Oct 022013
CC BY-NC-SA 2.0 - flickr user TheTallest

An example of what a phalloplasty result will NOT look like.

A new paper details a surgical technique for suprapubic phalloplasty, along with initial results in patients. Phalloplasty is an option for men who do not currently have a penis, whether transgender or cisgender. While the first phalloplasty was performed for a trans man, cis men sometimes lose their penis through accident, intersex conditions, or medical procedures and need/desire phalloplasty too.

Phalloplasty involves taking tissue from elsewhere in the body and forming a penis from it. Common choices include tissue from the forearm or latissimus muscle. The forearm phalloplasty may be the most common, but results in a large scar on the forearm (previously covered on OMH here). Some men may fear that such a scar would “out” their medical history. So Terrier et al developed and tested a suprapubic phalloplasty method in France, with collaboration from researchers in Quebec.

Suprapubic phalloplasty is a 3-stage phalloplasty without urethroplasty. Nature has an excellent image comparing suprapubic phalloplasty to forearm (NSFW), and you might find it helpful. These stages break down like so…

  • Stage 1: Tissue Expanders. Tissue expanders are bags which are slowly injected with saline (a sterile salt-water solution). Two tissue expanders are placed in the abdomen, below the belly button. These expanders were injected with saline roughly once a week, gradually stretching the skin and tissue below the belly button. The surgery for this stage lasts roughly an hour and a half on average. Patients were in the hospital a little under 3 days.
  • Stage 2: Tube creation. 3 months after stage 1, the tissue expanders are removed. Skin/tissue in the middle of the stretched skin is rolled up into a tube, which will be the shaft of the neophallus. The tube is left connected at top and bottom. It is left connected for the next three months until stage 3, to make sure it has sufficient blood flow. The surgery for this stage lasted roughly two hours on average. Patients were in the hospital a little under 5 days.
  • Stage 3: Tissue release. 3 months after stage 2, the tube is released. Through a heart-shaped cut above the top of the tube/neophallus, and the neophallus is disconnected from the top and allowed to hang down. The surgery for this stage lasted a little over an hour and a half on average. Patients were in the hospital 3 days.
  • Additional surgeries can be performed 6-12 months after stage 3. Glanuloplasty, creation and/or emphasis of a glans (penis tip), can be performed at 6 months. At 1 year, penile prostheses (to allow erection) and testicular implants can be inserted. Abdominoplasty, to reduce the size of the abdominal scar, is another option.

The surgical description did not mention when scrotoplasty, vaginectomy, or hysterectomy/oophorectomy should be performed. I would guess that they could happen in or after the 3rd stage. Within the paper they mention that the clitoris could be embedded into the scrotum during scrotoplasty, to allow for erogenous sensation. They explicitly do not do urethroplasty with suprapubic phalloplasties because of a high rate of complications with other similar phalloplasty techniques. So instead it appears, from images within the paper, that the urethra is underneath the penis on the scrotum.

What about results? Well Terrier et al present data from 24 individuals, 23 trans men and 1 cis man, who chose this form of surgery. The authors offered a number of individuals a choice between metoidioplasty (including urethroplasty), free-flap forearm phalloplasty (including urethroplasty) and this new suprapubic phalloplasty. The 24 men in this study voluntarily chose suprapubic phalloplasty.

Surgical complications varied by stage. I’ll break it down again…

  • Stage 1: 4 cases (17%) of minor complications, including migrations (moving around), perforations (holes), and abscesses (pus collection).
  • Stage 2: Roughly half had minor complications, chiefly infection and sutures/stitches which tore.
  • Stage 3: 1 case (4%) of tissue death at the tip of the penis. The dead tissue was removed without affecting penile length.
  • In addition, two patients chose to have more surgery for aesthetic reasons. There were also complications associated with penile implants. 36% of patients who chose a penile implant had a complication. There was no loss of the penis.

Results were generally satisfactory. 95% of the men who had suprapubic phalloplasty were satisfied, very satisfied, or extremely satisfied with their results. 79% were happy with their sex life, and statistically significantly more happy after surgery than before. Orgasms were as common after surgery as before. A 95% satisfaction rate is very good, perhaps even better than the satisfaction rate for other phalloplasties (70-90%). Of course, satisfaction is a very subjective thing, as Terrier et al are quick to point out. For example, the fact that the men in this study chose suprapubic phalloplasty may impact their perceived satisfaction. But… if they’re happy, does it matter?

The average penile length was 14 cm/5.5 in, with width of 10 cm/3.9 in. That’s well within the average size for cis male penises. The scar was, on average, 5.6 cm/2.2 in long, 5.7 cm/2.2 in wide. For most patients it could be reduced with surgery (abdominoplasty), and half chose to do so. In fact, the size of the scar was the variable most predictive of satisfaction with the surgery… not penile length, ability to pee standing, or sex life. Terrier et al provided images of their results. I won’t reproduce those here, but I can said that the skin tone is continuous and the scar definitely minimal. The scar could easily be hidden from public view, and could possibly be explained as some form of abdominal surgery for those who don’t want to disclose.

This method of suprapubic phalloplasty appears, from this report, to be a good option for men needing phalloplasty.

Surgical Outcomes and Patients’ Satisfaction with Suprapubic Phalloplasty was published in the Journal of Sexual Medicine. The abstract is publicly available.

  4 Responses to “Article Review: Surgical Outcomes and Patients’ Satisfaction with Suprapubic Phalloplasty”

  1. Interesting article, if a bit scrotum-shrinking.

    Knowing me as you do, you won’t find it surprising that I had a fit of the giggles when I ran across penis migrations. I wish I could draw.

    • That very “scrotum-shrinking” reaction may be a good indication of your cisgender-ness. Can you imagine what it would be like to either a) lose your penis or b) never have had it and/or c) having other bits that are fundamentally wrong for you? And can you then wrap your mind around a soul-deep need to be complete and right no matter the cost? That’s… something like the gestalt I get from listening to trans communities.

      I wish the image you conjured in my mind with the thought of a penis migrating was as funny as reality. In reality migration can be quite messy and painful.

  2. Is there any way I could see these pictures? I have no way to travel to a surgeon as of yet, but the more results I see, the more decisions I make on which to get.

    • The single best place I know of that has the most pictures for trans men and other trans masculine folks is Transbucket. Have you checked there?

      Do you have access to the journal at all? Maybe through your local library? If not, send me an e-mail at askapremed@gmail.com and I’ll help you get access to the paper.

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