Phalloplasty: What You Need to Know

Pros

• Some phalloplasty techniques preserve sensation.
• It allows transgender men to have an erection and experience penetrative sex—unlike a metoidioplasty, a simpler surgery in which the clitoris, which has been enlarged with hormones, is extended to create a smaller neopenis.
• Research shows that a phalloplasty greatly improves the sense of well-being and sexual satisfaction of transgender men.
• While it can be expensive, certain states mandate that medical insurers cover at least part of the cost.

Cons

• You’ll need to take hormone therapy for a year before the surgery.
• Your body could reject the donor tissue and skin, resulting in a failed graft and a second surgery.
• Risks include infection, severe scarring, or lack of mobility at the donor site.
• Maintaining a full erection requires an implant or inflatable device.
• Permanent hair removal, usually with either laser hair removal or electrolysis, needs to be done on the donor site.
• There’s a high risk of complications, particularly if you choose reconstruction of the urethra to allow you to pee standing up.

Phalloplasty surgery comes with many risks, primarily involving the urethra, but full long-term care after surgery has been linked with good outcomes. The risk of complications varies by technique, so it’s best to discuss the procedure with an experienced plastic surgeon.

Most surgeons adhere to the World Professional Association for Transgender Health standards of care. Not only does the WPATH require referral letters from two mental health providers, but it also states that you must:

• Have persistent gender dysphoria that has been documented by a mental health professional
• Undergo hormone therapy for at least 12 months beforehand
• Live as the gender congruent with your gender identity for 12 continuous months before surgery
• Be more than 18 years of age
• Properly manage any significant medical or mental health concerns

Your surgeon will ask you to answer a few questions, such as when you first knew you were a transgender or nonbinary individual, when you started taking hormones, how long you have been living in the male gender role, and who your mental health and primary care providers are. 

In addition to the risks, costs, and potential complications, your surgeon should also discuss any viable alternatives, the social and legal implications of phalloplasty, the impact on sexual function and fertility, and the irreversibility of the procedure.

Once your surgery has been scheduled, you’ll have to do a number of things to prepare for surgery. Depending on your donor site, you may need hair removal. 

You’ll also need a hysterectomy, to remove the uterus, and oophorectomy, to remove the ovaries, eight weeks before your scheduled surgery—though some surgeons may do this during your phalloplasty.

Your surgeon will request that you stop your hormone therapy about two weeks before your procedure. 

You might also need to do bowel prep beforehand and limit your intake of certain foods and medications.

The procedure can take up to eight hours, depending on which technique you and your provider have chosen and whether you’re having any additional procedures at the same time. You’ll be under general anesthesia (fully asleep) throughout the procedure. 

Radial forearm free-flap phalloplasty takes donor tissue from one forearm. The blood vessels and nerves stay intact, and they’re reattached via microsurgery techniques, which allow them to function within the new penis. 

The existing urethra can be extended, and an erectile rod or inflatable penile pump can allow for a full erection. The drawback of this technique is the extensive scar on the forearm.

Anterior lateral thigh flap phalloplasty takes donor skin and tissue from the upper thigh. The urethra can be extended, and there’s enough room for a silicone penile implant to be inserted. 

Though the thigh flap remains attached to the thigh as it’s rotated into place, patients report less physical sensation and erotic sensitivity with this donor site. 

It’s also worth noting that research shows a greater risk of complications with this donor site, compared to the forearm.

Abdominal flap phalloplasty takes skin from the abdomen. The graft remains attached to the abdomen at the base, but it’s shaped into a tube and rotated so it hangs from the pubic area. 

This type of phalloplasty preserves the arteries, veins, and nerves in the graft, which gives the new penis a strong blood supply and the ability to sense touch and temperature. It leaves a horizontal scar across the pelvis, but that can be easily concealed. 

An abdominal flap phalloplasty doesn’t typically allow for a restructured urethra, but that also means it has a lower risk of complications than thigh or forearm flaps.

A musculocutaneous latissimus dorsi flap phalloplasty takes tissue from the upper back, close to the arm. Doctors can use a larger flap to create a bigger neopenis, and the donor site usually heals well, with scars that are easy to hide. It also allows for an extended urethra.

However, while this flap contains nerves and blood vessels, it doesn’t offer the same level of erotic sensitivity as forearm or abdominal flaps.

It’s possible for a surgeon to do these procedures at the same time as a phalloplasty:

• A vaginectomy or vaginal mucosal ablation, to fully or partially remove the vagina
• A scrotectomy, which can turn the labia majora into a scrotum, often with testicular implants 
• A urethroplasty, which extends the urethra within the new penis
• A glansplasty, which creates the look of an uncircumcised tip, with a penile implant and allowing for erection

You’ll have to remain in the hospital for three to six days after your procedure so you’ll be fully cared for and monitored as you heal. 

For the week and a half after you return home, expect close supervision from your medical team to watch for any complications. If you had your urethra extended, you may need to wear a catheter for up to three weeks while you heal.

Good post-op care is critical following phalloplasty surgery. You’ll have to wear supportive underwear, keep the neopenis dry and elevated, and watch for any changes in color (such as the skin’s turning red or purple). 

If you chose to get a donor graft from your forearm, you may need physical therapy to restore full function to your hand in the weeks following surgery.

The risks of a phalloplasty can affect both the new penis and the donor site. 

Possible complications in the neopenis are urethral fistulas (an abnormal connection); urethral stricture (in which the urethra narrows so much that it obstructs urinary flow); rejection and death of the transferred tissue; incision ruptures; pelvic bleeding or pain; injury to the bladder or rectum; and a lack of sensation due to nerve damage.

The donor site is also at risk for pain, a decrease in sensation, incision openings, and scarring or discoloration.

You’ll see results immediately, and they will be permanent (barring a major complication).