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Phalloplasty

Phalloplasty is the reconstruction or reconstruction, or artificial modification of the penis using surgical methods. This term also sometimes refers to penis enlargement procedures.


What are the different techniques of Phalloplasty?

There are mainly 4 different techniques used for performing a Phalloplasty procedure. All these techniques have a common goal of extending the urethra using a flap of the patient’s own tissue sourced from another part of the body.

The surgical complexity is less for original males, as compared to female-to-male transgender patients as it involves extending the urethra. A transgender urethra ends bear the vaginal opening and requires more extensive lengthening. This part of the procedure is also more prone to complications.

For transgender men, all 4 Phalloplasty techniques can be effectively used, accompanied with a ‘Scrotoplasty’ procedure, which involves using the vulva (labia majora) to make the scrotum where prosthetic testicles can be inserted. If required, the surgeon can also perform oophorectomy, hysterectomy and/or vaginectomy, with this procedure.

As opposed to metodioplasty, the Phalloplasty procedure requires inserting an implant to achieve erection. This needs an additional surgery, mostly a few days following the Phalloplasty. There are several types of penile implants available today, which include malleable rod-implants which can be easily adjusted for erection and can be concealed when required.

This procedure requires a small horizontal incision in the pubic region where the pubic hair will conceal the small incision scar more effectively. There is no incision made on the penis anywhere.


Donor site –

Forearm

The forearm is an ideal site to collect donor tissue for lengthening the urethra. However, this may result in a visible scar, and there is also risk of losing arm function in some cases. Laser hair removal or electrolysis process is required for a hairless neophallus.

In some cases, a complete metoidioplasty is performed after a few months from the Phalloplasty surgery. This helps to reduce the complication risks from the Phalloplasty procedure. The surgeon will try to re-connect the nervous tissues from the clitoral tissue and regain sensation in the penile shaft. The nerves attached to the flap and connecting tissue may also be restored eventually. However, this does not guarantee the indication of achieving orgasm once it heals. On the other hand, it is also difficult to lose the ability to have orgasm.

These are the common steps involved in construction of the glans, however, the exact procedure may vary with different techniques.

  1. Surgery begins with the forearm marked for indicating incision area for donor tissue.  Once the graft is removed, a secondary skin graft helps to cover the original scar on the forearm.

  2. The graft is dissected to expose the veins and ante-brachial cutaneous nerves.

  3. If urethra needs reconstruction along with the phallus, it is also joined in this step. Else, the glans is shaped within this step or it may be performed as a separate procedure.

  4. A portion of vein from the patient’s groin area is used for grafting easily with the present tissue.

  5. The vein is then carefully attached to the femoral artery.

  6. The blood vessel supplying the graft and vein from the femoral artery is connected.

  7. The surgeon will remove the clitoral hood and its supporting ligament, while the nerve bundle in it is isolated at the same time.

  8. The flap of tissue is attached partially while the nerve bundle is rejoined.

  9. When urethra is extended it is then joined with a catheter which will be attached for 2 to 4 weeks following the surgery. Else, the surgeon will suture the remaining skin and/or fabricate the scrotum.


In case the patient chooses to have urethra extended up till the glans along with a Phalloplasty, then the surgeon will also:

  1. Inject the labia minora with a saline and epinephrine mixture.

  2. Split it open and separate the layers using a sharp and blunt dissection technique.

  3. Wrap the layers around a catheter and stitch it together.

  4. Use a mucosal flap from the vagina to bridge the urethra with the extensions. This is mostly performed as a separate procedure. The surgeon may also source graft material from the insides of the mouth (cheeks) or the intestines (on experimental level currently).


Side of the chest

This is a comparatively new technique used for removing a flap of tissue from the side of the chest (under the armpit). It is also known as musculo-cutaneous latismum dorsi free flap transfer). This is a step towards undergoing a Phalloplasty.

These are some of the advantages of this flap graft technique:

  • Hairless – Required almost no electrolysis for hair removal.

  • Aesthetically appealing – The skin tone matches the normal color of the surrounding skin.

  • Tactile sensation – Has effective sensation to even reach orgasm.

  • Hidden scar

  • Lower risks of complications.


There are a few drawbacks to this technique, namely:

  • Only tactile sensation achieved and does not provide erogenous sensation without motor nerves.

  • Nipple position may be changed and the nipple may seem closer to the shoulder.


This surgery is done in 3 parts, over a period of around 6 to 9 months. It is performed by:


For Neophallus creation using MLD free tissue flap

  • The surgery requires first marking the site for sourcing the flap in the side of the chest, under the armpit.

  • The flap is dissected and removed to expose the underlying veins and nerves (thoraco-dorsal).

  • The flap is removed with its original blood supplying vein intact. It is then shaped into a rough phallus by joining the edges together.

  • A portion of the vein in the groin is used to let the flap join easily with the present tissues.

  • The vein is attached to the femoral artery.

  • The blood vessel from the flap and its vein leading to the femoral artery are also joined together.

  • The clitoral hood and ligament are removed while the nerve bundle is isolated.

  • The flap of tissue is attached partially as the surgeon tries to attach the nerve bundles.

During the initial recovery period, the neophallus is secured from injury form surrounding tissues with a special dressing. This also helps to avoid complications with the blood supply.


After a period of around 3 months following this procedure, the surgeon will advise performing a Urethroplasty procedure to extend the urethra. This involves mainly:

  • Dissecting the neophallus and implanting a soft graft tissue (usually from inside the mouth) is useful for achieving ideal length to the urethra. This will allow comfortable urination while standing.

  • A catheter is placed for a few weeks for better healing and recovery.


After another 3 to 6 months have passed, the surgeon will advise a penis lengthening (Phalloplasty) procedure.

Tissue flap from leg

The sourcing of tissue flap from the lower leg is similar to that of the forearm procedure. However, in this case, the scar is easier to conceal with the clothing.

Flap from pubic area

The flap of tissue is sourced from close near the pubic bone. The incision usually runs horizontally across from one side of the hip to the other, under the level of the belly button. This flap may differ in appearance and may not be able to maintain an erection implant for a long time. The scar is also quite visible in this procedure. Electrolysis (for removal of hair) also becomes necessary.

Gillies technique

This technique was invented by Sir Harold Delf Gillies and was one of the foremost Phalloplasty techniques. This was a fairly basic technique which used a flap of abdominal tissue rolled into a cylindrical shape with the urethra extended using another section of skin graft. Earlier, implants for erection were flexible rods. Later on, the technique was improved and blood supply could be reconnected.

Abdominal muscle

These are less popular sources for skin grafts. This procedure also requires implanting a balloon device to help expand the amount of skin used for grafting. It however has a less natural-look and is not able to maintain an erection implant for long.

Subcutaneous soft silicone implant

This procedure for Phalloplasty requires inserting a sift silicone implant subcutaneously (under the skin) in the penis.

 

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