What Are the Types of Phalloplasty?

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A phalloplasty is the surgical construction of a penis, or phallus. Phalloplasty can be a component of surgical transitioning for some transgender men. (Other transgender men may choose to have a metoidioplasty or have no interest in genital surgery.) Phalloplasty may also be performed for cisgender men who were born without a penis or who lost their penis through accident or disease. It is usually performed by a plastic surgeon and/or a urologist.

Phalloplasty Basics

Fundamentally, the creation of a penis involves the creation of a tube within a tube. The inside tube is the urethra, the structure through which men urinate. The outside tube is the penile shaft. This structure, known as the neophallus (neo- for new), is surgically attached to the pelvis. The urethra of the neophallus is connected to the existing urethra. The blood vessels and nerves are attached to those of the pelvis. Then the exterior of the neophallus is sculpted to resemble a penis shaft and head.

Flap Types

The sections of skin and other tissue used for plastic surgery procedures such as phalloplasty are known as flaps. There are several flap types that can be used for phalloplasty. In the United States, the most common flap type used is the radial forearm flap, or RFF. This involves harvesting a large rectangle of skin from one of the patient's forearms.

The main advantages of this flap are that it's relatively large, easy to harvest, and sensitive to touch.

The main disadvantages are that the color may be quite different from the genital skin and that the procedure leaves a very noticeable forearm scar. The scar is so distinct, that for people familiar with RFF phalloplasty, seeing it is an indication that the person with the scar has undergone this surgery.

This can be problematic for some men, who do not want to advertise having undergone a phalloplasty.

Another significant disadvantage is that the forearm must be covered with a skin graft from one of the thighs. This leaves scars in two places that may be quite visible, depending on how a man is dressed. Finally, the RFF flap requires the surgeon to be skilled in microsurgery, since the flap is fully removed from the arm and needs to be reconnected to the nerves and blood supply near the groin.

Other flaps that are sometimes used for phalloplasty are harvested from the following areas:

  • Lattisimus dorsi
  • Super pubic region
  • Thigh

Pedicled thigh flaps are the other flap frequently used for phalloplasty in the United States. Unlike radial arm flaps, these flaps stay connected to their original blood supply. This means that they do not require microsurgery expertise on the part of the surgeon performing the phalloplasty. However, these flaps are somewhat harder to work with. The thicker layer of fat makes it harder to roll them into a tube to shape the penis. Pedicled thigh flaps are also associated with higher complication rates than radial forearm flaps. There is less comparison data for the outcomes of other flap types used in phalloplasty.

Penile Prostheses

Not all men who want a phalloplasty are interested in having erectile function suitable for penetrative sex. Some are primarily concerned with being able to stand to urinate or be naked in common spaces such as locker rooms. However, men who do want to be able to have intercourse with a partner will require the insertion of a penile prosthesis. A penile prosthesis is also known as a penile implant.

Most surgeons implant penile prostheses after the initial phalloplasty has had time to heal, but some will do a single stage procedure. There are benefits and disadvantages to both options.

Similarly, there are benefits and advantages to the different types of penile prostheses. Inflatable penile prostheses use fluid pumped from a reservoir to stiffen the penis. There are also semi-rigid or bendable implants. These maintain rigidity at all times but can be bent or straightened at need. Inflatable prostheses are used somewhat more often, as they do not require a man to get used to having a hard penis at all times. However, the surgery to implant them is somewhat more difficult than that for a semi-rigid implant.

Common Complications of Phalloplasty

Urethral problems are the most common complication of phalloplasty. Patients may develop a urethral fistula, where the tube carrying urine becomes open to the skin and causes urine to leak. This usually happens where the new urethra is joined to the old. However, it can happen anywhere along the neophallus.

Another potential urinary complication of phalloplasty is a urethral stricture. This is where the passageway becomes too narrow to carry urine. Other, much less common, complications of phalloplasty include partial or total flap loss and issues with the skin graft. Patients who receive penile prostheses may also have problems with those devices. In fact, this type of problem is relatively common, both immediately after implantation and several years out. Issues with a penile prosthesis can require removal or replacement of the implant.

Phalloplasty Differences for Transgender Men

In general, phalloplasty procedures are relatively similar for cisgender and transgender men. However, there are a few significant differences. The first difference involves preserving sexual sensation. For transgender men, the nerves of the phallus are either connected to those of the clitoris or the clitoris is embedded at the base of the penis. Either way, the goal is to preserve sexual sensation and orgasmic function in the genitals, by allowing penile stimulation to stimulate the clitoral nerves.

Another big difference is the lengthening of the urethra. For cisgender men, the urethra is correctly located for connection into the body of the penis. However, for transgender men, an extension has to be created to link the existing urethra into the base of the penis. This can add some difficulty to the surgery. This extension is also another place where there can be complications to healing.

Finally, for transgender men, the surgeon must surgically create a scrotum. This is usually done using the skin of the outer labia for transgender men. It is then possible to insert testicular prostheses, if the patient wants them. Depending on the preference of the surgeon, this can either be done at the time of surgery or, more often, after the initial surgery has had time to heal.

Single vs. Multi Stage Surgeries

A single stage phalloplasty involves the simultaneous construction of the phallus and urethra, as well as connection of the urethra. Where relevant, it also involves the creation of a scrotum and insertion of testicular prostheses. All of this is done as a single procedure, although any penile prostheses are generally put in at a later date.

A multi-stage phalloplasty breaks the surgery down into parts. This is more common, as it allows for more detailed management of each part of the surgery. However, some surgical teams do perform single stage procedures. This can be more convenient for patients who have to travel a significant distance for surgery. It is unclear whether there is an increased risk of complications for single-stage procedures. That said, many individuals who undergo a phalloplasty will need one or more revision surgeries, regardless of whether the procedure was initially intended to be single- or multi- stage.

Sources:

Ascha M, Massie JP, Morrison SD, Crane CN, Chen ML. Outcomes of Single Stage Phalloplasty by Pedicled Anterolateral Thigh Flap versus Radial Forearm Free Flap in Gender Confirming Surgery. J Urol. 2017 Jul 29. pii: S0022-5347(17)77248-5. doi: 10.1016/j.juro.2017.07.084.

Djordjevic ML, Stanojevic D, Bizic M, Kojovic V, Majstorovic M, Vujovic S, Milosevic A, Korac G, Perovic SV. Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience. J Sex Med. 2009 May;6(5):1306-13. doi: 10.1111/j.1743-6109.2008.01065.x

Frey JD, Poudrier G, Chiodo MV, Hazen A. A Systematic Review of Metoidioplasty and Radial Forearm Flap Phalloplasty in Female-to-male Transgender Genital Reconstruction: Is the "Ideal" Neophallus an Achievable Goal? Plast Reconstr Surg Glob Open. 2016 Dec 23;4(12):e1131. doi: 10.1097/GOX.0000000000001131.

Neuville P, Morel-Journel N, Maucourt-Boulch D, Ruffion A, Paparel P, Terrier  JE. Surgical Outcomes of Erectile Implants After Phalloplasty: Retrospective Analysis of 95 Procedures. J Sex Med. 2016 Nov;13(11):1758-1764. doi: 10.1016/j.jsxm.2016.09.013.

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