Phalloplasty is a surgical procedure to construct a neophallus. This complex reconstructive surgery is primarily a gender-affirming procedure for transgender men and non-binary individuals. Its aim is to create a functional and aesthetically congruent external genitourinary organ. The procedure involves multiple stages, carefully planned to achieve specific functional and cosmetic objectives.
Patient Candidacy and Preparation
Becoming a candidate for phalloplasty involves meeting specific health and psychological criteria, guided by the World Professional Association for Transgender Health (WPATH) Standards of Care. Guidelines recommend individuals provide letters of support from mental health professionals, confirming an understanding of the surgical process and its implications. Continuous hormone therapy, usually testosterone, is also required for at least 12 months, to facilitate physical changes and ensure psychological stability.
Several preparatory steps are necessary prior to the initial surgery. Permanent hair removal, through electrolysis or laser treatment, is performed at the chosen donor site. This prevents hair growth inside the newly constructed urethra, which could lead to complications such as urinary tract infections or stone formation. Patients are also advised to stop smoking several weeks before surgery, as nicotine can impair wound healing and increase the risk of complications by constricting blood vessels.
Phalloplasty Techniques and Surgical Staging
The construction of a neophallus relies on transferring a “flap” of skin and underlying tissue from another part of the body. This flap contains its own blood supply and nerves, which are reconnected at the recipient site. The selection of the donor site influences the characteristics of the neophallus, including its size, sensation potential, and appearance.
The radial forearm is a widely used donor site, providing a Radial Forearm Flap (RFF). This flap is harvested from the non-dominant forearm, with pliable skin and robust vascular and nerve supply. The RFF technique is favored for its potential to provide tactile and erogenous sensation due to sensory nerves, and for allowing urethral lengthening within the flap.
Another common option is the Anterolateral Thigh (ALT) flap, using tissue from the outer thigh. While the ALT flap can offer a larger volume of tissue, suitable for achieving greater girth, its nerve supply is less consistent than the RFF. This can result in variable sensation. The ALT site also leaves a scar on the thigh, which may be less visible than a forearm scar.
Phalloplasty is not a single operation but a complex, multi-stage surgical process, spanning several months to over a year. The initial stage involves creating the neophallus using the chosen donor flap and forming a portion of the urethra. Subsequent stages address functional and aesthetic goals, including urethroplasty to complete urethral lengthening, glansplasty to shape the neophallus tip, and the insertion of erectile and testicular implants.
Functional and Aesthetic Outcomes
A primary functional goal is to enable standing urination. This is achieved through urethroplasty, a procedure extending the native urethra through the neophallus. This lengthening allows urine to exit at the tip of the neophallus, replicating the typical male voiding position.
Sensation in the neophallus is achieved through microsurgical techniques. Nerves from the donor flap are connected to existing nerves in the pubic area, such as the clitoral nerve. This nerve coaptation aims to provide both tactile sensation, allowing touch, and erogenous sensation, contributing to sexual pleasure. Sensation varies based on the flap used and nerve regeneration.
The neophallus does not achieve an erection on its own. To allow for penetrative sexual function, an erectile device is implanted in a later stage. These devices include either a malleable rod, providing permanent rigidity, or an inflatable pump, allowing on-demand erection and flaccidity. Implant choice depends on patient preference and surgical suitability.
Aesthetic considerations also create a natural and congruent appearance. Scrotoplasty involves using existing tissue, from the labia majora, to construct a scrotum. This scrotum can then accommodate testicular implants, typically silicone prostheses, to enhance the aesthetic outcome. Glansplasty, or shaping the neophallus head, refines its appearance, involving tissue rearrangement to create a more defined tip.
Recovery and Potential Complications
Initial recovery following phalloplasty typically involves a hospital stay of several days, with pain management and a urinary catheter usually in place to allow the new urethra to heal. Patients receive instructions on wound care and activity restrictions to promote healing. The catheter typically remains for several weeks post-surgery to ensure the integrity of the newly constructed urethra.
Long-term healing continues for many months, requiring patience and adherence to post-operative guidelines. Swelling and bruising are common, gradually subsiding over weeks to months. Physical activity is restricted to prevent strain on the surgical sites, and regular follow-up appointments are necessary to monitor progress and address concerns.
Despite meticulous surgical planning, complications can arise, particularly involving the newly constructed urethra. Urethral fistulas, small openings that allow urine to leak, are among the most frequent complications, sometimes requiring subsequent surgical repair. Urethral strictures, or narrowing of the urethra, can also occur, making urination difficult and often necessitating additional procedures to widen the passage.
Less common but more severe complications include partial or total flap loss. This occurs when the blood supply to transferred tissue is compromised, leading to tissue death. While rare due to advanced microsurgical techniques, it represents a setback. Other issues include infection, hematoma (blood collection), and seroma (fluid collection), all of which may require medical intervention.