Phalloplasty is one of two options for genital surgery for trans men. While it’s more expensive and extensive than the metoidioplasty, the additional size is often appreciated by the men who opt for it.
Why would I want a phalloplasty?
Everyone has their own reasons. Here are some that I have heard:
- Ability to “pass” in male spaces, such as bathrooms and locker rooms. With genital surgery, the fear of having a towel around the waist slip at an awkward moment is gone.
- Relieving gender dysphoria. What’s not to like about that?
- Ability to pee standing up. Only with a urethral lengthening procedure, which carries its own risks.
- Having a large penis. It both clearly identifies you as male and allows for penetrative sex.
What is involved in phalloplasty? What are my options? And what different techniques are there?
Phalloplasty is one of the most complex genital surgeries, with a lot of different varieties. Phalloplasty is anywhere from 1 to 4 surgeries, and often includes these procedures:
- Creation of a phallus. There are two basic techniques: either a pedicled flap or a free flap. Pedicled flaps are from nearby areas and remain attached to the body at all times. Free flaps can be from other areas of the body (common areas are the forearm and back) and are fully detached and then reattached. Here’s an NSFW diagram comparing the two. We’ll talk more on these in a moment…
- Urethral lengthening. The inner labia, among other tissues, are used to lengthen the urethra so you can pee from the tip of the penis. Not all surgeons do this.
- Vaginectomy and scrotoplasty with implants. The vaginal tissue is removed and may be used in urethral lengthening. The labia are stitched together to make a scrotum, which can then have testicular implants.
- Hysterectomy and oophorectomy. Removal of the uterus, fallopian tubes, and ovaries.
- Penile implant. An implant to allow for erection is inserted. This is an additional surgery after the original surgeries have well healed, often 9 months or more.
- Glansoplasty. Refinement of the appearance of the head of the penis.
Different surgeons do these parts at different stages. Some surgeons don’t do certain techniques at all — I know of at least one surgeon who doesn’t do urethral lengthening in their phalloplasties.
Now, what about where the penis comes from? The tissue is typically “rolled up” to make a penis, no matter where it’s from. That’s an unflattering description, but it produces some fabulous results. As for the technique — they’re either a pedicle technique or a free flap technique. Pedicle techniques take tissue from the abdomen or inner thigh and rotate it into its final place. Pedicles have their original nerves and blood supply, so some say they have less erogenous sensation. Pedicles do have less visible scarring than free flap.
Free flap detaches tissue completely from its old location and attaches it using microsurgery to its new home as a penis. Sensation is often intact because of this microsurgery. The tissue is usually from the forearm, back, or inner thigh. Scarring can potentially be an issue.
Both techniques provide erogenous and non-erogenous sensation. Both can be used for penetrative sex and for urinating while standing. Both are considered aesthetically pleasing — it’s up to what you want and what your chosen surgeon recommends for you.
Can you tell me more about the surgery? Does it require full anesthesia? How long would I be in the hospital? What kind of recovery time am I looking at?
Phalloplasty is an intense surgery. All phalloplasties require full anesthesia. Pedicle generally requires less surgery time than free flap. I’ve seen hospital stays vary from 2-6 days, and initial recovery lasting 2-4 weeks. Return to work is often from 4-8 weeks depending on the surgery, your recovery, and how strenuous your work is.
For multiple stage phalloplasties, the first stage is often the longest and additional stages take less time and are less expensive.
What are the possible risks of phalloplasty?
The usual risks with surgery apply here: adverse drug reactions, bleeding, infection and the like. Permanent loss/reduction in sensation may occur, as with all surgeries. And pain can persist for a long time.
The penis itself can end up twisted (torqued), which is repairable by surgery. And rarely some or all of the tissue can become infected or even die.
Penile implants occasionally have complications. They can slowly erode through the penis or be associated with infection. These complications are rare with today’s techniques and implants.
Urethral lengthening caries its own risks, including urethral narrowing or blockage, and urethral fistula. Urethral fistula is when a hole forms between the urethra and somewhere it shouldn’t be — so urine may spray from the underside of the penis, for example. Narrowing, blockage, and fistula can be repaired surgically. The stream of urine may also spray or be not what you expect.
What about scars?
Pedicle techniques have less scarring than free flap. Free flap scars can be significant but aren’t always — it depends on how you heal.
How will phalloplasty affect my long-term health?
The phalloplasty itself doesn’t generally have long-term health implications unless there were complications. The same applies to the urethral lengthening.
Vaginectomy removes your risk for vaginal cancer. If you also had a hysterectomy/oophorectomy, you no longer are at risk for those cancers. However in order to maintain bone health it’s important to stay on sex hormones (testosterone) life-long.
Can I have penetrative sex with my partners after a phalloplasty?
If you have a penile implant, yes. A penile implant is required to achieve an erection.
Can I stand to urinate after a phalloplasty?
If you have a urethral lengthening procedure, yes.
What about the clitoris?
The clitoris can be buried at the base of the penis or tucked just underneath the penis. Either way, it can and does provide erogenous sensation.
Can I have a phalloplasty if I’ve already had a metoidioplasty?
I am not a surgeon, nor an expert on surgeries! Check out some of these other resources and surgeon websites for more information:
- Dr Crane
- Dr Leis
- Belgrade center
- This paper comparing techniques
- Hung Jury — a must-read book of essays by trans guys and their surgeries.