Phalloplasty

Overview

Phalloplasty is a complex surgical procedure primarily used for gender affirmation and also as a reconstructive option for congenital anomalies, severe penile trauma, or disease. The goal of phalloplasty is to create a functional and aesthetically pleasing neophallus that meets the individual’s needs and enhances their quality of life.

The procedure aims to construct a natural-looking penis that allows for standing urination, provides sensation and pleasure, enables erection with a penile implant, and supports sexual intercourse. It typically involves using skin flaps to form the new penis, which can help address both physical and emotional challenges, such as gender dysphoria.

The success and safety of phalloplasty are highly dependent on the surgeon’s expertise, with more experienced practitioners generally achieving better outcomes and reduced surgical risks. Recovery from phalloplasty can be lengthy, often requiring a month or more for full healing and optimal functional results.

Reasons for undergoing the procedure

Phalloplasty may be recommended to address congenital conditions, such as:

• Micropenis, or a very small penis
• Aphallia, or an undeveloped penis
• Epispadias or hypospadias, which are abnormal urethral openings
• Atypical genitalia, or genitalia that don’t appear normally masculine or female

Phalloplasty can also be performed on those who have experienced penile trauma from events like car accidents, complications from circumcision, or penile cancer.

Some women also go through this surgery to align their physical bodies with their gender identity and help alleviate gender dysphoria.

Risk

Complications are common with phalloplasty. Early detection of issues can help reduce their impact on long-term outcomes. 

Complications of this major and complex surgery include:

• Partial loss of the neophallus: Insufficient circulation can result in necrosis or tissue death. Adequate blood flow is essential for the neophallus.
• Urethral stricture: Narrowing or complete blockage of the urinary passage can occur when a scar tissue developed due to a reduced blood flow.
• Urinary fistula: An abnormal connection may form between the urinary tract and a nearby organ, such as the intestines, or create an external opening.
• Urine dribbling: Postvoid dribbling may occur, leading to urine leakage after urination.
• Bacterial infection: Open wounds are susceptible to bacterial infections, which can progress to sepsis if not addressed promptly.
• Anesthesia-related complications: Sore throat, nausea, vomiting, constipation, severe allergic reactions (anaphylaxis), and in rare cases, stroke, are its potential side effects.

Before the procedure

Before the procedure, patients should provide a list of all allergies and medications, including herbal supplements, and stop taking blood-thinning medications if applicable. It is also important to avoid eating or drinking for 8 to 12 hours before the surgery, although essential medications may be taken with a small sip of water.

Individuals may also receive health recommendations, such as quitting smoking or achieving a BMI under 32, to minimize surgical risks.

For individuals undergoing gender-affirming phalloplasty, preparation typically spans at least a year. It usually involves:

• Undergoing masculinizing hormone therapy for at least a year and living in accordance with one’s gender identity for the same duration.
• Mental health evaluation by a qualified professional, such as a therapist or psychiatrist, to assess the individual’s understanding and expectations of the surgery, with referral letters needed from two mental health providers.
• Comprehensive patient education to ensure a clear understanding of the procedure’s risks, benefits, and post-surgical care.
• Physical examination to evaluate overall health and medical history.
• Hair removal (electrolysis or laser) from the donor site for tissue creation.

During the procedure

For phalloplasty, tissue flaps are usually taken from the forearm or thigh, and the donor site will need a skin graft, which can be done during or after the surgery.

The duration of the surgery typically ranges from eight to ten hours, though it may be longer if additional procedures are performed. 

The procedure is often done as follows:

• General anesthesia is administered to put the patient to sleep, ensuring they do not feel pain or sensations during the procedure.
• A large flap of skin is harvested from the patient’s forearm or thigh, which includes nerves, arteries, and veins, but lacks erectile tissue.
• The harvested flap is shaped into a shaft and attached to the groin, though it will not include a head (glans).

If the phalloplasty involves multiple stages, the complete process could extend over 12 to 18 months. 

Additional gender-affirming surgeries can be performed alongside phalloplasty or staged separately to allow for healing between procedures:

• Hysterectomy, or the removal of the uterus
• Oophorectomy, or the removal of the ovaries
• Vaginectomy, or closure of the vagina
• Glansplasty, which involves creating a head for the penis
• Scrotoplasty, or creating a scrotum for testicular prostheses
• Extending the urethra for standing urination 
• Placing a penile implant for erections

After the procedure

Phalloplasty is performed as an inpatient procedure. One will stay in the hospital for at least a week to ensure proper blood supply to the new penis.

After phalloplasty, the patient will awaken from anesthesia, likely feeling groggy. Healthcare providers will monitor their health and manage pain as they fully regain consciousness. Additional procedures are often scheduled several months after the initial operation, in cases of staged surgery.

Outcome

After phalloplasty, rest is essential, and most individuals return to their normal activities only after at least six weeks. Regular follow-up appointments with the healthcare team are crucial for monitoring the healing process. Additionally, ongoing visits with a mental health professional experienced in transgender care are recommended to support recovery and adjustment during this period.

It is also important to monitor for potential complications during recovery. Seek immediate medical attention if any of the following is experienced:

• Unusual skin changes in the new penis
• Pain or difficulty urinating
• Persistent pain
• Signs of blood clots, like swelling in the groin or lower leg
• Infection symptoms, such as fever, chills, headaches, and swelling, discoloration, or pus
• Throwing up and having trouble staying hydrated
• Severe bleeding or bandages drenched in blood

These may also be recommended during recovery period:

• Use a Foley or suprapubic catheter for urination
• Refrain from too much physical activity, including exercise and household chores
• Change dressings on surgical wounds as needed
• Keep incisions clean and dry
• To manage pain, prevent infection, and address constipation, take the prescribed medications

Generally, phalloplasty benefits include:

• Relieves physical and emotional challenges
• Provides a natural-looking penis capable of sexual function
• Supports achieving gender identity

Specific advantages include:

• Extended Urethra: Allows urination while standing.
• Forearm Flaps: Offer excellent cosmetic results and better sensation.
• Thigh Flaps: Provide more length options and easier-to-hide scars.

A penile implant offers the ability to achieve an erection at will. Various implant options will be discussed and evaluated as needed.