Phalloplasty is a surgical procedure primarily sought by transmasculine individuals for gender confirmation, though it is also used for reconstructive purposes following trauma or congenital conditions. The goal is to create a functional and aesthetic phallus, which typically involves multiple, staged operations. In 2018, established surgical techniques were widely adopted, offering a standardized baseline for expected results before the integration of subsequent innovations. This era was characterized by the routine use of specific tissue transfer methods, providing valuable data on achievable aesthetic, functional, and post-operative outcomes.
Standard Surgical Techniques
Phalloplasty in 2018 relied on three main free flap techniques, which use tissue from a distant body site and require microsurgical connection of blood vessels and nerves.
Radial Forearm Free Flap (RFF)
The RFF was the most common technique, utilized in approximately 75% of procedures, highlighting its prevalence as the gold standard. It was valued due to its pliability, thinness, and reliable blood supply. This method harvested skin, subcutaneous tissue, and the medial or lateral antebrachial cutaneous nerve from the forearm to construct the neophallus. The RFF was highly successful in providing excellent sensation because the nerve could be coapted to the native dorsal clitoral nerve. It also allowed for a tube-within-a-tube design for simultaneous urethral lengthening, though the resulting forearm scar was typically visible.
Anterolateral Thigh Flap (ALT)
The ALT flap offered the advantage of a less conspicuous donor site scar on the thigh. This flap utilized skin, fat, and fascia from the outer thigh. While the ALT flap was often thicker than the RFF, sometimes requiring a secondary debulking procedure, its size allowed for significant bulk. In some cases, its inherent rigidity was sufficient for sexual function without an immediate implant.
Musculocutaneous Latissimus Dorsi Flap (MLD)
The MLD was a less frequent option, typically reserved for patients for whom RFF or ALT were not viable. The MLD flap provided a large amount of tissue and had a donor site easily concealed on the back. A limitation of the MLD was that it did not naturally lend itself to the tube-within-a-tube construction, meaning urethral lengthening often required a more complex, staged approach using local tissue or grafts.
Aesthetic and Functional Outcomes
Phalloplasty success in 2018 was measured by three goals: natural appearance, restored sensation, and the ability to void while standing.
Aesthetic Results
Aesthetic results focused on the size, shape, and contour of the neophallus. The mean length achieved across techniques was approximately 12.26 centimeters, with a mean circumference of 10.18 centimeters. Achieving a satisfactory aesthetic outcome was a major driver for patients, though formal reporting on these metrics in the medical literature was less common compared to functional results. Surgeons aimed to create a structure that could eventually accommodate an erectile device and incorporated glansplasty to refine the tip’s appearance. The final appearance was often refined across multiple stages, including procedures to reduce bulk or improve contour.
Sensation
Functional outcomes related to sensation were a significant strength of the microsurgical free flap techniques. Tactile sensation, defined as the ability to feel touch, was highly successful, with approximately 93.9% of patients achieving some level of sensation. This was achieved by connecting the donor flap nerve to the dorsal clitoral nerve. Erogenous sensation, involving sexual pleasure and orgasm, was also a goal. Studies indicated that a majority of patients, with rates ranging from 60% to 90%, reported experiencing erogenous sensation or sexual function. Maximizing both tactile and erogenous sensation relied on the preservation and coaptation of the native clitoral nerves.
Voiding While Standing
The third functional goal was the ability to void while standing, which required successful urethral lengthening (urethroplasty). This procedure extended the native urethra through the new phallus. Data showed high success rates, with about 92.2% of patients who underwent urethroplasty reporting the ability to void while standing. Urethral lengthening was complex, often utilizing the RFF’s tube-within-a-tube design or local tissue grafts.
Reported Post-Operative Management and Recovery
The post-operative course in 2018 was characterized by high complication rates, often necessitating subsequent management and revision procedures. The overall complication rate associated with the entire process sometimes exceeded 75%. The most frequent and complex issues involved the neourethra, the most technically challenging part of the construction.
Urethral Complications
Urethral complications primarily included fistulas and strictures. A urethral fistula, a small opening causing urine leakage, was reported in approximately 34.1% of cases. Urethral strictures, narrowings of the new urethra, occurred in about 25.4% of patients. These issues often required a series of corrective surgeries to resolve.
Flap and Donor Site Morbidity
Donor site morbidity was expected, particularly with the RFF technique, which required a skin graft to cover the forearm site. Total flap loss was uncommon (around 3%), but partial flap loss occurred in approximately 11% of cases and required careful management to prevent further tissue compromise. Post-operative management protocols were rigorous, focusing on flap monitoring for blood flow using Doppler signals, strict positioning of the neophallus to prevent kinking, and prolonged use of a urinary catheter for several weeks.
Staging and Recovery Timeline
Phalloplasty was almost always performed as a staged process, with major stages separated by several months of recovery. The initial operation typically involved phallus creation and urethral lengthening. Later stages included glansplasty, scrotoplasty, and the eventual placement of erectile and testicular implants. Patients were routinely counseled to expect revision surgeries due to the high complication rates associated with the neourethra. Patients typically remained hospitalized for five to seven days for flap monitoring. Full recovery and return to normal activity were often delayed until six to eight weeks post-operation. The entire surgical journey, including managing complications and subsequent stages, could span over a year.