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phalloplasty 101

Phalloplasty is one of the two main types of genital surgeries (also referred to as “bottom surgery”) available to trans masculine people. The name of the other procedure is metoidioplasty. Neither is better or worse than the other, and there are numerous reasons why people may choose one over the other. The right procedure (or combination of procedures) for you depends on your personal priorities and your body.


Phalloplasty is a complicated procedure and typically consists of multiple stages. Phalloplasty involves taking a flap consisting of skin, fat, nerves, and blood vessels from a part of your body, and transferring it to your genitalia to construct your phallus (penis).


Different surgeons stage phalloplasty (also known as ‘phallo’) differently, so it cannot be spoken of in absolutes. Generally, phalloplasty consists of a combination of the following procedures:

-Phallus creation: Using a donor flap (from the forearm, thigh, abdomen, etc.) consisting of skin, subcutaneous fat, nerves, blood vessels, etc., to create the penis.


-Nerve hookup: Using microsurgery to connect nerves in the flap to nerves in the genital area to allow for the potential of tactile and erogenous sensation in the penis. This procedure can only be done when the donor flap contains suitable nerve(s). Nerve hookup cannot be performed in abdominal flap phalloplasty.


-Urethroplasty/Urethral Lengthening (UL): Elongating the urethra through the penis to achieve the ability to stand to pee. Some people will choose to forego UL for various reasons, including avoiding potential urinary complications. Common potential complications of UL include:

  • Fistula: A small wound or opening that allows urine to exit from somewhere other than the intended urethral opening, such a hole in the scrotum or near the base of the phallus. Fistulas can sometimes heal on their own, but other times they may need surgical repairs.

  • Stricture: A spot in which the urethra narrows, usually due to thickening of scar tissue. This complication can make it difficult to urinate, which can lead to secondary complications such as UTIs and pain. Strictures often require surgical repairs.

-Scrotoplasty: Using labial tissue to create a scrotum. There are different techniques used to do this. A complex scrotoplasty (also called V-Y scrotoplasty) creates a forward hanging scrotal sack. Testicular implants can be placed within the scrotum during a later stage. A simple scrotoplasty (also called bifid) does not reposition the labia majora, but simply places testicular implants inside them. Most US surgeons perform some variation of a complex scrotoplasty.


-Vaginectomy/v-nectomy: Removal and closure of the vaginal canal and opening. This is not a necessary component of phalloplasty unless UL is desired, in which case most surgeons require a vaginectomy in order to reduce urethral complications. Seeking UL without a vaginectomy drastically increases the risk of complications. If you are getting a vaginectomy, you must have a hysterectomy done at least 3-6 months prior to the first stage of your phalloplasty. An oophorectomy (removal of ovaries) is not required for vaginectomy.


-Glansplasty: A procedure that creates a coronal ridge and glans penis. Glansplasty creates a circumcised look and is not a required procedure if not desired.


-Split thickness graft (STG): A thin graft of skin usually taken from the thigh to cover the exposed tissue after the donor flap is removed. This leaves a shallow wound similar to road rash, and the scar often fades significantly over time. This graft is harvested and placed over the donor site during the phallus creation stage or in some cases, a few weeks afterward if your surgeon uses Integra on the donor site.-

Natal phallus/natal tissue: Refers to what is also known as the clitoris. The natal phallus grows in response to hormone replacement therapy (HRT), but the amount of growth has no bearing on phalloplasty.


Burial of natal phallus: The concealment of the natal phallus/clitoris within the new phallus or scrotum. This procedure is generally not required, although some surgeons require burial of the natal phallus if doing UL. Many people are still able to stimulate their natal phallus after it has been buried. In some cases, burial of the natal phallus can result in loss of sensation and difficulty achieving orgasm. Because of this, some surgeons do not recommend burying the natal phallus until a later stage of surgery, after you have an idea of how the sensation is developing in your new phallus.


Insertion of testicular implants: Placing silicone or saline implants into the scrotum to achieve the appearance of testicles. Testicular implants are often inserted at the same time as an erectile device, but are sometimes done sooner.


Insertion of an erectile device (ED): Placing an implant within the penis to assist in achieving erections. This should be done as the last stage of phalloplasty. Some people forego the insertion of an internal erectile device and opt to use an external erectile device like a penis sleeve or The Elator.


The two types of internal erectile devices available are the semi-rigid/malleable rod and the inflatable pump. The rod has the same rigidity all the time and can be bent into different positions - it would typically be worn pointing down during everyday activities and then be bent into an erect position for intercourse. The inflatable pump is a hydraulic system with multiple parts including a reservoir of saline typically placed in the lower abdomen, a pump placed in one side of the scrotum (replacing one testicular implant), and then one or two cylinders inserted in the shaft of the penis. The pump in the scrotum is squeezed in order to fill the cylinder(s) with saline from the reservoir in order to create an erection.


Phalloplasty Donor Sites


There are several different parts of the body that can be used as phalloplasty donor sites. It’s important to research the various donor site options and determine which one most closely aligns with your priorities of having phalloplasty. Not everyone is a candidate for every donor site, so you should discuss your donor site options with surgeons during consultations. The most common donor sites include:


-Radial Forearm Flap (RFF): The donor flap is taken from the forearm, usually the non-dominant arm. Many surgeons and patients prefer this donor site for multiple reasons: the flap contains two or more nerves, typically offers the best quality nerves, and tends to have low amounts of subcutaneous fat. With RFF, a significant scar will be left on the forearm even after healing is complete, although it can be covered with sleeves or tattoos later on if the patient desires. RFF does carry some potential risks, including chronic swelling and/or limited mobility in the hand and wrist. You may be limited on the length and girth of your penis with RFF, depending on your desired size and the amount of available tissue on your forearm.


-Anterolateral Thigh Flap (ALT): The donor flap is taken from the front and outer thigh. This donor site creates a phallus that tends to be girthier, so many ALT patients may need debulking procedures done in subsequent surgeries in order to attain their desired girth. The ALT flap has one sensory nerve that can be connected to the genital nerve. The ALT scar is generally less conspicuous than RFF, since the donor site can be hidden by pants or long shorts. This donor flap carries somewhat higher risks of complications with the phallus and UL over RFF. ALT is often the preferred donor site for people who prioritize having a large penis.


-Musculocutaneous Latissimus Dorsi Flap (MLD): The flap is taken from one side of the back. Unlike RFF and ALT, this donor site can typically be closed without the use of a split thickness skin graft (but not always). Because of the way the donor site is pulled closed, MLD can sometimes pull one nipple to the side and create undesired aesthetic issues with the chest. This donor site typically results in less overall scarring than RFF or ALT, and the MLD scar can be fully covered by a shirt. Nerve hookup can be performed, however, MLD is typically only able to attain tactile sensation (rather than tactile and erogenous) due to the fact that the flap contains only a motor nerve rather than a sensory nerve.


-Abdominal (ab) Flap: The flap is taken from the lower abdomen. This is perhaps the least conspicuous donor site and usually the least intensive recovery. This donor site can typically be closed without the use of a split thickness skin graft, unless the patient is extremely thin. No nerve hookup can be performed, however, some sensation usually remains since the flap is not fully removed from the body. Ab flap carries a higher risk of complications with UL than other donor sites. This donor site is best suited for people who have lost a lot of weight and have loose abdominal skin.


There are other places donor skin can be taken from, but these are the most common, at least in the US. Other donor sites can include the calf or groin. But typically, surgeons will use the more common donor sites unless there are variables that cause the more common donor sites to be unusable.


Phalloplasty Staging


Each surgical team has their own method of staging for phalloplasty. Some surgeons do phalloplasty in only 1-2 stages, while others break it up into 2-4+ stages. There are various medical reasons why surgeons choose to stage phalloplasty differently, so please consult with surgeons prior to making a decision regarding which method is best for you. For any staging approach, complications can create the need for additional surgeries. In addition to surgeon preference, staging can also vary depending on the specific procedures you desire as well as your individual anatomy and healing.


Consultations


Consultations for phalloplasty can be exciting AND nerve-wracking. Once you find a surgeon you want to schedule an appointment with, it can often take up to, or even beyond a year to set a date. Don’t be discouraged by this -- it is always a good idea to schedule consultations with multiple surgeons, so at least you can have a few on-deck to be waiting for. It is important to find a skilled and experienced surgeon, and it is equally as important to find a surgeon whose personality you match well with.


You should prepare a written list of questions to bring with you. Many people tend to get nervous or overwhelmed during the appointment, and this can cause you to forget your questions. A written list of questions on a piece of paper (not a phone or tablet) is helpful not only to remind you of what you want to ask, but also to indicate to the surgeon that you are prepared and have specific points you want to hit before the appointment is over.


A great list of questions you might want to ask at your consult can be found here: https://static1.squarespace.com/static/599f136a6b8f5b8e60707a05/t/5a78c1bd24a69468ae3fb8e4/1517863358520/Consult+questions.jpg


Your surgeon should talk to you about your expectations and desired outcome from surgery. They can talk to you about how the procedure is performed and what parts of your body will be affected. They may also do a physical examination.


Sometimes, surgeons may feel dismissive, or it may feel like they have a boilerplate spheal they recite to everyone. They may even refuse to answer questions. These can be a red flag - a sign you need to go to a different surgeon. These situations can also be a good opportunity for you to advocate for yourself.


If your surgeon does not answer your questions during the consultation, you can ask them again, directly, and be very clear that this is a question you would like answered. If they still refuse to answer your questions - this is a red flag! It is part of your surgeon’s job to educate you about the care you are seeking.


If you forgot to ask a question during the consult and only remember once you are out of the office, you can ask for a phone call or another consult with the surgeon, or you may be able to email them or send a message through their patient portal.


If a surgeon recommends a particular procedure that would result in an outcome you are uncomfortable with, it is your right to voice this and/or get a second opinion. Sometimes the decision to get surgery can mean making compromises and the outcome may not be exactly what we wanted, but it is important to feel heard by the surgeon so that they are an active part of educating you and informing you why these choices need to be made. If you do not feel heard - it’s time to see another surgeon!


Lastly, during your consultation, the surgeon may use words for your body that you are uncomfortable with. An example of this could be using the word clitoris when you prefer using t-dick or natal dick. It’s okay to tell the surgeon! It can be helpful to preface this at the beginning of the appointment, but it is also okay to tell them in the moment.


It can be difficult for many reasons for transgender people to advocate for themselves in healthcare settings. It can be very difficult to speak up in a situation where there is an obvious power dynamic, such as when speaking with a medical provider. Trans people may be afraid of advocating for themselves, as it could mean a provider refusing care or labeling trans patients as ”noncompliant.”


It is important to remember that provider-patient relationships are meant to be collaborative. This means patients should have an equal amount of control and say in the relationship as their medical provider - whether that be a physician, a nurse practitioner, a physical therapist, etc.


Preparation for Surgery


To prepare for phalloplasty, most people need to undergo either electrolysis or laser hair removal. This is especially important for people having urethral lengthening, as excess hair on the skin used to create the urethra can lead to urinary complications post op. Electrolysis is generally the preferred method for hair removal and is the only form of permanent hair removal according to the FDA. Laser hair removal is not considered permanent according to many experts. Laser is also more limited since it is only effective for people with dark hair and light skin, and it cannot be performed on tattooed areas. Some patients opt to undergo both laser and electrolysis, but many do only electrolysis. It often takes 1.5-2 years or more of regular hair removal treatments to finish permanently removing all the hair. Most health insurance companies will only cover hair removal pre-op (if they cover it at all).


If you smoke, you should stop as soon as possible. Smoking and nicotine use greatly increase the risk of complications of a flap surgery like phalloplasty due to their effects on blood flow and circulation. For the best possible outcome from your surgery, you should stop smoking well in advance. All phalloplasty surgeons will require you to stop smoking before surgery, usually at least 4 weeks in advance, but the sooner, the better.


Post-Op Considerations


Phalloplasty is a major surgery with an intense recovery process. For stage one, you will typically be in the hospital for 5-7 days, and you will need at least 6-8 weeks off from work and school. For people with physical jobs, you may need 12+ weeks of recovery time before returning to work. After you are discharged from the hospital, you will need a full time caretaker for at least the first 1-2 weeks. Phalloplasty is a difficult recovery and you will need help with basic things such as preparing meals, showering, and changing bandages for the first few weeks post op. You will not be able to lift anything over 5-10 lbs for at least 6 weeks, so for that amount of time you will need help doing laundry, getting groceries, doing other household chores, etc. The process of healing and recovering is individual and variable for each person, so it is difficult to say exactly how long it will take you to get back to “normal” after surgery.


You may have a catheter when you leave the hospital after one or more of your stages, particularly if you undergo UL. Catheters may stay in anywhere from a few days to several weeks or even months if you have urinary complications. Most people undergoing UL will have a catheter for about 2 weeks post urethroplasty.


RFF patients should expect to be prescribed occupational therapy (OT). Once the arm is healed enough, OT is important to help patients regain strength and mobility of the hand and wrist. ALT patients may need to undergo physical therapy (PT) to regain full strength and mobility of their donor leg. Many ALT patients may find it helpful to use a cane or walker for a few weeks post op.


Post Op Depression


Post op depression can be a normal part of recovery - as unsettling as it feels in the moment. It happens for a myriad of reasons - hormonal imbalances, narcotics, and being out of your normal routine can all contribute.


While the expectation is that you will be happy immediately after surgery, this is not always the reality. If you experience post op depression, you should tell your surgeon, primary care provider, your therapist, and anyone else who is on your care team so they can help support you and provide you with resources.


Healing takes a long time, but neither it nor post op depression will last forever.


Complications


Phalloplasty has a relatively high complication rate in comparison to other less invasive surgeries. The most common complications are related to the lengthening of the urethra. The two most common UL complications are strictures (narrowing of the neourethra), and fistulas (an opening that causes urine to exit the body through somewhere other than the urinary meatus).


Erectile devices also tend to carry a high risk of complications. Infection is a serious risk any time a foreign object is being placed inside of your body. Erosion can also occur if the implant is not sized correctly, or if it shifts inside the body into a position that causes the implant to put pressure on the penile skin from within.


Another possible complication is necrosis, or tissue death, which typically occurs due to inadequate blood flow to the newly attached flap. Complications with the donor site can also occur, such as long term swelling or tightness of the hand/arm for RFF patients and long term swelling of the knee area for ALT patients.


Myths


There are many myths perpetuated by both the trans community and medical professionals about bottom surgery, especially phalloplasty. Derogatory comments are often made about the appearance or function of penises constructed through bottom surgery. It is important to dismantle the idea that all penises must be as close to someone’s idea of a natal penis as possible. All penises have variety in appearance and function - whether they are natal or surgically created.


That being said, the myths of phallo penises not appearing “natural” or “cis-passing” have been essentially disproven as gender affirming surgery has become more accessible and more people have been able to have surgery and share photos. Transbucket is a great place to start if you need to see photos of penises created through phalloplasty. With a little effort, you can find many photos of phallo penises in various stages of healing and recovery as well as penises that are fully healed.


Another common myth is that phallo penises will not have sensation. This is not necessarily true. Many surgical teams perform a microsurgical nerve hookup with the goal of allowing sensation to develop throughout the penis. Nerve hookups are successful to some degree in most phalloplasty surgeries, however, they do occasionally fail, typically due to complications or other variables with how your body heals. If sensation is a high priority for you, many surgeons will recommend RFF due to the fact that it is the only donor site with two or more sensory nerves that can be used for the nerve hookup. In summary, developing penile sensation - tactile, erogenous, and temperature - is absolutely a possibility from phalloplasty, but not a guarantee.


It’s important to be mindful about the language we use when speaking about phalloplasty penises and the people who have them. Speaking in a derogatory way about penises created by phalloplasty leads to post op people shying away from sharing their own photos and experiences. Additionally, language is important when you are trying to speak in a positive way.


For example, saying “This is the best phallo penis I have ever seen” is a backhanded compliment and can be taken as putting down others who have had phalloplasty. You can say someone has a nice penis without the comparison.


There is also a commonly used phrase in reference to RFF phalloplasty that is problematic - calling the RFF donor site the “gold standard” of phalloplasty. This label primarily refers to the potentially higher likelihood of developing high quality sensation and the slightly lower rates of complications with RFF over other donor sites. This is problematic because everyone’s priorities in having phalloplasty are different. Some people prioritize having a large penis over everything else, which might mean that ALT is the best choice for them. Others may prioritize less scarring and a less conspicuous donor site, so MLD or ab flap may be right for them. Nobody should impose their personal priorities on others, and it’s important that we as trans people support each other and respect each other’s donor site preferences.


There are many moving parts involved with bottom surgery, and despite the length of this article, it only scratches the surface of what it’s like to undergo phalloplasty. You should have a comprehensive support network going into phalloplasty - a knowledgeable and trans-affirming therapist, post op friends, other friends, at least one caregiver, etc. Of course everyone’s needs and circumstances are different, but we strongly recommend having a strong support network for this life-changing process.


And lastly - congratulations! Going through phalloplasty is difficult, but ultimately, the vast majority of people come out happier on the other side.


References

  • Ascha, M., Massie, J. P., Morrison, S. D., Crane, C. N., & Chen, M. L. (2017). Outcomes of Single Stage Phalloplasty by Pedicled Anterolateral Thigh Flap versus Radial Forearm Free Flap in Gender Confirming Surgery.

  • Blaschke, E., Bales, G. T., Thomas, S. (2014). Postoperative Imaging of Phalloplasties and Their Complications.

  • Caenegem, E. V., Verhaeghe, E., Taes, Y., Werckx, K., Toye, K., Goemaere, S., Zmierczak, H., Hoebeke, P., Monstrey, S., & T’Sjoen, G. (2013). Long-Term Evaluation of Donor-Site Morbidity after Radial Forearm Flap Phalloplasty for Transsexual Men.

  • Doornaert, M., Hoebeke, P., Ceulemans, P., T’Sjoen, G., Heylens, G. & Monstrey, G. (2011). Penile Reconstruction with the Radial Forearm Flap: An Update.

  • Esmonde, N., Bluebond-Langner, R., Berli, J. U. (2018). Phalloplasty Flap-Related Complication.

  • Golpanian, S., Guier, K. A., Tao, L., Sanchez, Priscilla G., Sputova, K., Salgado, C. J. (2016). Phalloplasty and Urethral (Re)construction: A Chronological Timeline.

  • Hoebeke, P. B.., Decaestecker, K., Beysens, M., Opdenakker, Y., Lumen, N., & Monstrey, S. M. Erectile Implants in Female-to-Male Transsexuals: Our Experience in 129 Patients.

  • Monstrey, S., Hoebeke, P., Selvaggi, G., Ceulemans, P. Van Landuyt, K., Blondeel, P. Hamdi, M., Roche, N. Weyers, S., & De Cuypere, G. (2008). Penile Reconstruction: Is the Radial Forearm Flap Really the Standard Technique?

  • Morrison, S. D., Massie, J. P., Dellon, A. L. (2018). Genital Sensibility in the Neophallus: Getting a Sense of the Current Literature and Techniques.

  • Nikolavsky, D., Hughes, M., & Zhao, L. C. (2018). Urologic Complciations After Phalloplasty or Metoidioplasty.

  • Weinberg, A. C., Nikoslavsky, D., Levine, J. P., & Zhao, L. C. (2017). Urethral Complications After Female-to-Male Gender Reassignment Surgery.

  • Selvaggi, G., Monstrey, S., Hoebeke, P., Van Landuyt, K. Hamdi, M., Cameron, B. & Blondeel, P. (2006). Donor-Site Morbidity of The Radial Forearm Free Flap after 125 Phalloplasties in Gender Identity Disorder.

  • Van de Grift, T. C., Pigot, G. L. S., Boudhan, S., Elfering, L., Kreukels, B. P. C., Gijs, L. A. C. L., Buncamper, M. E., Ozer, M., van der Sluis, W., Meuleman, E. J. H., Bouman, M-B., & Mullender, M.G. (2017). A Longitudinal Study of Motivations Before and Psychosexual Outcomes After Genital Gender-Confirming Surgery in Transmen.

  • Zhang, W. R., Garrett, G. L., Arron, S. T., & Garcia, M. M. (2016). Laser hair removal for genital gender affirming surgery.

Resources

  • Facebook Groups

  • FTM Bottom Surgery Discussion

  • Phalloplasty Discussion

  • Others - by searching in either of the above groups, you can find many additional private/hidden groups and blogs of people documenting their phalloplasty process


  • Reddit

  • reddit.com/r/ftm

  • reddit.com/r/transgender_surgeries

  • reddit.com/r/transurgery

  • reddit.com/r/ftmbottomsurgery

  • reddit.com/r/phallo


  • Websites

  • bit.ly/phallo-guide

  • phallo.net

  • radremedy.org

  • transbucket.com

  • healthytrans.com


  • Apps

  • Round - for tracking medication

  • Aloe Bud - self care


  • Support Groups

  • Tool Shed - a NYC-based peer support group for people pursuing or post-op phalloplasty/metoidioplasty, email nyctoolshed@gmail.com for more info.

  • Care Package - Atlanta, Georgia-based peer support group for people actively seeking or post-op phalloplasty/metoidioplasty, email carepackagetransmasc@gmail.com for more info.

  • The Bottom Line - Boston-based peer support group for people post-op or pre-op who have at least scheduled a consult, email thebottomlinebos@gmail.com for more info.



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