Phalloplasty is one of the most complex and important surgical procedures for transgender men and non-binary individuals undergoing gender-affirming surgery.
It involves constructing a human penis (neophallus) using tissue from other parts of the body, such as the forearm or thigh, and addressing both urinary and sexual functions.
Surgical Techniques in Phalloplasty
- Flap (Surgery) and Tissue Grafting: The creation of the neophallus typically uses a free flap technique, where a section of tissue, often from the forearm or thigh, is transferred to form the penis. The skin grafting process is integral to covering the graft, ensuring it has proper aesthetics and functionality. During the procedure, surgeons also attach blood vessels (such as veins and arteries) to provide circulation to the neophallus, while maintaining healthy blood flow.
- Urethral Reconstruction and Urinary Function: A crucial part of phalloplasty is constructing or extending the urethra, enabling the patient to urinate through the neophallus. Urethral reconstruction involves grafting tissue to create a functional urethra, but complications like urethral stricture or fistulas may occur. Imaging techniques like retrograde urethrograms and CT scans are often used to check the urethra’s condition post-surgery. To assist with healing and ensure proper urinary flow, a Foley catheter is commonly placed for a few weeks after surgery.
- Metoidioplasty and Vaginectomy: In some cases, patients may opt for metoidioplasty instead of phalloplasty. This procedure uses an enlarged clitoris (resulting from hormone therapy) to create a smaller neophallus. For those who undergo phalloplasty, a vaginectomy (removal of the vagina) may be performed to eliminate female genital structures. Some patients also undergo a hysterectomy to remove the uterus and ovaries.
- Scrotoplasty and Testicular Implants: Scrotoplasty is the procedure for constructing a scrotum. Surgeons often place testicular implants made of silicone to give the scrotum a natural look and feel. The scrotum, along with the neophallus, forms the sex organs of the patient after surgery.
- Erectile Function and Prosthesis: Some patients choose to have a penile prosthesis implanted to enable erection during sexual activity. These implants are typically made of silicone or other materials and inserted into the corpus cavernosum penis. While they allow for erections, complications such as erectile dysfunction, implant malfunction, or infection can occur, sometimes requiring revision surgery.
Postoperative Care and Healing
- Urinary Function and Catheter Use: After surgery, patients need careful monitoring to ensure the new urethra functions correctly. The use of a catheter is necessary until the urethra has healed enough for natural urination. Regular checks of urine output and possible complications like stenosis (narrowing of the urethra) are key to a successful recovery.
- Pain, Edema, and Hemodynamics: Post-surgical recovery involves managing pain, edema (swelling), and ensuring proper hemodynamic stability. These complications can arise from the healing of the neophallus, scrotum, and donor sites such as the forearm or thigh. Scar formation is also common, and patients may seek treatments for minimizing scarring.
- Sexual Function and Orgasm: Phalloplasty allows patients to experience sexual intercourse. Although semen production is not possible, many patients retain the ability to experience orgasm. Some patients may also choose to undergo hair removal around the groin area to enhance aesthetics.
- Body Shape and Donor Site Recovery: The appearance and recovery of the donor sites, such as the forearm or thigh, can affect the patient’s body shape. Scarring from tissue removal may be a concern, and additional surgeries or treatments might be necessary to address aesthetic issues.
- Nerve Regeneration and Sensation: Neuroregeneration in the newly constructed neophallus is important for restoring feeling. Nerve grafting is done to restore as much sensation as possible, but full recovery of sensitivity is not always guaranteed.
Potential Complications
- Infection and Healing Difficulties: Infection is one of the most significant risks in phalloplasty. Proper care of the surgical site, including the wrist and hand if a forearm flap is used, is crucial. Any sign of infection must be addressed immediately to prevent complications, such as fistulas or implant rejection.
- Scar Formation and Aesthetic Concerns: Scarring at the donor sites or on the neophallus can affect patients’ satisfaction with the surgery. Tattoos are sometimes used post-surgery to cover scars or enhance the aesthetics of the neophallus or donor sites.
- Pelvic and Abdominal Health: The pelvis and abdomen are involved in the surgery, particularly in cases where tissue is taken from the hypogastrium or surrounding areas. Ensuring proper healing in these regions is essential for the patient’s overall health and functionality.
- Transgender Health Care and Long-Term Management: Phalloplasty is a significant step in transgender health care and requires continuous follow-up with medical professionals, including urologists and plastic surgeons. Postoperative management may involve addressing erectile dysfunction, scar management, and ensuring the long-term function of the neophallus.
- Handedness and Physical Function: If tissue is taken from the forearm or hand, patients need to consider the impact on their handedness. Recovery can affect the function of the arm, especially if the dominant hand is used.
Emotional and Social Considerations
- Non-Binary Gender and Personal Identity: Phalloplasty is not only for transgender men but can also be an option for individuals who identify as non-binary gender. Each patient’s experience and needs are unique, and the surgery is tailored to help them align their body with their gender identity.
- Physical Sensations and Social Interaction: Patients may experience changes in physical sensations, particularly during urination or sexual activity. Learning to adapt to using public bathrooms post-surgery may also present a challenge for some patients due to social stigmas surrounding transgender individuals.
- Psychological Support: Throughout the surgical journey, from the operating theater to long-term recovery, patients must work with experienced physicians and receive mental health support. This helps them navigate the changes in their body and ensure that they are comfortable with their new sex organ and overall body shape.
