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FAQ: Phalloplasty

What is a phalloplasty?

A phalloplasty is a surgical procedure where a penis is created. A phalloplasty is a multi-staged procedure that may include a variety of different procedures, including creation of the penis, lengthening the urethra so you are able to stand to pee, creating the tip (glans) of the penis, creation of the scrotum, removal of the vagina, and placing erectile and testicular implants.  It is important to note that each staged surgical plan is unique to each patient and may or may not include some/all of the above procedures.

Are there different types of phalloplasty?

While the outcome is similar, there are three primary types of skin flaps the surgeon is able to use to create the penis. These options are a radial forearm free flap (arm), anterolateral thigh flap (leg), and musculocutaneous latissimus dorsi flap (side).  There are pros and cons to each approach.

What determines which donor site is used?

Factors that indicate which donor site is used include patient’s health and fat distribution, nerve functionality, blood flow, and patient goals and desired surgical outcomes.

What is a radial forearm free flap (RFFF)?

A radial forearm free flap (RFFF) involves taking the skin, fat, nerves, arteries, and veins from your wrist to about halfway up your forearm to create the penis. Typically, the surgeon will use your non-dominant hand so that you are better able to recover post-operatively with minimal effect on dominant hand function. During your surgical consultation an Allen’s test will be performed to test blood distribution in the arm and hand.

What is an anterolateral thigh flap (ALT)?

An anterolateral thigh flap (ALT) involves the skin, fat, nerves, arteries, and veins from your leg to create a penis. We will ask you to get a special 3D CT scan to look at the blood supply to each leg to determine which leg will be better for creating the penis.

What is a musculocutaneous latissimus dorsi flap (MLD)?

A musculocutaneous latissimus dorsi flap (MLD) involves the skin, fat, nerves, arteries, and veins from the side of your back to create a penis. The surgeon will ask you to get a special CT scan to look at the blood flow throughout the donor site area.

How is the surgery staged?

The surgery can be staged differently depending on where you decide to have the skin taken to create the penis.

RFFF - This approach requires creation of the penis at stage one, and a subsequent skin graft 3-5 weeks after the initial surgery.  The second stage, scheduled approximately 5-6 months later, may include lengthening of the urethra to allow for urination out of the tip of the penis, creation of the scrotum, and removal of the vagina, etc.  A third surgery, staged 12 months after the initial procedure includes testicular implants and an erectile prosthetic to help with rigidity.

ALT/MLD – This approach differs only in the first stage. During the first stage you will have the flap taken from the donor site and it will immediately be covered with a skin graft. The second and third stage are laid out the same way as RFFF.

Staging of Radial Forearm Free Flap (RFFF)

A diagram detailing stage one of forearm flap phalloplasty.
Stage 1: Phallus creation
A diagram detailing stage two of forearm flap phalloplasty.
Stage 2: Urethral lengthening and scrotoplasty
A diagram detailing stage three of forearm flap phalloplasty.
Stage 3: Penile prosthesis

Staging of Radial Forearm Free Flap (RFFF)

A diagram detailing stage one of forearm flap phalloplasty.
Stage 1: Phallus creation
A diagram detailing stage two of forearm flap phalloplasty.
Stage 2: Urethral lengthening and scrotoplasty
A diagram detailing stage three of forearm flap phalloplasty.
Stage 3: Penile prosthesis
 

Will I have a say in how the phalloplasty is staged and the surgical plan?

The staging and surgical plan are decided between you and the surgical team. The discussion and general plans are made during the initial appointment, and surgical plans are finalized in subsequent appointments with the team.

When should I have my hysterectomy?

If you are interested in this procedure, hysterectomies are typically done at stage 0, before any of the phalloplasty procedures.

Do I have to have a vaginectomy?

No, you do not have to have a vaginectomy. Each surgical plan is unique to each patient. The procedures that are done are carefully considered and discussed.

When do you perform the vaginectomy?

If a vaginectomy is performed, this is usually done at Stage 2.

What is urethral lengthening?

If you choose to have urethral lengthening, this procedure involves lengthening the native urethra so that you are able to pee out of the tip of the penis. It involves connecting the native urethra to the new urethra created in the shaft of the penis. Not all patients choose to have urethral lengthening; however, if you want to pee to stand, this is necessary. It is also important to know that if you decide not to have urethral lengthening in your stage I phalloplasty, you are not able to undergo lengthening later.

What are complications of urethral lengthening?

The most common complications for urethral lengthening include urethral strictures (narrowed areas of the urethra), fistula (creation of a passageway between the urethra and another location), and diverticulum (outpouching of the urethra).

Will I need to have a catheter after stage 1?

During your inpatient stay, you will have a catheter in your native urethra for at least 5 days. When you are getting ready to go home, the catheter will be removed in the hospital. You typically do not go home with a catheter after stage 1.

Will I need to have a catheter after stage 2?

If you decide to not have urethral lengthening, a Foley catheter will be placed in the operating room and removed prior to your hospital discharge.  If you decide to have urethral lengthening, you will go home with a Foley catheter in the new urethra that is clamped off, so it does not drain urine, in addition to a suprapubic tube.

What is a suprapubic tube?

A suprapubic tube (SPT) allows the urine from your bladder to be drained from a tube located in the lower part of your abdomen, below the belly button. Your SPT will remain in for 4-5 weeks, depending on healing and post-operative recovery.

When will my SPT be removed?

Prior to the SPT being removed, around 4 weeks after surgery, a urologist will perform a retrograde urethrogram (RUG), which involves putting dye up the new urethra into the bladder and taking an XRAY to look to see if the new urethra is open and ready to be peed out of. Once the RUG is performed, we will clamp off the SPT and you will be allowed to pee from your new urethra. If everything looks good after a few days, we will remove the SPT.

Can I get an erection with my penis?

In stage 3, our urologist can place an erectile prosthetic device, which will allow you to maintain an erection.

Is the penis functional?

Penis functionality is determined by the surgical plan. If it is important for you to pee out of the tip of your penis, then urethral lengthening is indicated. If sensation is most important, we will focus on a donor site with good nerve innervation. If penetrative sex is most important, and you would like to maintain an erection, then an erectile prosthetic is indicated for staging.

Will I need to have hair removal?

Yes, prior to surgery you will need to complete hair removal. We prefer you not start hair removal until after your consult with the surgical team, when a donor site can be chosen.  We will provide you with a template for hair removal at your initial appointment that you can give to your hair removal professional to assist them with your hair removal plan.

What if I have a tattoo on my preferred donor site?

We can still use the donor site, even if there is a tattoo, as long as there is good blood flow and nerve functionality.

What is nerve hook-up? Is this something you offer?

We do offer nerve hook up. Nerve hook up involves taking the existing nerves from the donor site, such as the arm, and connecting them to nerves located in the pelvis. This allows you to have sensation.

What kind of sensation and feeling can I expect following stage 1?

Sensation recovery varies by patient. Nerve regeneration can begin as early as 3 weeks post-operatively or may take longer in some patients. Sometimes sensation can take up to a year or longer. We cannot guarantee return of nerve sensation. It typically begins as a shooting/spark feeling as your nerves regenerate and build stronger connections. As time goes on, the tingling feeling begins to subside.

How does the donor site affect sensation after surgery?

Different donor sites have different nerve qualities. The arm donor site has the greatest number of nerves available for nerve hook-up and is best if your main goal is sensation. The leg donor site has greater variability, but tends to have less available nerves. The nerve associated with the MLD flap is a motor nerve, meaning there will likely be no sensation on the phallus.

What is clitoral burying?

Clitoral burying involves transposition of the clitoris into the base of the penis, to increase sensation. This is typically done at stage 2.

Is orgasm possible after phalloplasty?

Orgasm is possible after phalloplasty, especially if your main goal is preserving sensation. It is important to note that your penis will not ejaculate with semen at the time of orgasm.

How is penis size and placement determined?

Penis size is dependent on your body. Thinner patients with less fat on their arms or legs will have a penis with less girth. Alternatively, patients with a greater amount of fat will have a thicker penis.

The length of your penis depends on your donor site, but typically is about 5-6 inches. After the first stage, the penis may decrease in size as post-operative swelling decreases and the tissue settles into its new location.

What determines scrotum size and placement?

Scrotum size is specific to the patient and dependent on the amount of skin that is present in the genital area prior to phalloplasty. The greater amount of genital tissue, the larger the scrotum size and subsequent size of the testicular implant.

What scrotoplasty technique is used?

The VY scrotoplasty technique is practiced here.

What kind of testicular implants do you use?

Right now, we use the ART round carving blocks that have been approved by the FDA. Unfortunately, while there are lots of options, very few are approved by the FDA, and as such we are limited in what we are able to offer patients.

Do I need to purchase my own medical supplies?

No, you do not need to purchase your own medical supplies. All the items that you need will be provided to you by the hospital, and we work with your insurance company to ship you additional supplies and set up home health care.

How long will I need to stay in town after surgery?

For Stage 1 of phalloplasty, we ask you to stay local for 6-8 weeks following surgery. After Stage 2, you will need to stay local for 5-6 weeks, at a minimum. Stage 3 only requires 7-10 days. Staying local requires being able to feasibly come to clinic or the hospital should a complication arise – typically staying within 90 minutes of our facilities. Our social worker can help you with resources, and will work with you to make sure you have everything you need for a great post-operative experience.

Download the phalloplasty FAQs as a PDF.

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