There are many different techniques for phalloplasty, from the free flap which takes a graft from the donor site, which can be from the forearm(RF), the back(MLD) or the outside of the thigh(ALT), to the pedicled flap which leaves the graft attached to the donor site to increase blood supply also known as the suitcase technique which uses donor sites from the adominal, pubic and groin to make the neophallus. You may also decide to have the urethral lengthening, scrotoplasty and insertion of a penile prosthesis.
I have put together a brief out line to some of the procedures, for more detailed information on the techniques that can be used, check out the links at the bottom of the page.
Free Flap Techniques for Phalloplasty
Free flap uses a skin graft that is taken from a donor site along with its blood supply, nerves and sometimes muscle and transferred to the pubic area.
The Back (Musculocutaneous Latissimus Dorsi)
The MLD flap is constructed from taking a graft from the side of the upper torso, under the arm. Only a thin strip is needed. This technique offers many advantages over the traditional forearm technique.
Re-innervated Latissimus Dorsi Flap
This technique gives you the ability to have sexual intercourse without the need for prosthesis. The voluntary contraction of the phallus appears soon after the surgery, which leads to the changes of diameter length and shape.
Advantages to having MLD:
inconspicuous scarring, no need for hair removal (hairlessness), and improved colour or appearance.
Disadvantages to having MLD:
Tactile and erogenous sensation may be limited compared to Radial Forearm(but is usually better than abdominal and groin flap phalloplasty).
The Forearm(RF Radial Forearm)
This technique is available within the UK.
A flap from the forearm skin is formed into a skin-lined tube that will eventually be the neourethra. This tube is then rolled up within a larger flap. This tube within a tube is then transplanted to the pubic area and microsurgical anastomoses made to connect the artery, veins and nerves.
The radial artery from the arm is transplanted to provide a blood supply to the phallus via the inferior epigastric artery from the lower abdominal muscles. They do advice you to have hair removal on the donor site, it can be removed by laser, intense pulse light or by electrolysis. Which method is used can depend on your skin and hair type.
Advantages to having the radial forearm:
The result usually looks good, compared to other techniques.
The urethra can be less problematic.
Disadvantages to having the radial forearm:
The scar of the donor site may create some self consciousness when wearing short sleeved shirts. The donor site will need a skin graft to help the area heal, which is usually taken from the buttocks. Recovery time is a lot longer this way, than using the abdominal flap technique.
The outside of the thigh(ALT Anterior Lateral Thigh)
AnteriorLateral Thigh phalloplasty can be done using the pedicled or free flap technique. It is similar to the RF except the donor site is taken from the thigh. The flap is made from the lateral circumflex vessels and the nerve is taken from the lateral cutaneous.
Advantages of AnteriorLateral Thigh:
The donor site is fairly easily concealed, and operating times can be significantly lower than other procedures.
Disadvantages of AnteriorLateral Thigh:
Sensation is alot less.
Free Flap or Pedicled technique
Choosing what procedure would be best for you is down to you alone, no one else can make this decision for you, what procedure someone else had may not be suitable for you. Consider the following factors when deciding which approach is most appropriate to your needs:
- Standing to void
- Locker room appearance
- Penetrative sex
- Scarring potential
- Sexual sensation
- Removal of visible and invisible female parts
- Number of operations
- Potential complications
- Donor site problems
All these things you will be able to discuss in detail with your surgeon of choice.
The scrotoplasty is commonly done in two parts. The first stage is the insertion of a prosthetic testicle implant into each of the labia majora in order to create a more natural appearance. After that, the two sides of the labia are joined into a single unit to create the scrotal sack. These procedures may be performed in a single operation or as two separate surgeries, depending on the surgeon’s preferences. In some cases tissue from the patient’s own body may be used to simulate testicles.
A circumferential skin flap is raised like the brim of a hat which is then rolled in.
The use of a full thickness skin flap allows a nice helmet or mushroom head to be created. A skin graft is then wrapped fairly tightly around the bare fat below the head to cause a slight constriction as it heals to accentuate the bulbousness of the head.
These can differ depending on which surgeon you choose and what technique you decide to go with. The London team split theirs into four stages:
- Stage 1 – Formation of the phallus
- Stage 2 – Formation of the uretha
- Stage 3 – Glans sculpting, testicular prostheses
- Stage 4 – Penile prosthesis
There may be more than one operation involved at each stage and there should be at least three months in between each operation. If you are looking into having all four stages this will take at least 12-18 months to complete. It is not uncommon for the entire process to require two to three years.
All phalloplasty options should provide you with a sensate penis, that is, one with ordinary skin sensation. However, it may not have the sexual sensation of a penis, but this depends on the surgical techniques used by your surgeon. Sensation will be delayed for a few months after having surgery.
Depending on the technique you decide to have, they do advice you to have hair removal done on the donor site, which can be removed by laser, intense pulse light or by electrolysis. Which method is used can depend on your skin and hair type. This procedure maybe available on the NHS.
Two referrals or signatures are usually required before a surgeon will undetake lower surgery. They do recommend that you have a Hysterectomy before having lower surgery.
Choosing a Surgeon
If you are having the surgery done in the UK you maybe referred onto Mr Christopher at the St Peter’s Andrology Centre in London. Once you have been referred onto a surgeon, you will have an in-depth consultation with them to help you decide what you want. It may also be possible to have your surgery abroad which can be funded by the NHS if the quality of treatment and the cost are comparable or better than that available in the UK.
To download the London teams Patients’ Guide to Phalloplasty Techniques click here. (Graphic)
To download the Gires Transgender Wellbeing and Healthcare click here.
To download the Total Phallic Reconstruction in Female-to-Male Transsexuals click here. (Graphic)
Photos and Websites
Please be aware that some of these websites will contain images that are graphic.
BrownStein & Crane (Photo gallery contains graphic images)
Belgrade Center for Genital Reconstructive Surgery (Photo gallery contains graphic images)
Phalloplasty FTM Surgery Network (contains graphic video)
Perovic art of Urogenital Surgery
University Plastic Surgery
Hung Jury – Is a selection of FTM’s documenting their experiences of having lower surgery.
Overall satisfaction, sexual function, and the durability of neophallus dimensions following staged female to male genital gender confirming surgery: the Institute of Urology, London U.K. experience Maurice M. Garcia, Nim A. Christopher, Francesco De Luca, Marco Spilotros, David J. Ralph.Department of Urology, University of California San Francisco, San Francisco, CA,USA. St. Peter’s Andrology Centre and The Institute of Urology, University College London, London, UK. We sought to assess patient genital-GCS related satisfaction, regret, pre/post-op sexual function, genital preferences, and genital measurements post-op. Accepted for publication Apr 17, 2014.