a significant aspect of phalloplasty, contributing to both tactile and erogenous experiences. This involves a nerve hook-up, connecting existing nerves, often from the clitoris, to nerves within the transferred neophallus tissue. The goal is to facilitate nerve regeneration into the new structure.
Patients can expect to regain various types of sensation, including tactile (touch and pressure) and, for many, erogenous sensation. Studies indicate tactile sensation is present in a large majority of patients, with one systematic review reporting 93.9% (771 out of 821) having tactile sensation. Erogenous sensation, including the ability to achieve orgasm, has also been reported by a high percentage of patients; some studies indicate over 75% of cismale patients and over 95% of transmale patients experience it. Nerve regeneration is gradual, often taking months to years for full sensation to develop. Some patients begin to regain sensation around 73 days post-surgery, with continued improvement over several months.
Understanding Potential Complications
Phalloplasty, despite advancements, is a complex procedure with complications. Urethral complications are among the most frequently encountered, including strictures (narrowing of the urethra) and fistulas (abnormal openings). The rate of urethral stricture can be as high as 51%, though some reports indicate rates between 23-35%. Urethral fistulas can occur in 20-77% of cases. These issues often require further surgical intervention, with urethroplasty needed in 94-96% of stricture cases, though these repairs can be challenging and may fail in up to 50% of attempts.
Flap-related complications can also arise. These include partial or complete flap loss, which, while uncommon, can necessitate significant revision or salvage procedures. Wound healing problems and hematoma (blood collection) at the donor or recipient site are also possibilities. General surgical risks like infection, bleeding, and adverse reactions to anesthesia are also present. Revision surgeries are frequently part of the phalloplasty journey, addressing both complications and aesthetic refinements.
Factors Influencing Results
Several factors can significantly influence the success and outcome of phalloplasty. The expertise and experience of the surgical team and specialized center play a substantial role in minimizing complications and optimizing results. Surgeons with extensive experience often have lower complication rates.
A patient’s overall health also impacts healing and outcomes. Pre-existing health conditions, such as diabetes or obesity, can affect the body’s ability to heal efficiently. Smoking, in particular, is known to compromise blood flow and increase the risk of wound complications and flap issues. Adherence to post-operative care instructions is equally important for achieving optimal results. This includes diligent wound care, activity restrictions, and participation in any recommended physical therapy. Individual healing responses and unique body characteristics, such as skin elasticity and scarring tendencies, also contribute to the final aesthetic and functional outcomes, leading to patient variations.