Phalloplasty is a standard surgical procedure for transgender and non-binary people for penis construction. The main goals of phalloplasty are the artificial construction, modification and/or enlargement of the penis.
The history of phalloplasty goes back to 1946 when Dr. Harold Gillies performed the first sex reassignment surgery by phalloplasty on a trans man.
Phalloplasty is usually done on three conditions:
- Those who have congenital disabilities like epispadias, micropenis, or hypospadias
- Those who lost their penis, e.g. by accident
- For trans men who seek sex reassignment
Phalloplasty in Sex reassignment Surgery (FTM)
Phalloplasty is commonly chosen not only for the realistic appearance of the male genitalia but to give you the complete ability to perform well during sex and also experience an orgasm like a natural penis.
Preparing for the surgery
Before you decide on undergoing a phalloplasty surgery:
- You should have prior therapy on hormone replacement for at least two years.
- Prior operations like hysterectomy and oophorectomy are mandatory. These surgeries should be done at least eight weeks before phalloplasty.
- Prepare mentally for the change in lifestyle after the sex replacement.
- Pay attention to your doctor’s consultations
- Prepare your body for surgery by maintaining a protein-rich diet. Prep your bowel system by avoiding certain foods that your surgeon will list out for you.
The phalloplasty procedure
To create a realistic penis, flaps of skin will be harvested from various donor areas of your body. These tissues are typically used to develop both the shaft of the penis and your urethra as well, which is basically a structure resembling tube within a tube. While the inner tube is the urethra through which you will urinate, and the outer tube will form the penile shaft. In simple words, phalloplasty is the creation of a phallus from a flap of skin.
Your natural (female) urethra is shorter than the artificial (male) urethra. For this reason, your surgeon will need to lengthen your female urethra to allow smooth flow of urine from the tip of your constructed penis. The surgeon will leave your clitoris at the base of your new penis for stimulation. This allows orgasm with the neophallus just like the orgasms you had with your vagina.
After transferring the skin flap to the intended area, the small blood vessels are sewn with an operating microscope, sewing the sensory nerves together for maximum sensation. Skin flaps are taken from areas of your body that is not exposed, to keep the scars out of sight.
A series of surgery is performed in tandems which are as follows:
- Hysterectomy (removal of the uterus)
- Oophorectomy (removal of ovaries)
- Vaginectomy (total or partial removal of the vagina)
- Phalloplasty (turning flap of skin to phallus)
- Scrotoplasty (turning labia majora to the scrotum)
- Urethroplasty (lengthening the urethra inside the new penis)
- Glansplasty (sculpting the tip of the penis to appear uncircumcised)
- A penile implant (for the erection of the penis)
These procedures do not have to be followed in a single timeline because most trans-men do not take all the surgeries. Those who opt for all the methods either do them together, or keep years of gaps between each operation.
The surgeons who can perform all the procedures for a full sex reassignment comes from three specialities – Plastic surgery, Gynecology, and Urology.
Different surgical techniques
- Flap from the arm: Grafting skin from the arm is the most accessible form of the method used for phalloplasty. However, it leaves an undesirable scar that is visible around the exposed area of the arm. Before the transfer, the area will be made free of hair by using a laser or electrolysis. If the recovery is undone, there is a chance of hampering the functions of your arm.
- Flap from the side of the chest: This technique involves taking the flap from the side of the chest, near the armpit. It has an advantage over the flaps taken from the arm; scarring is unexposed, there will be less or no hair, and the color of the skin will match the color of your new penis.
- Flap from the lower leg: Grafting flap from the leg is similar to that of forearm flap, except that you can conceal the scars by wearing socks or full-length pants. You will be required to use electrolysis or laser to remove hair before grafting is done. Sometimes a flap from the leg is combined with the arm flap to create urethral lengthening and to carve the glans penis as well.
- Flap from the pubic area: For this the skin flap is harvested from the pubic area, running below the belly button. This will generally result in a noticeable horizontal scar. Grafting flap from the pubic area may not maintain a long-term erectile implant and will also appear less natural.
- Gillies technique: This technique was designed by Dr. Harold Delf Gillies, the first surgeon to perform phalloplasty. It involved rolling a flap of skin grafted from the abdomen into a tube. The concept of tube-within-a-tube was used to simulate a penis.
Risks and Complications
With the evolution of medical technology, the risks of sex reassignment surgeries have reduced to a great extent. However, like any surgery, there are still some risks and complications involved that you should be prepared for.
- You may experience urethral fistulas where you will experience leakage of urine or feces
- Urethral stricture may obstruct your urinal flow by narrowing your urethra
- Just like other surgeries, there is the risk of infection
- Flap failure or loss of phallus may result from blood supply issues or other diseases
- You may experience pain in your pelvic area, and bleeding may follow
- The most common fear is lack of sensation, which is a possibility
Besides the complication occurring in your pubic area, your donor area will go through some complications as well.
- Apart from the unsightly scarring, there will be discoloration of the skin too
- Tissue granulation which means your wound area will appear red and bumpy
- Bruising and pain in the donor area are common complications
Recovery and Post-Op Care
Recovery time usually takes four to six weeks, after which you can resume your normal activities. If your work demands strenuous undertaking, you will need at least eight weeks to recover from the surgery. In the first few weeks, you can go for walks, but it is best to avoid heavy exercises.
You will be using a catheter for the first few weeks after which you should be able to urinate through your new phallus.
For sexual stimulations, it may take time for your new penis to feel a sensation as it will take a generous amount of recovery time for the nerves tissues to heal. Expect full recovery to happen in two years.
After the surgery, you will need to take some self-care measures.
- Do not put too much pressure on the phallus
- Elevate the phallus to decrease swelling; it should improve the circulation as well
- Keep the wound areas dry, and clean it by taking a sponge bath. Avoid applying ice.
- Take care in handling the catheter. Avoid pulling or jerking the tube.
- Wait for the doctor’s permission to use your phallus for urinating.
Do I have to go for vaginectomy before phalloplasty?
A: No, it is not necessary to have a vaginectomy before or after a phalloplasty. But if you want to remove your vagina, there are ways to remove ½ or 2/3 of the vaginal organ by going for a sub-vaginectomy during a phalloplasty.
Can I go for a Scrotoplasty as a part of phalloplasty?
A: Yes, Scrotoplasty is one of the options you can get from your surgeon with other options like glanplasty for a circumcised appearance of the penis.
Can I choose the size and length of my penis?
A: The resulting size of your penis will depend on the length and thickness of your forearm skin.
Can I father a child after phalloplasty?
A: No, this procedure will not help you father a child. This surgery aims to create male genitalia most naturally, but to have children your body needs organs that produce sperm.
Do I need to do exercise to build muscles before the surgery?
A: No, it is not necessary to build muscles before or after surgery. However, it is essential to stay fit and healthy.
Will the donor site on my arm feel the same after the surgery?
A: The skin grafting in your arm will affect your nerves, so the sensation in your arm will not be the same after the surgery. It is vital that you give attention to the donor area after the surgery.
Can I tattoo the donor site?
A: Wait for at least one year after the surgery to get a tattoo on your donor site.