Phalloplasty is a surgical procedure that constructs a penis using tissue from another part of the body. It is one of the most complex operations in reconstructive surgery, often performed across multiple stages over a year or more. People undergo phalloplasty for a range of reasons: as part of gender-affirming care for transgender men and transmasculine individuals, to reconstruct a penis lost to injury or cancer, or to address conditions present from birth such as a penis that didn’t fully develop.
Who Gets a Phalloplasty
The procedure serves several different patient populations. For transgender men, phalloplasty is one option for genital surgery as part of a broader transition. For cisgender men, it may be necessary after traumatic injury from car accidents, surgical complications, or penile cancer. It is also used to treat congenital conditions where the penis didn’t form typically during development, including micropenis, epispadias (where the urethral opening is on top of the penis), hypospadias (where the opening is below the tip), or aphallia, a rare condition where the penis doesn’t develop at all.
For transgender individuals seeking phalloplasty as gender-affirming surgery, the World Professional Association for Transgender Health (WPATH) guidelines call for an assessment from a qualified health professional and, in most cases, at least six months of hormone therapy before surgery, unless hormones are not desired or are medically contraindicated. These criteria exist to ensure patients are stable in their treatment plan before proceeding with an irreversible procedure.
How the Surgery Works
Phalloplasty builds a penis (called a neophallus) from a flap of tissue taken from a donor site elsewhere on the body. The surgeon shapes this tissue into a cylindrical form, connects blood vessels under a microscope to keep the new tissue alive, and joins nerves from the flap to local nerves so that sensation can eventually develop. The two most common techniques use tissue from the forearm or the thigh.
Forearm Flap
The radial forearm free flap is the most commonly performed technique worldwide. Surgeons take skin and tissue from the inner forearm, which is thin, pliable, and has reliable blood vessels and a long vascular stalk that makes microsurgical connection easier. These qualities give the forearm flap the best cosmetic results and the lowest complication rates of any donor site. The tradeoff is a visible scar on the forearm that can be difficult to conceal.
Thigh Flap
The anterolateral thigh (ALT) flap takes tissue from the outer thigh, leaving a scar that’s much easier to hide under clothing. The thigh generally provides more tissue, resulting in greater girth. However, ALT flaps carry a somewhat higher risk of complications, including urethral narrowing and partial tissue loss. One study found a partial flap loss rate of 7.8% for ALT compared to 3.4% for forearm flaps, though the difference wasn’t statistically significant.
Urethral Lengthening
Many patients opt to have the urethra extended through the neophallus so they can urinate while standing. This is one of the most technically demanding parts of the entire procedure, requiring the surgeon to create a new urinary channel from local tissue or grafted skin and connect it through the length of the constructed penis.
Urethral complications are the most common issue after phalloplasty. Fistulas (unintended openings where urine leaks through) occur in 10% to 64% of cases, while strictures (narrowing that blocks urine flow) develop in 14% to 57%. These wide ranges reflect differences in surgical technique and how complications are tracked across centers. Despite the high revision rates, about 80% of patients in one long-term study reported they could usually void while standing, though only about half felt comfortable doing so in public restrooms.
Nerve Hookup and Sensation
Restoring feeling in the neophallus depends on a nerve connection made during surgery. The surgeon identifies a sensory nerve within the donor tissue flap and joins it directly to one of the nerves at the surgical site. For forearm flaps, this is a nerve that runs along the outer forearm. For thigh flaps, it’s a nerve from the skin of the outer thigh. In transgender patients, this connection is typically made to one of the dorsal clitoral nerves, which is preserved beneath the neophallus to serve as the source of both protective and erotic sensation.
Sensation returns slowly. Nerves regrow at roughly a millimeter per day, and meaningful recovery takes years, not months. Research using objective testing shows that tactile sensitivity improves significantly over time but remains reduced compared to the original donor site, with the base of the neophallus recovering more feeling than the tip. In one study of forearm flap patients, all had developed both tactile and erotic sensation by one year. But broader research indicates that sensory recovery continues well beyond that point, and it remains unclear when it fully plateaus.
Erectile Implants
A constructed penis does not become erect on its own because it lacks the specialized erectile tissue of a natal penis. Patients who want rigidity for penetrative sex can have a prosthetic device implanted in a later surgical stage, typically after the neophallus has fully healed and sensation has begun to develop.
Two main types of implants exist. Inflatable devices use a small pump (placed in the scrotum) to fill internal cylinders with fluid, creating an erection that can be deflated afterward. Malleable devices are semi-rigid rods that can be bent upward for intercourse and positioned downward against the body at other times. Several malleable prostheses are now designed specifically for neophallus implantation. The choice between the two involves tradeoffs in convenience, natural appearance, and long-term durability.
Preparation Before Surgery
One of the most time-consuming parts of the process happens before any surgery takes place: hair removal. Any skin that will be rolled inward to form the urinary channel must be completely free of hair growth, because retained hair follicles inside the urethra can cause chronic infections, blockages, and stone formation. For forearm flap patients, the entire inner surface of the forearm needs to be treated. For thigh flap patients, the specific area depends on the surgeon’s planned design.
Laser hair removal and electrolysis are the standard methods, and the process takes many months. Treatment sessions are spaced at least six weeks apart to catch hair in different growth cycles, and surgeons typically want to wait three months after the final session before operating to confirm no regrowth occurs. Patients also need to avoid sun exposure for at least six weeks before and after each laser session. All told, hair removal alone can add six months to a year to the surgical timeline.
Stages and Recovery
Phalloplasty is rarely a single operation. Most surgical plans involve two to four stages spread over a year or more. The first stage typically creates the neophallus and connects blood vessels and nerves. Urethral hookup may happen during the same operation or in a subsequent stage. Erectile implant placement, glansplasty (shaping the head of the penis for a more natural appearance), and any revision surgeries come later.
Each stage requires its own recovery period. The initial surgery involves the longest hospital stay and the most significant physical restrictions. Full recovery from the primary operation takes several months, with limitations on lifting, exercise, and any activity that could stress the surgical sites. The donor site, whether forearm or thigh, also needs time to heal and may require skin grafting to close.
Because urethral complications are so common, many patients undergo at least one additional corrective procedure. Long-term follow-up studies with a mean duration of over five years confirm that phalloplasty is best understood as an ongoing surgical process rather than a single event. Patients who go into it with realistic expectations about the timeline and the likelihood of revisions tend to navigate the process with less frustration.
Complication Rates
Beyond urethral issues, the most serious surgical risk is partial or complete loss of the tissue flap. Modern techniques have reduced this dramatically. Early reports from the late 1980s documented flap loss rates as high as 60%, but contemporary series report partial loss around 3% to 4% for forearm flaps. Total flap loss is now rare at experienced centers.
Other potential complications include wound separation at the base of the neophallus, infection, blood clots, and scarring or reduced function at the donor site. The forearm donor site can affect grip strength or wrist mobility in some cases, while the thigh donor site may cause temporary numbness along the outer leg. Choosing a surgical team with high case volumes is one of the most meaningful things patients can do to reduce their risk, as outcomes in phalloplasty are strongly linked to surgeon experience.