Phalloplasty is a complex, multi-stage gender-affirming procedure involving the creation of a neophallus. This surgery aims to meet a patient’s goals for appearance, sensation, and function, including the ability to stand to urinate and achieve penetrative intercourse. Outcomes are realized over a series of surgeries and a prolonged recovery period. Understanding the typical results and the path to achieving them is important for setting realistic expectations.
How Surgical Technique Affects Results
The choice of donor site for the tissue flap determines the initial characteristics of the neophallus and the location of the resulting scar. The two most common techniques are the Radial Forearm Free Flap (RFF) and the Anterolateral Thigh Flap (ALT).
The RFF technique utilizes thin forearm tissue, allowing for easier shaping and often providing better tactile sensation due to robust nerve connections. This method is often associated with a more reliable urethral construction in the initial stage, but it results in a visible skin graft scar on the forearm.
The ALT technique uses tissue from the thigh, which offers the advantage of concealing the donor site scar. However, thigh tissue is often thicker, which can lead to a neophallus with greater girth and may necessitate subsequent procedures for aesthetic refinement or debulking. While increased tissue bulk can sometimes make nerve connections more challenging, the overall potential for sensation return is considered comparable between RFF and ALT. The initial choice of technique limits or expands the possibilities for the final aesthetic and functional results.
Appearance and Sensation Recovery
The aesthetic result is directly influenced by the quantity and quality of the transferred tissue. The neophallus size typically ranges around 5 to 6 inches in length, with girth depending heavily on the patient’s body fat composition in the donor area. Patients with greater subcutaneous fat, particularly with the ALT flap, may experience a thicker result, which can be addressed later through debulking procedures.
Appearance is further refined by subsequent procedures. Scrotoplasty creates a scrotum, and glansplasty sculpts the tip to resemble the glans penis, creating the coronal ridge and sulcus. Scarring is an inherent part of the process, occurring both at the donor site (covered with a skin graft) and at the base of the neophallus where the flap is connected.
Sensation recovery is a gradual process that can take many months to several years as nerves regenerate. Protective sensation (the ability to feel touch, temperature, and pain) is typically achieved in the majority of cases because the sensory nerve from the donor flap is connected to the genital nerve. Erogenous sensation, or the ability to experience pleasure, is more variable but commonly returns following the nerve hookup. Many patients achieve good sexual sensation, though the intensity and distribution may continue to evolve years after the initial surgery.
Functional Urinary and Sexual Outcomes
Achieving reliable urinary function, specifically standing micturition, is a complex objective of phalloplasty. This requires urethroplasty, which involves lengthening the native urethra to the tip of the neophallus. While most patients who pursue this goal ultimately achieve the ability to stand to void, this process carries a high rate of potential complications.
The most common complications are urethrocutaneous fistulas (unwanted openings along the new urethra) and urethral strictures (areas of narrowing). Fistulas can occur in a significant percentage of patients, often requiring subsequent surgical revisions. Reliable urinary function frequently requires multiple stages to achieve a durable result.
The neophallus does not naturally achieve an erection because it lacks the erectile tissue (corpora cavernosa). To allow for penetrative sexual function, a separate, later surgery implants an erectile device, such as an inflatable penile prosthesis or a semi-rigid rod. This stage is typically performed at least 12 months after the initial phalloplasty to ensure the tissue is fully healed and sensation has returned. The success rate for maintaining the original prosthesis is around 62% after several years, with common late-onset complications including mechanical failure, malpositioning, or infection, which may require device replacement or removal.
Understanding Staged Procedures and Revisions
Phalloplasty is a staged procedure involving multiple planned surgeries spaced out over 12 to 24 months or more. This multi-stage approach allows the body to heal completely between major steps, optimizing the conditions for success in subsequent procedures. The planned stages often include the initial flap creation, urethral lengthening and scrotoplasty, and the implantation of the erectile device and testicular prostheses.
Revisions are common and should be viewed as an expected part of the overall process. Unplanned revisions are often necessary to manage complications like urethral fistulas or strictures, which have a high incidence rate following urethral lengthening. Aesthetic refinements, such as debulking the neophallus or performing a glansplasty, are also scheduled as later revisions to optimize the final appearance. High patient satisfaction is strongly linked to understanding this multi-stage reality, as the final result evolves over time.