Phalloplasty is a major, complex reconstructive surgical procedure designed to create a neophallus, or a new penis-like structure. It represents a significant step in gender-affirming care for transmasculine individuals seeking to align their physical form with their gender identity. The procedure is also a recognized reconstructive option for cisgender men who have experienced substantial loss or damage to the penis due to severe trauma, cancer resection, or congenital defects such as aphallia. This surgery involves a methodical series of operations aimed at achieving specific functional and aesthetic results.
Defining the Functional and Aesthetic Goals
The goals of phalloplasty fall into three categories: aesthetic appearance, functional utility, and restored sensation. The primary aesthetic goal is creating a neophallus with appropriate size, girth, and contour, often including the construction of a glans, or tip. This visible change can profoundly alleviate gender dysphoria and improve body image.
Functional goals center on the ability to urinate while standing up, which necessitates urethral lengthening. Another major functional aspiration is the ability to engage in penetrative sexual intercourse, made possible through the later insertion of a penile prosthetic device. Sensation goals aim for both protective sensation to prevent injury and erogenous sensation for sexual pleasure. Sensate outcomes are accomplished by meticulously connecting sensory nerves from the neophallus tissue to a local nerve in the genital area.
Primary Methods of Tissue Creation
The construction of the neophallus relies on moving a flap—a section of skin, fat, blood vessels, and nerves—from a donor site to the genital region. The choice of flap significantly influences the final outcomes and surgical complexity. Two techniques are the most common and reliable methods for creating the neophallus structure.
The Radial Forearm Flap (RFF) technique, often considered the gold standard, utilizes tissue from the non-dominant forearm. Forearm tissue is thin, pliable, and well-vascularized, allowing surgeons to create a neophallus of suitable size and shape. The RFF contains nerves that can be successfully connected to the native genital nerves, offering strong potential for tactile and erogenous sensation.
The RFF procedure involves a “free flap” transfer, meaning the tissue is completely detached, and its blood vessels (arteries and veins) are reconnected to recipient vessels in the groin using microsurgery. This reconnection is necessary to maintain blood flow to the new structure. A disadvantage is the prominent, permanent scarring on the forearm, which must be covered with a skin graft taken from another part of the body, such as the upper arm or buttock.
The Anterolateral Thigh Flap (ALT) is a popular alternative using tissue from the outer thigh. The donor site scar is less conspicuous and can often be hidden beneath clothing. However, thigh tissue can be thicker than forearm tissue, potentially requiring additional debulking procedures to achieve the desired girth and contour.
The ALT flap can be used as a free flap, requiring microsurgical reattachment, or sometimes as a pedicled flap where a portion of the original blood supply remains attached. A drawback is that the tissue often lacks the necessary length and pliability to create the full-length urethral channel in a single stage. Patients opting for standing micturition with the ALT flap may require a second, smaller flap, often from the forearm, specifically to construct the urethra. Less common options include the Latissimus Dorsi Flap (from the back) and the abdominal flap (from the lower abdomen).
The Multi-Stage Surgical Sequence
Phalloplasty requires a series of operations spaced several months apart, rather than a single session. This multi-stage approach allows adequate time for healing, vascular integration, and scar maturation between procedures. The sequence involves coordinated effort between plastic surgeons, who handle the flap transfer, and urologists, who manage the intricate urinary tract reconstruction.
Stage 1 focuses on creating the neophallus using the chosen flap technique. During this initial stage, the new structure is attached to the pubic area, and the sensory nerves are connected. If the patient desires to urinate from the tip, a urethral channel is often constructed inside the new phallus, connecting it to the native urethra.
Stage 2 typically occurs three to six months after the first, allowing the flap to fully heal and establish a stable blood supply. This stage often involves completing the urinary tract reconstruction. Associated procedures like a vaginectomy, the removal of the vaginal canal, are frequently performed when urethral lengthening is done, as this provides healthier tissue to reinforce the new urethra and minimize complications.
Scrotoplasty, the creation of a scrotum, is also usually performed in this stage, often using tissue from the labia majora. The skin is repositioned and shaped to form two pouches. Additionally, a glansplasty, a procedure to sculpt the tip of the neophallus for a more natural appearance, may be performed.
Subsequent stages are reserved for inserting prosthetic devices. Testicular implants are placed within the newly constructed scrotal pouches. The final step for many patients is the placement of an erectile device—an internal pump or rod that allows the neophallus to become rigid for penetrative intercourse. This step is delayed until the neophallus has completely healed, often nine to twelve months after the initial creation, to prevent infection or erosion of the implant.
Recovery and Post-Operative Expectations
The recovery process after phalloplasty is lengthy and demanding. Following the initial flap creation, patients typically require a hospital stay of five to seven days for close monitoring of the neophallus’s vascular supply. This monitoring addresses the risk of compromised blood flow inherent to microsurgical free flap transfers.
For the first two to four weeks after the initial stage, a urinary catheter is required to divert urine, allowing the newly constructed urethral channel to heal. The initial recovery period at home, where daily activities are limited, usually lasts four to six weeks. Patients must avoid heavy lifting and strenuous activity to prevent strain on the surgical sites.
Long-term healing, including the full resolution of swelling and scar maturation, can take up to a year or more. If a Radial Forearm Flap was used, patients often require occupational or physical therapy to regain full strength and mobility in the donor arm. Throughout the multi-stage process, adherence to meticulous wound care and regular follow-up appointments is necessary to manage healing at both the neophallus and donor sites.