Phalloplasty: Overview

A phalloplasty, also called transmasculine bottom surgery, is the surgical construction (or in less common cases, reconstruction) of a penis using a skin graft from a patient's forearm, thigh, or upper back.

While potentially rewarding—both physically and psychologically—the decision to undergo a phalloplasty requires ample thought and consideration. There are multiple risks involved, the surgery is extremely challenging, and the preparation and healing process are extensive.

What Is Phalloplasty?

A phalloplasty creates a penis, called a neophallus. Fundamentally, this involves making a tube within a tube:

• The inside tube is the urethra, through which urinate flows out of the body.
• The outside tube is the penile shaft.

Once the neophallus is constructed, it is surgically attached to the pelvis, with the new urethra being connected to the patient's existing urethra. The exterior of the neophallus is then sculpted to resemble a penis shaft and head.

A phalloplasty is done in a hospital under general anesthesia by a plastic surgeon and/or a urologist.

Most commonly, this inpatient surgery is performed in transgender men or non-binary people as a type of gender-affirming surgery. Other indications for phalloplasty include certain congenital anomalies (e.g., ambiguous genitalia or an absent penis), or penile amputation as a result of trauma, infection, or cancer.

Various Surgical Approaches

A phalloplasty may be performed as a single-stage or multi-stage process.

• A single-stage phalloplasty involves the simultaneous construction of the phallus and urethra, as well as the connection of the urethra. Where relevant, it also involves the creation of a scrotum and insertion of testicular prostheses. All of this is done as a single procedure, although any penile prostheses are put in at a later date.
• A multi-stage phalloplasty breaks the surgery down into parts. This is typically preferred by surgeons and is much more common, as it allows for more detailed management of each aspect of the surgery.

Flap Types Used in Surgery

In order to create the penis, the surgeon will use a section of skin and tissue (called a flap) from another part of the patient's body. There are different types of flaps that can be used during a phalloplasty.

In the United States, the radial forearm free-flap is the most common. This involves harvesting a large rectangle of skin from one of the patient's forearms.

The main advantages of a forearm flap are that it's relatively large, easy to harvest, and sensitive to touch. In addition, since the forearm is thin and pliable in most people, the urethra can be simultaneously constructed from it.

The main disadvantages are the following:

• The length of the new penis is limited by the forearm length.
• The color of the forearm flap may be quite different from the genital skin.
• Since the forearm must be covered with a skin graft from one of the thighs, there will be a scar in two places that may be quite visible, depending on what the patient wears.
• The forearm flap requires the surgeon to be skilled in microsurgery, since the flap is fully removed from the arm and needs to be reconnected to the nerves and blood supply near the groin. Such surgeons may be harder to access if you live in certain locations.

A flap from the muscle located on your back, called the latissimus dorsi flap, may also be used to create a penis. Research suggests that this flap provides a good volume for the newly constructed penis, fulfilling both aesthetic and functional requirements.

However, the latissimus dorsi flap is thick, so it can only be used to create the penis, not the urethra. Therefore, a urethra would need to be constructed in subsequent stages. In addition, the nerve associated with the latissimus dorsi flap is a motor nerve, so there will be no skin sensation on the phallus.

Anterolateral thigh (ALT) flaps are also used for phalloplasty. Unlike radial arm and latissimus dorsi flaps, these flaps stay connected to their original blood supply. This means they do not require microsurgery expertise on the part of the surgeon performing the phalloplasty.

That said, thigh flaps have a thicker layer of fat, making it harder to roll them into a tube to shape the penis. If the ALT flap is too thick to reconstruct a urethra, excess penile skin or another flap, like a radial forearm flap, may be used.

Criteria and Contraindications

A phalloplasty is a complex, often multi-stage process. Patient goals and expectations and potential surgical complications all need to be carefully discussed and considered.

To help facilitate communication between surgeons and transgender and non-binary individuals considering phalloplasty, the World Professional Association for Transgender Health (WPATH) has created a set of principles to set standards of care.

The WPATH criteria state that patients considering phalloplasty:

• Have two referral letters from qualified mental health professionals
• Are of the age of majority (which is 18 in most U.S> states)
• Have persistent, well-documented gender dysphoria
• Have the capacity to make a fully informed decision and to consent for treatment
• Have any medical and/or mental health conditions well controlled
• Undergo 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless a patient has a medical contraindication or is otherwise unable or unwilling to take hormones)
• Live in a gender role that is congruent with their gender identity for 12 continuous months

Keep in mind that the above principles are not meant to serve as rigid or "set-in-stone" criteria for surgery. Rather, they serve as a source of guidance for surgeons and their patients.

In the end, the criteria may not be relevant for all patients. For example, the last two criteria may not apply to a non-binary individual.

Likewise, even if a patient meets all the criteria, a surgeon may deny surgery if the patient's goals cannot be met with the surgeon's advised techniques, or if the risks of the surgery for a particular patient outweigh any potential benefits.

Providing the best and safest care for each patient—whether that means moving forward with surgery or not—is the all-encompassing goal.

Potential contraindications to phalloplasty include:

• Active smoker
• Body mass index (BMI) greater than 35 and/or abdominal obesity

Potential Risks

Some of the risks associated with undergoing a phalloplasty include:

• Bleeding
• Injury to the urinary tract or rectum
• Pain (including painful intercourse)
• Dissatisfaction with the size or shape of the penis
• Wound infection or dehiscence
• Pelvic or groin hematomas
• Partial or total flap loss
• Urethral fistula (when the urethra becomes open to the skin, causing urine to leak)
• Urethral stricture (when the urethra becomes too narrow to carry urine)

Risks are also associated with the donor site where a graft originates on the body. These include pain, decreased sensation, or hematoma at the site as well as poor wound healing or adhesions.

Purpose of Phalloplasty

Phalloplasty is most commonly performed in transgender men or non-binary people as part of their surgical transition, though it may also be performed in association with other health conditions.

The goals of a phalloplasty include not only creating a neophallus for aesthetic purposes but also to provide:

• Orgasmic sensation (by preserving the innervated clitoris at the base of the neophallus during surgery)
• Sensation to the neophallus (this will vary based on the type of flap used)
• A urinary stream through the neophallus, including the ability to stand up while urinating (if the patient desires)
• A potential for having an erection for penetrative intercourse (this will require a penile prosthesis)

Less commonly, phalloplasty may be indicated in people assigned male at birth who:

• Were born without a penis, with a small penis (penile hypoplasia), or with ambiguous genitalia
• Underwent a circumcision-related injury
• Lost or severely injured their penis, often through a car or heavy moving machinery accident, burn incident, or blast injury (e.g., explosive device injury or mine blast)
• Experienced sexual partner-inflicted penile injury or mutilation
• Had an infection of their penis (e.g., balanitis or necrotizing fasciitis)
• Had penile cancer that required surgical removal of their penis

How to Prepare

For transgender or gender non-binary people, preparation for a phalloplasty begins over a year prior to undergoing the operation with the initiation of testosterone therapy. For people undergoing surgery for other causes (as listed in the preceding section), some of these steps, such as taking testosterone, are not required.

Besides taking hormone therapy for a year and fulfilling the other aforementioned criteria set forth by the WPATH, you will need to:

• Visit with a mental health professional to confirm your readiness and appropriateness for surgery
• Stop smoking
• Lose weight if your BMI is greater than 35
• Adopt a high-protein diet at least one month prior to surgery (to aid with post-surgical healing)
• Undergo permanent hair removal at the flap donation site, depending on which is chosen by the surgeon

Most surgeons also require that patients undergo removal of their uterus (hysterectomy) and ovaries (oophorectomy) months prior to the scheduled phalloplasty. Sometimes, patients undergoing phalloplasty may desire to preserve their uterus. One or both ovaries may also be retained for fertility preservation.

As your surgery date gets closer, you may be advised to stop the following medications:

• Testosterone therapy
• Blood-thinning medications like aspirin or ibuprofen

Besides preparatory strategies, you will need to have multiple thorough and candid discussions with the surgical team about your expectations from the surgery, the different surgical pathways and techniques involved, and the potential risks.

A surgical plan tailored to your desires and goals will be formulated. For example, if you wish to be able to urinate while standing after a phalloplasty, then urethral lengthening is also required. To lengthen the urethra, surgeons often use a vaginal flap, which requires surgical removal of the vagina.

What to Expect on the Day of Surgery

On the day of your phalloplasty surgery, you will arrive at the hospital and be taken to a pre-operative room. Here, you will change into a hospital gown, and a nurse will take your vital signs and place a peripheral IV.

Once in the operating room, an anesthesiologist will administer medications to put you to sleep. You will not experience any pain or be conscious during the surgery, nor will you remember the procedure afterward.

Generally speaking, and as applicable, the following procedures are usually performed before, along with, or after a phalloplasty surgery.

• Urethroplasty: Creation of a tube (the new urethra) within the new penis and lengthening of the existing urethra in order to connect the two
• Vaginectomy: Removal of the vagina
• Glansplasty: Shaping of the glans to create a circumcised-looking penis
• Scrotoplasty: Creation of the scrotum (this is usually done using the skin of the outer labia)
• Clitoral reconstruction: Burying the clitoris under the base of the new penis
• Testicular prostheses: Placing implants in the testicles in order to enhance the appearance of the scrotum
• Penile prostheses: Placing a penile implant, which allows the patient to have an erection and penetrative intercourse

Recovery

After a phalloplasty, you will be taken to a post-anesthesia care unit, where you will wake up from anesthesia. You can then expect to recover in the hospital for five to seven days.

During your stay in the hospital, you will likely do the following:

• Take a blood thinner and/or wear compression boots to prevent blood clots in your legs
• Start drinking and eating, as tolerated, approximately 24 hours after surgery
• Have your groin and scrotum drains removed around postoperative day five
• Have the Foley catheter in your penis removed before leaving the hospital
• Wear supportive underwear, often provided by a surgical team
• Begin walking with the assistance of a physical therapist

Moreover, the surgical team will perform regular checks on your new penis during your hospital stay to ensure it is receiving a healthy blood supply.

Once discharged from the hospital, the surgeon will give you various post-operative instructions, such as:

• How to care for your groin/penile dressings, donor flap site, and suprapubic catheter (this will stay in for several weeks after surgery).
• Taking various medications to control symptoms like pain, nausea, and constipation.
• Avoiding certain activities for a period of time (e.g., smoking for at least one month and moderate activities for at least six weeks).
• Arranging for a caregiver to help with both personal care and household chores.

Long-Term Care

While undergoing a phalloplasty is a major decision, research has found that transgender people who have undergone the operation are, overall, highly satisfied.

After surgery, though, it's important that patients remain devoted to their follow-up care, which includes:

• Attending regular appointments with their plastic surgeon, urologist, and physical therapist
• Undergoing routine testing for sexually transmitted infections every three to six months, if sexually active

Additionally, patients who receive penile implants after a phalloplasty may develop complications related to the implant, such as device failure or infection. These problems can occur immediately after implantation or several years out, and they require removal or replacement of the implant. Because of this, close follow-up with a surgeon is needed.

A Word From Verywell

No doubt, undergoing a phalloplasty is time-intensive, both emotionally and physically. That said, for the vast majority, the surgery comes with no regret. It can offer the last piece of the puzzle many are looking for to finally (and deservingly) feel comfortable and safe with their own bodies, sense of self, and relationships.