Phalloplasty is a surgical procedure focused on constructing or reconstructing a penis, known as a neophallus. This complex operation addresses two primary needs: gender affirmation for transgender individuals and reconstruction following trauma, cancer, or congenital defects. It is a multi-stage process that can span months or even years to achieve the desired aesthetic and functional outcomes. The procedure aims to create a natural-looking structure that may allow for standing urination, sensation, and the potential for penetrative sexual function with the eventual use of a prosthetic device.
Candidate Assessment and Preparation
The process of preparing for phalloplasty is extensive, focusing heavily on patient readiness and risk mitigation. Patients typically undergo a thorough consultation process to establish realistic expectations regarding the final appearance and functional goals, such as the ability to urinate while standing. Psychological preparedness is formally assessed, often requiring letters from mental health professionals to confirm readiness for such a significant body alteration.
Medical clearance is a mandatory step, including a full physical examination and lab work to ensure the patient is fit for a major surgery. Modifiable risk factors, like body mass index (BMI) and nicotine use, must be addressed. Many surgical centers require a BMI under 35 and demand complete nicotine cessation for at least four to six weeks before and after the surgery.
For gender affirmation patients, sustained hormone therapy is typically required, as the testosterone helps promote hypertrophy of local tissue and can influence the final surgical outcome. Preoperative hair removal, using laser or electrolysis, is necessary on the intended donor site to prevent hair growth within the newly constructed urethra, which could lead to complications like strictures or stone formation. The surgeon will also perform specialized tests, such as the Allen test on the forearm, to confirm adequate blood flow before selecting a donor site for the tissue flap.
Primary Surgical Techniques and Tissue Acquisition
The construction of the neophallus relies on acquiring tissue flaps from donor sites, which contain skin, fat, nerves, arteries, and veins that are used to form the bulk of the new structure. The two most common methods are the Radial Forearm Flap (RFF) and the Anterolateral Thigh Flap (ALT), each offering a distinct balance of benefits and drawbacks.
The Radial Forearm Flap is frequently considered the standard approach due to the thin, pliable nature of the forearm tissue, which allows for easier shaping and the inclusion of nerves that provide excellent tactile and erogenous sensation. This method involves a “free flap” technique, where the tissue is completely detached from the arm, and the blood vessels and nerves are meticulously reconnected to corresponding structures in the groin using microsurgery. A consequence of the RFF is the large, noticeable skin graft scar that remains on the forearm.
The Anterolateral Thigh Flap is a valuable alternative for patients who wish to avoid a highly visible scar on the arm, as the donor site scar is more easily concealed. The ALT flap is often thicker, which can sometimes lead to the need for subsequent debulking procedures to reduce girth, and it may provide less initial sensation compared to the RFF. Urethral construction using the ALT flap often requires a secondary, smaller flap because the tissue is less pliable for the complex ‘tube-within-a-tube’ creation.
Sequential Stages of Reconstruction
Phalloplasty is a modular process completed through a series of operations separated by months of healing time. The subsequent stages focus on refining the structure and adding functionality after the initial creation of the phallic shaft.
Urethroplasty extends the urethra through the length of the neophallus, enabling the patient to urinate from the tip while standing. This is a complex, multi-stage procedure itself, often requiring a minimum of three months of healing between the initial creation of the new urethra and its connection to the native urethra. The meticulous nature of this stage is paramount, as urethral complications are among the most common issues in phalloplasty.
Glansplasty, or the shaping of the tip, is typically performed to create a more natural, cosmetic appearance. This involves surgically refining the tissue at the end of the shaft to resemble the glans penis. This procedure is often performed at the same time as the urethral connection or other secondary stages.
The final functional goal is the insertion of an Erectile Device, or penile prosthesis, which is necessary because the constructed tissue does not contain the specialized erectile bodies of a biological penis. This stage is usually performed six to twelve months after all soft tissue reconstruction and urethral healing is complete. The device is typically an inflatable prosthesis, allowing the patient to create an erection for penetrative intercourse.
Post-Operative Care and Healing Timelines
Recovery following the primary phalloplasty operation demands strict adherence to medical guidelines, characterized by an extended hospital stay and careful wound management. Patients typically remain in the hospital for about a week following the initial flap procedure for continuous monitoring of the flap’s blood supply. During this time, patients are often required to remain on bed rest for the first few days to ensure the delicate microsurgical connections remain intact.
A urinary catheter is placed to divert urine, allowing the newly constructed urethra to heal without pressure, and it generally remains in place for three to four weeks. Swelling and bruising are expected at both the recipient site and the donor site, though it may take several months for all swelling to fully subside. The donor site, particularly the forearm, is covered with a skin graft and requires careful dressing changes and immobilization to protect the area.
Long-term recovery involves gradual return to activity. Sedentary work is often possible after two to four weeks, but physically demanding jobs should be avoided for at least six weeks. Sensation in the neophallus begins to return slowly as the nerve connections regenerate, a process that can take many months to a year or more. Patients are advised to avoid sexual activity for at least three to four months.
Potential Complications and Remedial Procedures
Given the technical complexity of phalloplasty, patients should be aware that remedial or “revision” procedures are a common part of the overall process. One of the most common specific complications is urethral stricture, a narrowing of the newly formed urethra due to scar tissue or hair growth, making urination difficult. The rate of urethral stricture can be significant, sometimes affecting up to 35% of patients.
Another frequent complication is a urethral fistula, an abnormal opening between the urethra and the skin, causing urine to leak from a point other than the tip of the neophallus. Both strictures and fistulas often require subsequent corrective surgeries, sometimes multiple times, to achieve a functional urinary stream. In rare but severe cases, a stricture may require a long-term perineal urethrostomy, meaning the patient must sit to void.
A risk specific to the free flap technique is partial or total flap failure, where the tissue does not receive adequate blood supply after the microsurgical connection, leading to tissue death. This requires immediate surgical intervention and may necessitate a complete reconstruction using a different donor site. If an erectile device is eventually implanted, specific complications include infection and erosion, where the implant protrudes through the skin. Both require the device’s removal and a waiting period of several months before a replacement can be attempted.