Phalloplasty
Encyclopedia
Phalloplasty refers to the construction (or reconstruction) of a penis
or, sometimes, artificial modification of the penis by surgery
, often for cosmetic purposes. It is also occasionally used to refer to penis enlargement
.
The first phalloplasty done for the purposes of sexual reassignment was performed on trans man
Michael Dillon
in 1946 by Dr. Harold Gillies
, which is documented in Pagan Kennedy
's book The First Man-Made Man.
. A penis of up to 7 inches (14–18cm) long with a circumference up to 5.9 inches (11–15cm) can be created with each of the methods.
Surgery on cisgender men is more simple than on trans men, because the urethra requires less lengthening. The urethra of a trans man ends near the vaginal opening and has to be lengthened considerably. The lengthening of the urethra is when most complications occur.
With all types of phalloplasty in trans men, scrotoplasty
can be performed using the labia majora (vulva
) to form a scrotum
where prosthetic testicles can be inserted. If vaginectomy
, hysterectomy
and/or oophorectomy
have not been performed, they can be done at the same time.
Unlike metoidioplasty
, phalloplasty requires an implanted erectile prosthesis to achieve an erection (and enable sexual penetration). This is usually done in a separate surgery to allow time for healing. There are several types of erectile prostheses, including malleable rod-like medical devices that allow the neo-penis to either stand up or hang down. Penile implants require a neophallus of appropriate length and volume in order to be a safe option. The long term success rates of implants in constructed penii are less than the success rates of reconstruction in cisgender men. Good sensation in the reconstructed penis can help reduce the risk of the implant eventually eroding through the skin.
Earlier techniques used a bone graft as part of reconstruction. Long-term follow-up studies from Germany and Turkey of more than 10 years proved that these reconstructions maintain their stiffness without late complications. Unfortunately, it results in a penis that has no ability to become flaccid again without breaking the internal bone graft.
Lengthening can also achieved by a procedure that releases the suspensory ligament where it's attached to the pubic bone, thereby allowing the penis to be advanced toward the outside of the body. The procedure is performed through a discreet horizontal incision located in the pubic region where the pubic hair will help conceal the incision site. No incision is made on the penis itself.
As of November 2009, there is research in progress to synthesize corpus cavernosa (erectile tissue) in the lab on rabbits for eventual use in patients requiring penile construction surgery. Of the rabbits used in the preliminary studies, 8 had biological responses to sexual stimuli that was similar to the tissue of a male rabbit that was not part of the study.
Sometimes a full-scale metoidioplasty is done a few months before the actual phalloplasty to reduce the possibility of complications after phalloplasty. Sensation is retained through the clitoral tissue
at the base of the neophallus, and surgeons will often attempt to graft nerves together from the clitoris or nearby. Nerves from the graft and the tissue it has been attached to may eventually connect. This does not necessarily guarantee the ability to achieve genital orgasm after healing, as the most important task of nerve reconnection is to ensure the penis is able to sense injury.
The following explanation of this technique has many similarities to other approaches, but the construction of the glans differs.
If the patient chooses to have the urethra extended to the glans of the neophallus, it is formed by the following steps:
Post-op depression which required temporary use of anti-depressants were noted by 27% of those who replied, with one suicide attempt not related to the surgery outcome. After surgery, 40% were able to apply for employment positions that they were unable to fill when they were legally female. 93% of patients stated that after phalloplasty, they were happy with their genitals.
This is a three part surgery that takes place over a period of six to nine months. The steps consist of:
Neophallus creation using MLD free flap
During initial recovery, the neophallus is protected from contact with other tissues with a specially constructed dressing as to avoid blood supply complications.
After three months, urethroplasty (urethral extension) is performed.
After another three to six months, a device that allows an erection can be inserted.
A study of post-op men showed that on average, 25% had one or more serious complications of the neopenis. The ones reported consisted of:
In the same study, chances of complications of the extended urethra were higher, averaging 55%. The most common complications reported were:
Penis
The penis is a biological feature of male animals including both vertebrates and invertebrates...
or, sometimes, artificial modification of the penis by surgery
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
, often for cosmetic purposes. It is also occasionally used to refer to penis enlargement
Penis enlargement
Penis enlargement procedures are techniques alleged to make the human penis increase in girth, length, or hardness. Often, in the course of advertising fraudulent products, the distinction between temporary enlargement, i.e...
.
The first phalloplasty done for the purposes of sexual reassignment was performed on trans man
Trans man
A trans man, transman, trans guy, or FTM is a transgender or transsexual man: a person who was assigned female at birth, but who identifies as male....
Michael Dillon
Michael Dillon
Laurence Michael Dillon was a British physician and the first female-to-male transsexual to undergo phalloplasty. His brother, Sir Robert Dillon, was the eighth Baronet of Lismullen in Ireland....
in 1946 by Dr. Harold Gillies
Harold Gillies
Sir Harold Delf Gillies was a New Zealand-born, and later London based, otolaryngologist who is widely considered as the father of plastic surgery.-Personal life:Gillies was born in Dunedin, New Zealand...
, which is documented in Pagan Kennedy
Pagan Kennedy
Pagan Kennedy is an author and pioneer of the 1990s zine movement, along with writer/publishers like Lisa Crystal Carver of Rollerderby, Jim Goad of ANSWER Me! and Larry Crane of Tape Op. Her autobiographical zine Pagan's Head detailed her life...
's book The First Man-Made Man.
Indications
A complete construction or reconstruction of a penis is done on:- Patients with congenital anomalies such as micropenis, epispadias, and hypospadias,
- Patients who have lost their penis,
- Female-to-Male transsexualTrans manA trans man, transman, trans guy, or FTM is a transgender or transsexual man: a person who was assigned female at birth, but who identifies as male....
patients.
Techniques and related procedures
There are four different techniques for phalloplasty. All of the techniques involve taking a graft of tissue from a donor site and extending the urethraUrethra
In anatomy, the urethra is a tube that connects the urinary bladder to the genitals for the removal of fluids out of the body. In males, the urethra travels through the penis, and carries semen as well as urine...
. A penis of up to 7 inches (14–18cm) long with a circumference up to 5.9 inches (11–15cm) can be created with each of the methods.
Surgery on cisgender men is more simple than on trans men, because the urethra requires less lengthening. The urethra of a trans man ends near the vaginal opening and has to be lengthened considerably. The lengthening of the urethra is when most complications occur.
With all types of phalloplasty in trans men, scrotoplasty
Scrotoplasty
Scrotoplasty, also known as oscheoplasty, is reparative or plastic surgery of the scrotum.As part of the surgical options for trans men, scrotoplasty is one of several operations performed to transform/reform the external genitalia into a penis and a scrotum.In this procedure, the labia majora are...
can be performed using the labia majora (vulva
Vulva
The vulva consists of the external genital organs of the female mammal. This article deals with the vulva of the human being, although the structures are similar for other mammals....
) to form a scrotum
Scrotum
In some male mammals the scrotum is a dual-chambered protuberance of skin and muscle containing the testicles and divided by a septum. It is an extension of the perineum, and is located between the penis and anus. In humans and some other mammals, the base of the scrotum becomes covered with curly...
where prosthetic testicles can be inserted. If vaginectomy
Vaginectomy
Vaginectomy is a medical procedure to remove all or part of the vagina. It is usually used as a treatment for vaginal cancer. Vaginectomy is also used as part of some types of female-to-male sex reassignment surgery.-Cancer:...
, hysterectomy
Hysterectomy
A hysterectomy is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total or partial...
and/or oophorectomy
Oophorectomy
Oophorectomy is the surgical removal of an ovary or ovaries. The surgery is also called ovariectomy, but this term has been traditionally used in basic science research describing the surgical removal of ovaries in laboratory animals...
have not been performed, they can be done at the same time.
Unlike metoidioplasty
Metoidioplasty
Metoidioplasty, sometimes referred to as a meto or meta or spelled "metaoidioplasty", is an alternative to phalloplasty for trans men...
, phalloplasty requires an implanted erectile prosthesis to achieve an erection (and enable sexual penetration). This is usually done in a separate surgery to allow time for healing. There are several types of erectile prostheses, including malleable rod-like medical devices that allow the neo-penis to either stand up or hang down. Penile implants require a neophallus of appropriate length and volume in order to be a safe option. The long term success rates of implants in constructed penii are less than the success rates of reconstruction in cisgender men. Good sensation in the reconstructed penis can help reduce the risk of the implant eventually eroding through the skin.
Earlier techniques used a bone graft as part of reconstruction. Long-term follow-up studies from Germany and Turkey of more than 10 years proved that these reconstructions maintain their stiffness without late complications. Unfortunately, it results in a penis that has no ability to become flaccid again without breaking the internal bone graft.
Lengthening can also achieved by a procedure that releases the suspensory ligament where it's attached to the pubic bone, thereby allowing the penis to be advanced toward the outside of the body. The procedure is performed through a discreet horizontal incision located in the pubic region where the pubic hair will help conceal the incision site. No incision is made on the penis itself.
As of November 2009, there is research in progress to synthesize corpus cavernosa (erectile tissue) in the lab on rabbits for eventual use in patients requiring penile construction surgery. Of the rabbits used in the preliminary studies, 8 had biological responses to sexual stimuli that was similar to the tissue of a male rabbit that was not part of the study.
Graft from the arm
An operation using the forearm as a donor site is the easiest to perform, but results in a cosmetically undesirable scar on the exposed area of the arm. Arm function may be hampered if the donor site does not heal properly. Electrolysis and/or laser hair reduction is required for a relatively hairless neophallus.Sometimes a full-scale metoidioplasty is done a few months before the actual phalloplasty to reduce the possibility of complications after phalloplasty. Sensation is retained through the clitoral tissue
Clitoris
The clitoris is a sexual organ that is present only in female mammals. In humans, the visible button-like portion is located near the anterior junction of the labia minora, above the opening of the urethra and vagina. Unlike the penis, which is homologous to the clitoris, the clitoris does not...
at the base of the neophallus, and surgeons will often attempt to graft nerves together from the clitoris or nearby. Nerves from the graft and the tissue it has been attached to may eventually connect. This does not necessarily guarantee the ability to achieve genital orgasm after healing, as the most important task of nerve reconnection is to ensure the penis is able to sense injury.
The following explanation of this technique has many similarities to other approaches, but the construction of the glans differs.
- The surgery starts (after the patient is prepped) with the forearm marked for graft size. After the graft is taken, another graft may be used to reconstruct the arm (resulting in a secondary scar).
- The graft skin is dissected to expose the veins and antebrachial cutaneous nerves. (the latter done carefully for later reattachment)
- If the urethra is being constructed at the same time as the phallus, it is joined at this step. If not, the glans is shaped. Sometimes glansplasty is done in a separate surgical stage after urethral extension.
- A segment of vein going to the patient's groin is "borrowed" to allow easier joining of the graft with the preexisting tissues.
- The vein is carefully attached to the femoral artery.
- The blood supplies from the flap and the vein leading to the femoral arteryFemoral arteryThe femoral artery is a general term comprising a few large arteries in the thigh. They begin at the inguinal ligament and end just above the knee at adductor canal or Hunter's canal traversing the extent of the femur bone....
are joined. - The clitoral hood and ligament is cut away, and the nerve bundle is isolated for the time being. Important: while this assumes the clitoral tissue is assimilated (buried) into the penis base, some surgeons give the option of leaving it as-is in a post metoidioplastyMetoidioplastyMetoidioplasty, sometimes referred to as a meto or meta or spelled "metaoidioplasty", is an alternative to phalloplasty for trans men...
like state. - The flap is partially attached physically while the surgeon attempts to join the nerve bundles.
- If the urethra was extended, it is now joined with a catheter that will remain in place for healing purposes for two to four weeks. Otherwise, the skin is sutured up and/or the scrotum is fabricatedScrotoplastyScrotoplasty, also known as oscheoplasty, is reparative or plastic surgery of the scrotum.As part of the surgical options for trans men, scrotoplasty is one of several operations performed to transform/reform the external genitalia into a penis and a scrotum.In this procedure, the labia majora are...
.
If the patient chooses to have the urethra extended to the glans of the neophallus, it is formed by the following steps:
- The labia minora is injected with a mixture of saline and epinephrine.
- It is then split open and layers separated using sharp and blunt dissection.
- The layers are wrapped around a catheter and stitched.
- A mucosal flap from the vagina may be used to bridge the urethra with the extension. This is often done in a separate procedure. Alternative graft locations include the mouth/cheeks or experimentally, the intestines. If the labia minora is not used during construction of the urethral extension, (or in the chance there is enough material remaining) it can be used during glansplasty to provide for better results compared with a full thickness skin graft.
Patient satisfaction and concerns
The overall aesthetic satisfaction rate for forearm phalloplasty is 90% in spite of its shortcomings. 83% of patients who replied to a study reported good superficial (skin) sensation. Only 9% had erogenous sensitivity in their neopenis, and only 51% were able to perform satisfactorily during intercourse (defined as being able to penetrate their partner successfully without difficulty or pain).Post-op depression which required temporary use of anti-depressants were noted by 27% of those who replied, with one suicide attempt not related to the surgery outcome. After surgery, 40% were able to apply for employment positions that they were unable to fill when they were legally female. 93% of patients stated that after phalloplasty, they were happy with their genitals.
Graft from the side of the chest
A relatively new technique involving a graft from the side of the chest under the armpit (known as a musculocutaneous latissimus dorsi free transfer flap) is a step forward in phalloplasty. The advantages of this technique over the older forearm flap technique include:- Hairlessness (little to no electrolysis needed)
- Aesthetic appearance of normally colored skin (the glans may be tattooed to proper color)
- Capable of tactile sensation (as with any form of phalloplasty, this does not necessarily mean the ability to have a genital orgasm after healing, as the erogenous zone is limited to the base of the penis)
- Leaves an inconspicuous scar
- Has a lower occurrence of complications from both the initial surgery and the erectile prosthesis insertion
This is a three part surgery that takes place over a period of six to nine months. The steps consist of:
Neophallus creation using MLD free flap
- The surgery starts (after the patient is prepped) with the side of the chest marked for graft size.
- The graft skin is dissected to expose the veins and the thoracodorsal nerves.
- The graft, while still attached to the blood supply, is formed to a rough phallus shape by rolling the edges together.
- A segment of vein going to the patient's groin is "borrowed" to allow easier joining of the graft with the preexisting tissues.
- The vein is carefully attached to the femoral artery.
- The blood supplies from the flap and the vein leading to the femeral artery are joined.
- The clitoral hood and ligament are cut away and the nerve bundle is isolated.
- The flap is partially attached physically while the surgeon attempts to join the nerve bundles.
During initial recovery, the neophallus is protected from contact with other tissues with a specially constructed dressing as to avoid blood supply complications.
After three months, urethroplasty (urethral extension) is performed.
- The neophallus is dissected and a buccal (oral) mucosa graft inlaid into the created cavity and extended to the native urethra and joined to permanently allow urination while standing
- A catheter is placed for several weeks to allow for proper healing
After another three to six months, a device that allows an erection can be inserted.
Graft from the leg
The lower leg operation is similar to forearm graft with the exception that the donor scar is easily covered with a sock and/or pants and hidden from view. Other details are same as forearm graft, especially the need for permanent hair removal before the operation. A graft from the leg or another area where the scar is less noticeable may be combined with free forearm graft to sculpt the glans penis.Pubic area flap
The graft location is around the pelvic bone, usually running across the abdomen under the belly button. As such, there is a large horizontal scar that may not be aesthetically acceptable. The grafts have a less natural appearance and may not maintain an erectile implant long term. Electrolysis is required before surgery with the alternative being clearing of hair via shaving, or chemical depilatory.Gillies technique
This technique was pioneered by Sir Harold Delf Gillies as one of the first competent phalloplasty techniques. It was simply a flap of abdominal skin rolled into a tube to simulate a penis, with urethral extension being another section of skin to create a "tube within a tube." Early erectile implants consisted of a flexible rod. A later improvement involved the inclusion of a blood supply pedicle which was left in place to prevent tissue death before it was transplanted to the groin. Most latter techniques involve tissues with attached pedicle.Abdominal muscle
Skin grafted muscle flaps have fallen from popularity. This procedure is a minimum of 3 steps and involves implantation of an expansion balloon to facilitate the amount of skin needed for grafting. The grafts have a less natural appearance and are less likely to maintain an implant erectile long term.Common complications
As phalloplasty has improved over the decades, the risks and complications from surgery have been reduced. However, there is still a possibility of a need for revision surgery to repair incorrect healing.A study of post-op men showed that on average, 25% had one or more serious complications of the neopenis. The ones reported consisted of:
- Loss of the phallus from either disease or blood supply issues
- Cephalic vein thrombosis (blood clot)
- Arterial ischaemia (shortage of blood supply)
- Infection
- Distal limited necrosis (death of parts of the penis)
- Haematoma (bruise)
In the same study, chances of complications of the extended urethra were higher, averaging 55%. The most common complications reported were:
- Urinary fistula (hole) requiring perineal urethrostomy
- Urinary fistula (hole) with conservative treatment
- Urinary retention (from stenosis or narrowing of the new urethra)
- (Erectile) prosthesis change (from complications)
- (Erectile) prosthesis explantation (removal of the prosthesis without replacement)
See also
- Sex reassignmentSex reassignmentSex reassignment may refer to:* Sex reassignment, changing the sex assignment of an infant or child by parents and doctors, usually because of fuller understanding of an intersex condition....
- List of transgender-related topics
- Penis transplantationPenis transplantationPenis transplantation is a surgical transplant procedure in which a penis is transplanted to a patient. The penis may be an allograft from a human donor, or it may be grown artificially, though the latter is untested in humans...
- Foreskin restorationForeskin restorationForeskin restoration is the process of expanding the residual skin on the penis, via surgical or non-surgical methods. It can be performed for several reasons, among them being a desire to create the appearance of a natural foreskin covering the glans penis, or to increase sexual sensitivity of...
External links
- Video: Minimally Invasive Penile Implant Surgery (note: while this is being performed on a cismale, the procedure is similar during phalloplasty)