Feb 222016

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.

Suggestive flower is suggestive

Suggestive flower is suggestive

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?


More information?

I am not a surgeon, nor an expert on surgeries! Check out some of these other resources and surgeon websites for more information:

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.

Apr 182013

CC BY-NC-ND 2.0 - flickr user seizethedaveThe first study of long-term effects of radial forearm flap phalloplasty was published just this month. The aesthetics, functionality, and health status of the donor site on the forearm was examined. This study was reported by researchers at the Center for Sexology and Gender Problems at Ghent University Hospital in Belgium.

Does “radial forearm flap phalloplasty” sound like gibberish? Let’s break it down. Phalloplasty is one of the genital procedures available for trans men (the other is metoidioplastywhich we’ve previously covered). In a phalloplasty, tissue from elsewhere on the body is used to make a penis. “Radial forearm” refers to the part of the body used: a section of forearm, including blood vessels and nerves. “Flap” means the tissue from the forearm is removed completely from the body then put on in another location. “Flap” is in contrast to “pedicle”, where the tissue remains connected in one spot. So a radial forearm flap phalloplasty, essentially, is where tissue from the forearm is used to make a penis. At the same time, hysterectomy and bilateral oophorectomy are done.

As with any surgery involving a graft, both the donor and receiver tissues are damaged. This procedure leaves a scar on the forearm where The researchers report that scarring, reduced bone density, limited range of motion, decreased finger/hand strength, loss of graft, delayed healing, and sensory changes have all been reported. But how common are they? Enter the current research.

Who participated in this research? 44 trans men who had had the procedure. They were an average of 9 years post-surgery, with a range from 9 months to 22 years. Six had a metoidioplasty before their phalloplasty. The median age at surgery was 28. All participants were on hormone therapy, and had been for an average of 10 years; most on a mix of testosterone esters delivered intramuscularly (which is fairly standard practice). The trans male participants were compared to a control group of cis women. There was no weight difference (BMI) between the two groups, but there were more tobacco smokers in the experimental (trans men) group than in the control group (cis women). The control group was not on any metabolic or hormonal altering treatment. In addition to general questions (e.g., tobacco use, medications, medical conditions), the forearm scars of participants were assessed. Questions relating to scar pain, stiffness, and sensation were included. Bone density and body mass were also measured.

The results are very clear. The researchers found no differences in physical activity, lean mass (muscle and bone) of the forearm, or bone health between trans men and cis women. No bone breaks in the donor forearm were reported. In other words, there were no functional problems with the donor forearm. Most (70%) scars had enough blood flow. No itching or pain was reported. The age of the trans man at the time of surgery did not appear to be associated with any negative outcomes.

Best of all, most trans men were satisfied with the way their forearm scar looked. Here’s the breakdown:

  • 26% satisfied
  • 21% very satisfied
  • 30% neutral
  • 19% unsatisfied
  • 5% very unsatisfied

None of the trans men reported regretting their surgery because of their forearm scars. The threat of damage to the forearm itself from this procedure appears to be less than previously thought, though as always it’s not risk-free.

I have to object, however, to using only cis women as controls for a group of trans men. Trans men are not women. The trans men in this study had been post-op for as much as 22 years, meaning no ovaries, so very low levels of “female” sex hormones. Combined with testosterone therapy, their hormone levels much more closely resemble that of males than females. It just doesn’t make any scientific sense. Worse, it carries the subtext that trans men are women, not men. Brain evidence and anecdotal evidence from trans people themselves indicate otherwise, and that such attitudes are extremely harmful.

This research was published in the Journal of Sexual Medicine.

Jul 052011

A new study looking at transsexual health just came out. This one looked at the well-being and sexual health of transmen after sex reassignment surgery ( SRS – phalloplasty in this case). Unfortunately, I don’t have access to the full article so I can’t go into too much detail.

The study was conducted in the Netherlands, with 49 transmen. Most of the men had had phalloplasty on average eight years before the study and reported an increase in sexual activity after transition/surgery. They report that they can have orgasms, and that the quality of their orgasms has changed as a result of transition. Despite high rates of surgical complications, most were happy with the results of their sexual reassignment surgeries. They were also generally happy people.

These things may seem like, “Well… duh.” But this is the first study I’ve seen that confirms that “common sense” idea. I’m glad to see it. What do you think?