Phalloplasty is a broad medical term that could indicate many different surgical procedures; it could be a plastic or reconstructive surgery in the case of defects or trauma to the penis of cisgender male patients, or it could be an aesthetic procedure when the goal of surgery is improving some characteristics of the penis in cisgender males, or it could be a reconstructive procedure in the case of FtM transgender patients in which case it is also known as bottom surgery or penile reconstruction.
Indications for the phalloplasty
There are many possible reasons why a phalloplasty is performed. In the cisgender male it is generally done in case of:
- Aphallia or penile agenesis
- Trauma to the penis to a variable extent
- Penile tumors that need to be excised
- Congenital penile curvature
- Cosmetic penis enlargement
In cisgender males the phalloplasty is any surgical procedure of the penis with the goal of modifying it or reconstructing it, both to solve congenital problems and to solve acquired problems; moreover it can also indicate an aesthetic surgery with the goal of increasing the penis shape, size and/or length. This last option is seeing an increase in demand year after year.
In FtM transgenders the phalloplasty represents uniquely the penile reconstruction surgery with the goal of creating a neo-penis and make the gender identity of the patient congruent with their physical appearance; the phalloplasty represents a treatment for gender dysphoria and facilitates social inclusion.
In this blog post we will specifically cover the phalloplasty for transmen undergoing sex reassignment surgery (SRS).
Criteria for the phalloplasty procedure
The Standards of Care 7th edition of the World Professional Association for Transgender Care (WPATH) set the following criteria to have access to the phalloplasty procedure:
- Persistent and well documented diagnosis of gender dysphoria
- In full possession of one’s faculties. Able to make a fully informed decision and to give consent for treatment.
- Age of majority in a given country.
- The absence of absolute medical contraindications (medical conditions which would make it too risky to perform the surgery).
- At least 12 continuous months of masculinizing hormone replacement therapy
- At least 12 continuous months of living in a gender role that is congruent with their gender identity.
These criteria, especially the last point, are set to allow the patient to experience and adapt their gender role, before they undergo an invasive and irreversible surgery and to minimize risks and maximize post-op satisfaction.
One more pre-requisite before undergoing a phalloplasty is the elimination of all hair on the donor area by using a laser or IPL device for permanent hair removal; this is because this area will later be used for the creation of the neo-penis and in some cases of the neo-urethra, so it needs to be hairless.
Goals of phalloplasty in FtM transgender patients
From the patient’s point of view, the goals of the phalloplasty are generally the following:
- The creation of an aesthetically pleasing and accurate neo-penis which doesn’t raise doubts in social settings
- To be allowed to void while standing
- To be allowed to have penetrative sexual intercourse
- To have tactile and erogenous sensation in the neo-penis
- To minimize the scarring and loss of function in the donor area or other complications
- To undergo sex reassignment surgery in a single surgical session
There is also the added goal from the surgeon’s point of view of finding a technique which is simple, with low risks and complications rate and which is easily reproducible.
Since 1936, the year when the first phalloplasty was performed, this surgery evolved considerably trying to reach all the objectives listed above; a final and unique solution though hasn’t yet been reached, with no technique superior to all the other available. In particular, all surgeons concur that for now a satisfactory result cannot be achieved by performing a single surgical procedure.
The phalloplasty is indeed completed over several surgical sessions to cover distinct phases of the reconstruction, and not in a single day and surgery.
During the first stage, the vaginectomy, the phalloplasty and the scrotoplasty are usually performed. The urethroplasty or urethral lengthening can be done during the first step, could be split into the first and second step, or could be done during the second step. The second stage might include part or all of the urethroplasty and the balanoplasty (surgical reconstruction of the glans of the penis). The testicular implants might be inserted in the second step or in the third one. The third stage could include the insertion of the testicular implants as well as the erectile implant for the neo-penis, when requested by the patient. During the second step often some revisions or touch ups are performed such as in case of complications to the neo-urethra, or to improve the aesthetics of the neo-penis. The whole 3-stage procedure might require as long as two years to be completed (post-op recovery from the surgeries included).
The results of the phalloplasty are variable and depend upon multiple factors such as the anatomy of the patient, the surgeries already undergone and the ones that will be performed with the phalloplasty, the surgical technique and the skills and experience of the surgeon.
The surgical techniques in FtM sex reassignment surgery (SRS)
Besides the metoidioplasty procedure or meta which we covered in another blog post, there are multiple surgical techniques to perform the sex reassignment surgery on transgender males all of which fall into the category of phalloplasty. None of these procedures is the best one available due to better functional and aesthetic outcomes or lower risks and complication rates. Hence it is an individual choice which could be influenced by specific anatomical characteristics of the patient, by aesthetic outcomes (what location will have a visible scar), by surgical considerations, by financial considerations (different techniques have different costs) or by the chosen surgeon as each surgeon usually performs a single technique which he prefers. Among the many surgical techniques developed over the years and available as of today, there are:
- ALT Phalloplasty: pedicled anterolateral thigh flap phalloplasty or anterolateral thigh free flap phalloplasty.
- RFF Phalloplasty: radial forearm free flap phalloplasty.
- Double Flap or Combined Flap Phalloplasty: RFF and ALT combined techniques.
- Suprapubic flap or abdominal flap or Pryor’s technique phalloplasty
- Bird-Wing Abdominal Flap Phalloplasty
- FFF Phalloplasty: fibula free flap phalloplasty
- Kim’s Phalloplasty: conjoined bilateral pedicled groin flap phalloplasty
- MLD Phalloplasty: musculocutaneous latissimus dorsi free flap phalloplasty
- Reinnervated MLD Phalloplasty: reinnervated musculocutaneous latissimus dorsi free flap phalloplasty
All of these techniques have the base goal of harvesting enough tissue from the donor area with the right characteristics: innervation, vascularization, thickness, easiness to harvest, dimensions, etc. This harvested tissue, known as flap, is then rolled-up in a tubular shape and will form the neo-penis. A second strip of tissue, with different characteristics than the first one and smaller in width, is tubularized to form the neo-urethra which will be used for urethral lengthening. At this point there will be two tubular structures one inside the other. With the surgical microscope the surgeon will anastomose (medical term that means conjoin) the arteries, veins and nerves of this newly created structure from the donor area with the previously dissected arteries, veins and nerves of the recipient area to provide vitality and sensation to the tissues. The neo-urethra is anastomosed with the existing urethra to finalize the urethral lengthening.
As stated already, the transplanted nerve present in the flap from the donor area are connected to nerves which are present in the recipient area. Based on the surgeon and on the technique employed these connections might vary. In general, there are two nerve connections available: one is the ilioinguinal nerve to provide tactile sensation, the other is made with one of the two branches of the dorsal nerve of the clitoris to provide erogenous sensation. The second dorsal nerve will be left intact and the clitoris itself is buried at the base of the neo-penis so that the manipulation of the phallus will stimulate the clitoris which is still innervated.
The passages above are the ones usually performed and common to all the phalloplasty procedures; below we will describe the features of the various surgical techniques.
1. ALT Phalloplasty: pedicled anterolateral thigh flap phalloplasty or anterolateral thigh free flap phalloplasty
The flap harvested following this technique includes the skin, the adipose tissue and the fascia, with blood supplied by the lateral femoral circumflex artery and innervation provided by the lateral cutaneous nerve of the thigh.
Due to the complex path followed by the blood vessels involved in this surgery, which varies among individuals, this surgical technique could be difficult to perform.
A determining factor when choosing this procedure is the thickness of the skin and of the adipose layer which needs to be evaluated by the surgeon: an excessive thickness is contraindicated for this surgery and also precludes the use of the harvested tissue for the creation of the neo-urethra. Limited thickness will instead guarantee good tactile sensation to the transplanted flap.
Advantages of the ALT phalloplasty:
- The donor area is rarely exposed, and the scar is easily hidden under clothing.
- The broad donor area allows for large dimension flaps.
- The color of the donor area is similar to that of the recipient area, improving the aesthetic result.
- If pedicled flap is used, the surgery is faster and lasts on average 90 minutes less than when free flaps are used.
- The donor area is not subject to loss of functionality post-op
Disadvantages of the ALT phalloplasty:
- It is not indicated for patients with thigh skin too thick or with too much adipose tissue (>2cm)
- The flap is generally thicker; hence it is harder to shape it.
- It’s more complex due to the variable disposition of the blood vessels.
- The sensation of the neo-penis is inferior than that obtained with other techniques.
- There’s a higher urethral complication rate compared to other techniques.
2. RFF Phalloplasty: radial forearm free flap phalloplasty
The free radial forearm flap phalloplasty is considered to be the gold standard technique by some surgeons in the context of female to male sex reassignment surgery.
The tissues are harvested from the non-dominant arm. The flap includes the radial artery, the cephalic and basilic veins, and the lateral and medial cutaneous nerve of the forearm.
This procedure is not indicated for all of the patients: the screening is done by performing the Allen test to assess arterial blood supply of the hand and predict post-op arterial insufficiency.
Advantages of RFF Phalloplasty:
- Better sensation due to the anatomical characteristics of the flap.
- Reduced thickness of the donor area allows for easier shaping of the neo-penis
Disadvantages of RFF Phalloplasty:
- Partial loss of function (less strength) of the hand and forearm where flap was harvested
- Free flaps have higher risk of failure when compared to pedicled flaps
- The scar is less easily concealable under clothing
- The scar on the forearm is very peculiar to this surgery and many patients consider it a stigma, opting for other surgical techniques.
- It requires a skin graft to the donor area from the thigh or the glutes.
3. Combined ALT/RFF Phalloplasty
The combined ALT/RFF phalloplasty is a modification of the ALT technique which utilizes a flap harvested from the thigh to create the neo-penis and a smaller flap harvested from the forearm to reconstruct the neo-urethra.
Advantages of the combined ALT/RFF Phalloplasty:
- The forearm flap has characteristics that make it more suitable for urethral reconstruction.
- It is less invasive on the forearm, leaving just a rectilinear scar.
- Shows less risk of urethral complications
- The use of a pedicled ALT flap lowers the risk of tissue necrosis
Disadvantages of the combined ALT/RFF Phalloplasty:
- It is a more complex procedure with more time spent in the OR when compared to other techniques.
4. Suprapubic flap or abdominal flap or Pryor’s technique phalloplasty
The suprapubic flap phalloplasty is performed by harvesting a pedicled flap of about 11cm in height and 12cm in width measured from the base of the clitoris; this flap includes the skin and derma up to the fascia that covers the rectus abdominis muscle. These tissues are then shaped and shifted into position.
Advantages of Pryor’s technique phalloplasty:
- Pedicled flaps don’t require vascular microsurgery and have a lower rate of complications
- The scar is less visible and usually well tolerated by the patients
- Less complications to the donor area
- Less time in the OR and faster post-op recovery
- The hysterosalpingo-oophorectomy can be performed at the same time and using the same incisions.
- Easier to perform
Disadvantages of Pryor’s technique phalloplasty:
- Worse aesthetic result when compared to other techniques
- It requires a second stage procedure if the patient wants urethral lengthening too.
- Being a pedicled flap, tactile sensation is preserved, but there is no erogenous sensation which relies uniquely on clitoral stimulation that will be buried or hidden at the base of the neo-penis.
- High risk of urethral complications if the urethroplasty is performed during the same stage as the phalloplasty
5. Bird-Wing Abdominal Flap Phalloplasty
Bird-Wing pedicled flap phalloplasty was developed as an alternative to other techniques to minimize the scarring of the donor area and to improve and speed up the post-op recovery. The scar resulting from this surgery is a straight horizontal line in the lower abdomen.
Advantages of the Bird-Wing Abdominal Flap Phalloplasty:
- Easier to perform and faster, doesn’t require microsurgery
- Less visible scar
- Faster healing
- Less post-op complications
Disadvantages of the Bird-Wing Abdominal Flap Phalloplasty:
- Does not include the urethroplasty. If the patient wants the urethral lengthening it need to be performed in the second stage.
- There is no erogenous sensation of the neo-penis, only tactile sensation is preserved.
6. FFF Phalloplasty: fibula free flap phalloplasty
Fibula free flap phalloplasty is an alternative technique that was developed for those who don’t want to have a visible scar on the forearm. It is an osteocutaneous free flap; it includes the peroneal artery and vein, the lateral sural cutaneous nerve and part of the bone tissue of the fibula.
The harvested bone is anchored to the pubic bone providing rigidity, while the branch of the sural nerve is connected to one of the two branches of the dorsal nerve of the clitoris with the possibility, but not certainty, to gain erogenous sensation of the neo-penis; the clitoris and the other dorsal nerve remain intact to preserve the physiological erogenous sensation
Advantages of FFF phalloplasty:
- Less visible scar
- Does not require a penile implant
- In some cases, there is erogenous sensation of the neo-penis
Disadvantages of FFF phalloplasty:
- The transplanted bone can fracture, curve or can be resorbed over time
- The permanent rigidity can be difficult to hide and be a source of discomfort
- There can be functional limitation and complications in the donor area
- It could require revision surgery to improve the aesthetics
7. Kim’s Phalloplasty: conjoined bilateral pedicled groin flap phalloplasty
Dr. Kim’s phalloplasty was developed by Dr. Kim Jin Hong, a South Korean urologist who specialized in urogenital reconstructive surgery under Prof. Sava Perovic in Belgrade.
It utilizes two bilateral pedicled inguinal flaps harvested to create the neo-penis. It is an easier, faster and less expensive technique when compared to others. The procedure is split into 3 steps spaced at least 3 months apart from each other’s: the phalloplasty, scrotoplasty with testicular implants are performed during the first stage; the second stage is the implantation of the erectile device; during the third stage, the vaginectomy and urethroplasty are performed.
Advantages of Kim’s phalloplasty:
- It costs about 35% less than other procedures
- The scars are less visible and easily hidden under clothing or swim trunks.
Disadvantages of Kim’s phalloplasty:
- The size of the neo-penis depends uniquely upon the dimensions of the patient (the size of the donor area)
- Semi-rigid malleable implants can be implanted, but the inflatable ones can’t.
- The size of the penis is smaller than with other techniques, averaging 10,5cm in length.
8. MLD Phalloplasty: musculocutaneous latissimus dorsi free flap phalloplasty
MLD phalloplasty utilized a flap harvested from the dorsal region which includes part of the latissimus dorsi muscle, thoracodorsal nerve and vessels. Only a strip of muscle tissue is harvested which will be wider the thinner is the patient. The resulting scar is long and linear if the skin is sufficiently elastic to be sutured and closed after harvesting the flap. The urethroplasty is performed at a later stage at least 6 months apart from the first one. The nerve connection is made between a sensory nerve in the recipient area with a motor nerve from the donor area.
Advantages of the MLD phalloplasty:
- Better sensation than with inguinal or abdominal flaps
- Good aesthetic result and good dimensions of the neo-penis
- Good anatomical characteristics of the donor area (dimensions, volume, neurovascular pedicle length)
- Less risk of dyschromia of the skin and tissue resorption than with fasciocutaneous flaps.
- If the skin of the donor region is prepped at least 3 months in advance with massages and topical application of creams to improve the elasticity, it is possible to suture the donor area leaving just a linear scar
Disadvantages of the MLD phalloplasty:
- Worse sensation than with RFF technique
- Not indicated in overweight patients due to the increased thickness of the flap
- Not much erogenous sensation; tactile sensation that improves over time
9. Reinnervated MLD Phalloplasty: reinnervated musculocutaneous latissimus dorsi free flap phalloplasty
The reinnervated MLD phalloplasty is a variation of MLD phalloplasty that allows the patients to have penetrative sexual intercourse without a penile implant.
The difference with the ordinary MLD is that there is an incision in the medial region of the thigh to expose both a branch of the obturator nerve that innervates the gracilis muscle and a branch of the medial circumflex femoral artery.
The harvested flap has ¼ of its length exposed without skin and subcutaneous tissues, just the muscle, while the other ¾ have the ordinary characteristics. This exposed side allows the surgeon to anchor the harvested muscle to the fascia of the rectus abdominis. A small subcutaneous tunnel is created in the inguinal region to allow for the passage of vessels and nerve of the flap that will be connected with those dissected from the thigh.
The connection between the dorsal motor nerve and a motor nerve from the thigh allows for voluntary contraction of the neo-penis. After surgery, the patients undergo a rehabilitation protocol with muscle electrostimulation at least 3 days a week for at least 6 months; once voluntary control of the muscle is gained the physical therapy is continued until contraction and control are satisfactory to the patient.
In one study with 22 patients, 19 of which followed-up, and who underwent this procedure between 2001-2005, 95% (18) were able to contract the muscle and experience a voluntary erection.
Advantages of the reinnervated MLD phalloplasty:
- The erection is possible without an implant
Disadvantages of the reinnervated MLD phalloplasty:
- Although the erection is possible, it’s not guaranteed the ability to have penetrative sexual intercourse.
Risks and complications of the phalloplasty
Differently from other procedures, the phalloplasty as a high rate of post-op complications and high risks. High is also the post-op satisfaction when the surgery is successful, reason for which although the high risks many patients decide to undergo the procedure.
It is a relatively new surgical technique, extremely complex and still not widely practiced around the world; steps forward and new developments are expected with overall improvements and lower risks.
Different techniques have different risks and complications. Different surgeons practicing the same technique have different statistics on complication rate, success, and satisfaction.
As any surgical procedure, among the risks there are the infections, hemorrhages, tissue damage and pain. Urethral complications with fistulae and strictures are quite common when an urethroplasty is performed. Lack of sensation, partial or total necrosis, dissatisfaction due to the aesthetics, shape or dimensions are among the other possible complications.
The donor area can experience complications too, with reduced strength and/or mobility, pain, loss of sensation, extended scarring, infections, slow healing, adhesion formation.
Risks and complication rates specific to the technique and chosen surgical team will be thoroughly explained during consultation.
Accessory surgeries combined with the phalloplasty of performed before or at later stage in transgender patients
- Urethroplasty or urethral lengthening
- Testicular implants
- Balanoplasty or glans reconstruction
- Coronaplasty or reconstruction of the penis crown
- Cosmetic tattooing of the glans
- Penile implant
Urethroplasty in transgender patients who undergo phalloplasty
The urethral lengthening can be performed in different ways and at different stages, depending upon the surgeon.
- Total vascularized urethroplasty: it is performed using tissues obtained from the harvested flap (such as the ALT or RFF flaps), or from tissues harvested from the labia minora, labia majora, vaginal mucosa or from the groin.
- Total non-vascularized urethroplasty: this procedure utilizes a graft harvested from the oral mucosa (higher rate of stenosis and fistulae).
- Partial urethroplasty: when the urethra is lengthened up to the base of the neo-penis instead of the tip (lower rate of complications, but the patient won’t be able to void while standing).
Balanoplasty and coronaplasty or reconstruction of the glans and crown
These two procedures improve the aesthetics of the neo-penis and can be performed either in the first stage or in the second stage of the multistage sex reassignment surgery.
These procedures create a penis similar in look to a circumcised penis and with the cosmetic tattooing of the glans a great degree of realism can be achieved.
There are many different techniques that employ the use of flaps or grafts harvested from different anatomical structures to modify the aesthetics of the tip of the penis.
Penile implants for FtM transgender patients
The penile prosthesis implantation is generally, but not always, the last surgery performed in the multi-stage phalloplasty; it is usually done at least 6-12 months after the penile reconstruction, when the neo-urethra and neo-penis healed and the patient recovered all possible sensation in the area. Post-op recovery time is about 6-8 weeks after which the patient should be able to have sexual intercourse.
There are mainly three categories of penile implants:
- Non-hydraulic penile implants (non-inflatable), semi-rigid, malleable or non-malleable.
- Hydraulic bi-component penile implants (inflatable, 2 pieces)
- Hydraulic tri-component penile implants (inflatable, 3 pieces)
Biologic implants that were studied over the years belonged to the first category: bone grafts from the fibula or ulna or cartilage grafts. This type of implant is almost never placed anymore due to the inconvenience of having a constant erection, the tissue resorption that happens over time and the risk of fracture, perforation and tissue damage.
To the first category belong also other non-inflatable implants: semi-rigid and malleable prosthesis; they are made of one or two shafts of stainless steel covered in silicone. They provide enough rigidity to allow for penetrative sex but are always semi-rigid; they can be bent in various shapes to imitate the flaccid or erect state of the neo-penis. The advantage of this type of implant is that they are easy to use, they just need to be bent by hand and are ready for use. The surgery to implant them is the easiest, they are the least expensive and the absence of mechanical parts make them long lasting, about 20 years.
Bi-component inflatable implants are made up of one or two cylinders that are implanted in the shaft of the penis, one reservoir filled with saline solution at the base of the cylinders, and one pump and one release valve that are placed in the scrotum.
To have an erection, the patient needs to squeeze the pump a couple of times to pump the saline solution into the cylinders and achieve an erection. To get back to flaccid state, the patient needs to gently bend the penis downwards and this action will activate the valve and make the fluid drain back into the reservoir in the scrotum. The advantages of this implant are that it is easy to use, and it is the least expensive among the inflatable implant category.
The hydraulic tri-component penile implants are made up of three pieces. The difference with the bi-component ones is that the reservoir is not placed at the base of the cylinders, but it is located in a pocket created in the lower abdomen allowing for greater volume of fluid. It works similarly to the 2-pieces implants, but to return to the flaccid state there is a mechanism to press on the pump. The advantages of the 3-piece implant are that it is easy to use, the larger pump in the scrotum allows for faster erections, more rigidity, better flaccid state as well as less pressure on tissues at rest, lowering the risk of injuries. The presence of a number of mechanical parts makes them more susceptible to mechanical issues, with devices lasting up to 10-15 years, but with malfunctioning reported since the third year.
For the placement of the erectile implant it might be necessary to remove one testicular implant or in case of too little scrotal volume it might be necessary to use a tissue expander before implanting the device.
The main challenge in the implant surgery is that contrary to cisgender males, transmen lack some anatomical structures such as the tunica albuginea which is the perfect housing for the cylinders: it protects the surrounding tissues, keeping the cyilinders in place and avoiding injury. Moreover, the lack or limited sensation in the neo-penis increases the risk of tissue damage, especially at the tip of the penis as without feeling pain the patient would not know about an injury. The vascularization of the flap that makes up the neo-penis is inferior to that of a natural tissue, hence the healing processes are slower too, with an increased risk of infection. Lastly, on the contrary of cisgender males who usually require such implant at a later age, transmen are usually younger and most likely more sexually active, which increases the risk of incurring damage.
To avoid all of these issues some surgeons opt for the use of tissues or materials to encase the implants and/or to anchor them to the pubic bone, to recreate a sort of artificial tunica albuginea, but more resistant.
As the phalloplasty, the erectile implant surgery still has ample room for improvement. At the moment, the complication rate needing a revision surgery is about 25-75%. Infection rate is about 8-15% and to lower that risk now they soak the prosthesis in antibiotics before implanting them. Despite the high complication rate, a lot of patients still request this surgery, due to the high post-op satisfaction.
About flaps and grafts
What is the difference between free flaps and pedicled flaps?
One of the differences among the various phalloplasty procedures is about the type and location where the flap is harvested.
Pedicled flaps are pieces of tissue that preserve a connection with the donor area; this connection provides blood flow and sensation, so they do not need any anastomosis. The flaps are simply rotated and shifted into position, keeping their original innervation and blood supply.
Free flaps are tissues harvested and completely detached from the donor area and then transplanted into the recipient area. They need to be connected to blood vessels and nerves in the recipient area to keep vital and regain sensation.
Pedicled flaps are more reliable, meaning they have lower risks of complications or total failure; partial failure is still possible and depends from the shape and type of the flap. Free flaps instead are an all-or-nothing procedure: it is either a success or a total failure, with a failure rate of about 1-5%.
What is the difference between musculocutaneous flaps, fasciocutaneous flap and osteocutaneous flap?
Another difference between flaps is related to the type of tissues that are harvested from the donor area.
Musculocutaneous flaps consist of the skin, subcutaneous tissue, the underlying fascia and part of the muscular tissue; one of the main features of this type of flap is that the blood supply doesn’t come from a cutaneous artery, but from deeper arteries that supply blood to the muscle and that from here propagates towards the upper layers of tissue up to the skin. The increased thickness makes it more rigid in consistence and it also provides increased resistance against bacterial infections (about 100 times more resistant than a fasciocutaneous flap).
What is the difference between grafts and flaps?
Grafts are classified based on what type of tissue they are made of: it could be the skin, like in the case of burn victims who get skin grafts; it could be bone as it often happens in maxillo-facial surgery and dentistry; it could be a cartilage graft such as in nose bridge augmentation using a rib cartilage graft; or it could be fat tissue as in fat grafts used to reshape areas in cosmetic surgeries; and so on, it could be nerves, tendons, etc.
The difference with flaps is that grafts do not possess their own blood supply: they rely on the recipient area to receive nutrients and survive.
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