Phalloplasty is the first and largest step of penis/phallus reconstruction. It is often performed with or without:

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• Urethral lengthening (UL)

• Vaginectomy

• Scrotoplasty/perineal reconstruction

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The most common surgery is phalloplasty with urethral lengthening, vaginectomy, scrotoplasty, perineal reconstruction, and associated procedures (skin graft harvest, suprapubic tube insertion, and others). However, some patients do not need or want UL, and some do not need or want vaginectomy. Others may not want a pouchlike scrotum. We recognize that surgical goals vary from patient to patient and that there are resultant combinations that better meet a patient's individualized surgical goals. Consultations with the surgeon are required to discuss the advantages and disadvantages of each unique combination. 

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Further reconstruction of the penis is sometimes required due to variations in anatomy and healing. Examples include:​

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• Monsplasty (for prominent prepubic skin leading to perineal or inferior positioning of the phallus/scrotum)

• Scrotoplasty or neoscrotal revisions

• Glansplasty (for glans atrophy/flattening or penises that do not have a glans)

• Penis liposuction/plication (for penises with too much girth)

• Penis reposition (for asymmetric scarring or off-midline healing) 

• Penile length reduction (for penises that are too long)

• Penile Implants

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The two most common donor sites used for phalloplasty are the radial forearm (RF) and the anterolateral thigh (ALT) flaps. These donor sites have a reliable blood supply and offer a higher chance of tactile and erotic sensation over time. RF flaps used for phalloplasty have the highest chance of achieving phallus sensation. Abdomen and musculocutaneous latissimus dorsi (MLD) flaps generally don't have sensation and require multiple stages for urethral lengthening. 

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"Staged" Phalloplasty: 

• For phalloplasty, there are two main options: single stage vs staged phalloplasty.

• Staging is a confusing term because it has different definitions for different patients and surgeons. 

• "Single stage" phalloplasty involves the creation of a neophallus, UL, vaginectomy, scrotoplasty, and perineal reconstruction in one surgery.

  • Benefit: one major recovery, aesthetic male genitalia and UL for standing micturition​

  • Disadvantage: potential for more complications 

• Staged phalloplasty is the general separation of the urologic surgical components of the operation from the microsurgery/donor site components. Therefore, stage 1 of staged phalloplasty may be similar to a metoidioplasty.  Alternatively, phalloplasty may be performed first followed by the metoidioplasty related procedures (vaginectomy, UL, scrotoplasty, and perineal reconstruction).

  • Benefit: less intense surgery with potential for fewer complications

  • Disadvantage: two major recoveries

• Staging details should be reviewed with your surgeon during a consultation.

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PREOP REQUIREMENTS for phalloplasty include:

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• Three letters (2 from mental health professionals, 1 from a hormone provider or primary care doctor).
• Overall good health.
• No smoking, nicotine use, or inhalational products (including vaping, marijuana, and 2nd hand smoke) around 3 months before and after surgery (ideally 6 months before and after surgery). This includes chewing tobacco and nicotine free inhalational products. Use of these products can cause about a 5-fold increase in complications. Use within this 3-6 month window before surgery may prompt rescheduling of the surgery to a later time.
• Perioperative assistance (friends, family, or hired clinical help).
• No hanging mons/pannus​ (lower abdomen adipose and skin).
• Hysterectomy is done separately and should be completed about 3 months prior to phalloplasty for patients wanting vaginectomy. 

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PROCEDURE OVERVIEW:

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General information:

• Team members: microsurgeons, reconstructive urologist, associated surgical and perioperative care staff

• Duration of surgery: 6-8 hours

• Hospital stay: 5 days on average​

• In town stay: 5-6 weeks on average

  • ALT phalloplasties should consider 6 weeks ​

Reconstructive urology portion:

• Cystoscopy, SP tube insertion: camera that looks into bladder with placement of a catheter through the lower abdomen skin.

• Vaginectomy: removal/fulguration of the mucosa with closure of the canal and suture ligation of Bartholin glands.

• Urethral lengthening: minora tissue is used to extend the urethra from where it is  currently to the head of the native penis. Skene glands are preserved.

• Transposition of native penis: the penis with urethra at the tip and all its associated nerve and blood supply is moved to a more superior location.

• Burial: the outer skin is excised to allow dorsal nerve dissection and burial of the native penis.

• Scrotoplasty: the majora tissue is dissected free and folded into a pouch that lies more anteriorly.

• Perineal reconstruction: the perineum is the area between the anus and the back of the scrotum. This is reconstructed with inner thigh tissue.

• The minora urethra is then connected to the thigh or arm flap urethra to establish continuity.

Microsurgeon portion:

• Creation of the phallus and urethra within the phallus.

• Connect the skin nerve of the phallus flap to the native penis dorsal nerve.

• Connect the blood vessels to vessels in the groin with microsurgical techniques.

• Skin graft from thigh covers the contralateral thigh or arm donor site. 

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The above is a generalized description of the procedures, and steps vary depending on patient anatomy, medical/surgical history, and surgical goals.

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