Phalloplasty: What to Expect on the Day of Surgery

Phalloplasty is a lengthy surgery that can take anywhere from six to 12 hours. The procedure may require several stages, and a number of different techniques may be employed.

If you’re planning on undergoing this procedure, it’s important to understand what happens on the day of surgery.

Before the Surgery

Phalloplasty patients typically arrive at the hospital early in the morning—about two hours before the procedure itself—and will change into a hospital gown. The first task is to ensure your body is completely ready for the operation. In the preoperative exam, several important steps are taken.

• Consultation: Medical staff will review your medical history and screen for any diseases or health conditions that can cause problems. They’ll also ask about any drugs or supplements you’ve taken in the days prior to surgery.  
• Physical examination: A baseline evaluation of your health status is performed to assess readiness for anesthesia and surgery. This means assessing vital measures, such as heart rate and blood pressure, and performing blood tests.
• Hair removal: The site of the donor tissue—usually the forearm or the inner thigh—needs to be completely hairless to reduce irritation and infection risk. The healthcare provider may need to remove any hair using electrolysis.
• Sedation: You’ll need to be safely put to sleep before the procedure, so you’ll be connected to an IV delivering anesthetic drugs.

During the Surgery

Rather being a singular technique and surgery, phalloplasty varies a great deal based on the individual case. This highly complicated surgery is typically broken down into several stages, and additional steps may need to be taken based on treatment aims. In consultation with the surgeon, you will decide whether you would like:

• A functioning urethra
• The ability to have erections
• Nerve sensation in the penis
• A scrotum
• Testicles
• Vagina removal
• Removal of ovaries

Ultimately, this procedure may involve quite a bit of mixing and matching of techniques and related surgeries.

As noted above, this class of surgical procedures takes six to eight hours and is performed while you’re asleep. You won’t feel anything after the pinch of the IV delivering anesthesia.

Throughout the treatment, you’ll be hooked to machines monitoring your vital signs: heart rate, oxygen levels, blood pressure, and respiration. In addition, you’ll be attached to a respirator to help you breathe, an IV for medication, and a catheter for urine, as well as other tubes for drainage of fluids.   

In terms of the creation of the penis shaft and head itself, there are three primary approaches, varying based on the location of the donor site.

• Radial forearm free flap procedure: This approach involves removing tissue, including skin, fat, nerves, veins, and arteries, from the inner forearm of the nondominant arm. This is shaped and positioned and then transplanted, with its arteries and veins connected at the point of transfer.  
• Anterolateral thigh flap procedure: Sometimes called a pedicled flap procedure, this approach employs skin, fat, nerves, arteries, and veins from the inner thigh of your leg to shape the penis. Because of the location of the donor site, the tissues are never fully severed from their blood supply. Prior screening will determine which leg is appropriate.
• Musculocutaneous latissimus dorsi flap procedure: With this technique, the donor site is located on the side of the back. The entire tissue, including all veins, arteries, fat, and skin, is severed from blood supply, shaped, and transplanted to the new location. As with ALT, screening is used to find an appropriate part of the back.

The healthcare provider will have to weigh many factors when determining which of these approaches is best for your case.

In addition, there are a number of additional surgeries—usually performed after successful resolution of the above—that may be employed to meet your goals, including:

• Penile urethroplasty helps form or correct problems with the urethra for the penis.
• Perineal urethroplasty (urethral lengthening) involves forming a urethra in the perineum, the area between the scrotum and anus.
• Perineoplasty is a means of removing scar tissue or other deformities around the anus and vagina.
• Scrotoplasty involves the formation of testicles from donated parts of tissue; this may or may not involve having testicles implanted.
• Vaginectomy is the removal of the vagina.
• Hysterectomy and oophorectomy are procedures that remove the uterus as well as the ovaries.
• Glansplasty is the shaping and creation of the head of the penis.
• Testicular implant can be employed to add testicles. 
• An erectile device implant allows the penis to become erect.

These procedures tend to be performed separately after initial work is done, and they’re only undertaken once you’ve recovered from previous treatments.

After Surgery

Given the scope of this procedure, you can expect a lengthy recovery in the hospital; patients should plan to be admitted for at least five days afterward, though some may need longer.

Prior to discharge, healthcare providers need to ensure there are no complications and that you’re healing appropriately. Note that you’ll still have a catheter for urination for at least the first couple weeks after surgery, if not longer, and you’ll be given guidance for how to use and care for it.

Typically, the steps are as follows.

Transfer to the Recovery Room

Following the procedure, while you’re still asleep, you’re transferred to the recovery room. Here, the main aim is to monitor your vital signs and ensure nothing is going wrong.

At this point, compression stockings will be put on you; this promotes blood circulation and prevents blood clots from forming. In addition, you’ll have multiple catheters in your urethra, as well as drains from other parts of the groin.

Using Anesthesia

Once you’re fully awake from the surgery—usually about two hours afterward—you’ll be taught how to use the patient-controlled analgesia (PCA) pump, which allows you to self-administer pain-managing drugs via IV. You'll then be taken to a patient room.

First 48 Hours

In the 24-hour period following surgery, you won’t be able to eat any solid foods, and throughout recovery, you’ll follow a carefully managed, restricted diet. With some exceptions that your healthcare provider will tell you about, you may start taking other medications you’ve been prescribed or are taking over the counter.

During this time, too, you’ll need to take daily aspirin and keep wearing compression stockings to help prevent blood clots.

Days Two and Three

Throughout the first 72 hours after surgery, you’ll be checked on by a healthcare provider or nurse every one to two hours. These professionals will examine your penis’s color, blood saturation, temperature, and other important measures. This is to ensure that the transplant is getting enough blood and nutrients.

Days Three to Five

After 72 or so hours, you’ll be taken to a more general hospital room to recover, where, so long as nothing is going wrong, you’ll be checked on less often. It’s during the latter stages of in-hospital recovery that you’ll start to undergo physical therapy to help you start walking again.

Day Five

Barring complications, on the fifth day following surgery, the dressing will be taken off of the donor site and redressed with specialized gauzes and a splint. The drains attached to your groin are also removed at this point, as well as any devices used to monitor your heart.

Before Discharge

What do the surgeons need to see before you’re able to go home? Here’s a quick breakdown.

• Healthy transplant: You’re discharged when the penis is looking healthy, there are no signs of infection, and it’s clear that the area is getting enough blood and nutrients.
• Pain management: As you recover in the hospital, you’ll need to eventually stop using the PCA pump and will be given pain-managing pills. Prior to discharge, you’ll need to demonstrate that you can manage your pain this way.
• Nutrition: Following a major surgery like this, patients can become nauseous or lose appetite. Before you go home, healthcare providers need to make sure you aren’t feeling sick and are eating enough.
• Mobility: The surgery team will also want to see that you are able to walk on your own before letting you go home.

As you’ll be counseled, it’s important to have a friend or family member drive you home. You’ll return to the hospital later to remove the catheter. Before leaving the hospital, during the final evaluations and consultations, don’t be afraid to ask your practitoner questions or relay concerns. 

A Word From Verywell

There’s no doubt that phalloplasty is a significant and life-altering surgery, and the entire process can have a heavy emotional toll. For those seeking gender confirmation, mental health counseling is a required element of the procedure. Take advantage of this process to discuss any questions you may have and emotions you may be experiencing.

In addition, there are a number of other great resources out there for those considering or undergoing this treatment, such as the National Center for Trans Equality and the Trans Lifeline. Remember that you’re not alone: with the support of family and friends—as well as dedicated medical professionals—you’ll be ready for phalloplasty.