Lower Surgery for FtM

FtM Lower Surgery Guide

Lower Surgery Options

Are you looking for a little extra help on deciding which lower surgery procedure you prefer to have? Listed below are the two types of surgeries available Phalloplasty (Phallo) and Metoidioplasty (Meta). In short Phallo means taking a skin graft from a donor site and then attaching it to the pubic area. Meta means taking what growth you have had from testosterone and creating a micro-penis.

Phalloplasty (Phallo)

Free Flap Technique

The free flap technique takes a graft from the donor site, which can be from the forearm (RF), the back (MLD) or the outside of the thigh (ALT).

Pedicled Flap Technique

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 abdominal, pubic and groin to make the phallus.

The Forearm (RF)

This technique takes a section of skin from the forearm to form two tubes, one for the lengthening of the urethra and the other to form the phallus. The urethra tube is then placed inside the phallus tube and then attached to the pubic area. The artery, veins and nerves are then reconnected using microsurgical anastomoses.

The radial artery from the arm is then transplanted to provide a blood supply to the phallus via the inferior epigastric artery from the lower abdominal muscles. This procedure will require hair removal on the donor site.

Advantages to having RF:

The result usually looks good, compared to other techniques.
The urethra can be less problematic.

Disadvantages to having RF:

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 Muculocutaneous Latissimus Dorsi (MLD) Flap

The 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.

MLD Muculocutaneous Latissimus Dorsi flap

Advantages to having MLD:

inconspicuous scarring
no need for hair removal (hairlessness)
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).

Anterior Lateral Thigh (ALT) Flap

Anterior Lateral 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 ALT:

The donor site is fairly easily concealed
operating times can be significantly lower than other procedures

Disadvantages of ALT:

Sensation is a lot less

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Optional Procedures

Scrotoplasty

Scrotoplasty is the construction of a scrotum. It takes one possibly two stages to complete. The first is the insertion of a prosthetic testicle implant into each of the labia majora in order to create a more natural appearance. The second is to join the two sides of the labia together, creating the scrotal sack. Whether you pick Phallo or Meta, scrotoplasty is available for both.

If you have chosen to have phallo with the erectile implant, one of the sides will have the erectile pump.

Glans Sculpting

Another choice to make is whether you want your new penis to look more pleasing to the eye. This is where glans sculpting comes in. The operation consists of using a skin flap to create a nice helmet or mushroom head. Creating the appearance of a circumcised penis.

Operating Stages

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:

First Stage – Formation of the phallus
Second Stage – Formation of the urethra
Third Stage – Glans sculpting, testicular prostheses
Fourth Stage – 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 happen it will just take a few months after having surgery to come through.

Depending on the technique you decide to have, they do advise you to have hair removal on the donor site. This procedure maybe available on the NHS.

Erectile Implants

There are two main penile prostheses, the malleable and inflatable. The malleable or semi-rigid prostheses consists of a silicone rod with a flexible steel core which allows it to be both stiff and bendable. The inflatable type uses tubes filled with fluid to create an erection, as and when required.

The London team use the three part inflatable rather than the semi-rigid as they were too rigid and prown to erosion.

For more information on erectile implants check out the websites below:

Phallo.net
Transhealth

Metoidioplasty

Metoidioplasty (meta) which is where they use the growth of the clitoris from taking Testosterone, to create a neophallus (micro penis). You can also have urethral lengthening done so that you can stand to pee. Along with scrotal reconstruction with testicle prostheses.

Its normally done in two stages.

Stage 1 – The first procedure

It is essentially a join-up urethroplasty but the urethral opening is brought up to the tip of the clitoris rather than the side and the clitoris is formed into a pseudo-glans. The remaining non-hairy labial folds are excised and the hairy labial skin is dropped down to make the mini-phallus stick out more.

Stage 2 – The second procedure

Small testicular prostheses are inserted at a second operation if required. The best results are obtained when there is significant clitoral enlargement from long-term testosterone treatment. If the clitoris is small then this is not a recommended procedure. One of the problems is that the urethral width is quite narrow for technical reasons and voiding difficulties and strictures are not uncommon. But the difficult choice is choosing which procedure would be best for you and what it is you want from it.

Do you want a penis that falls within the male range or will you settle for a micro penis(less than 2 inches)

If you have not already had a hysterectomy by the time, you are ready for lower surgery. It is OK though as it is part of one of the surgeries.

Choosing the right lower surgery option

Choosing the right technique for you is down to you alone, no one else can make this decision for you. Take as much time as you need on deciding which one you go with, don’t just pick the one that everyone recommends.

Consider the following factors when deciding:

Standing to pee – Who doesn’t want to be able to do this. Both meta and phallo allow you to do this.
Penetrative sex – Phallo is the better option here as the growth from meta isn’t enough on its own.
Scarring potential – Can you cope with the scarring that each procedure leaves behind. Phallo more so with having visible scarring.
Sexual sensation – The Radial forearm is supposed to give the most sensation compared to the others.
Removal of visible and invisible female parts – You have the option to have everything removed and closed up.
Number of operations – Can you cope with the number of operations that these surgeries require.
Potential complications – No-one wants to think about complications, but it can happen.
Donor site problems – There will always be a risk with any surgery you have.

Have a think about what type of lifestyle you lead, what type of job you do could also affect the type of technique you go for. For example your job could entail needing strength in your arms, can you cope with the lack of strength in one arm.

Choosing a Surgeon

When it comes to picking a surgeon there’s only one team in the UK that specializes in lower surgery and that is led by Mr Christopher. When you see the consultant you will have an in depth consultation, going over all surgeries available and find out which one suits your needs.

Genital Reconstruction Surgeons

UK

Mr Christopher – The St Peter’s Andrology Centre, London

Overseas

Dr. Crane – BrownStein & Crane, San Francisco
Loren S. Schechter – University Plastic Surgery, Chicago
Miroslav L. Djordjevic – Belgrade Center for Genital Reconstructive Surgery
Dr. Preecha Tiewtranon – Multidisciplinary Aesthetic Surgery Institute, Thailand
Dr. Kathy Rumer – Metoidioplasty Surgeon – FTM Surgery Network