Phalloplasty

Editors-In-Chief: Martin I. Newman, M.D., FACS, Cleveland Clinic Florida, [mailto:Newmanm@ccf.org]; Michel C. Samson, M.D., FRCSC, FACS [mailto:samsonm1@ccf.org]

Overview
Phalloplasty refers to the (re-)construction of a penis or, sometimes, artificial modification of the penis by surgery, often for cosmetic purposes. It is also often used to refer to penis enlargement. The first phalloplasty done for the purposes of sexual reassignment was performed on transman Michael Dillon in 1946 by Dr. Harold Gillies, which is documented in Pagan Kennedy's book The First Man-Made Man.

Complete construction or reconstruction
A complete construction or reconstruction of a penis is done on both cisgendered men who have lost their penis through either illness or accidents, and on transmen, that is, female-to-male transgendered or transsexual people.

The basic procedures have similarities (except in extreme cases of micro/macropenis), although surgery on cisgendered men can be simpler, since the urethra still ends in the front of the genital area, whereas the urethras of transmen end near the vaginal opening and have to be lengthened considerably. The lengthening of the urethra is a difficult part of total phalloplasty, and also the one where complications often occur.

Most people get their penises enlarged due to self confidence issues.

With all types of phalloplasty in transmen, the labia (see vulva) are united to form a scrotum, where prosthetic testicles can be inserted.

An erectile prosthesis can be inserted into the neophallus to replace the erectile tissue and enable sexual penetration. This is usually done in separate surgery for healing reasons. There are several types of erectile prostheses, ranging from malleable rod-like medical devices so the neo-penis can either stand up or hang down, to elaborate pumping systems. 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 a reconstructed penis have been poor. Good sensation of the reconstruction can help reduce the risk for the implant eventually eroding through the skin. It is for this reason that living bone was first used inside the reconstruction. Long-term follow-up studies from Germany and Turkey of more than 10 years now prove that these reconstructions maintain their stiffness without late complications.

There are three different techniques for phalloplasty:

Graft from the arm, leg, abdomen or musculocutaneous latissimus dorsi
This technique involves using a free graft of tissue that is removed from its original place, rolled up, with a part of it forming the new urethra, and grafted to its new place between the thighs. In the past, the donor site was usually the inner side of the forearm but sometimes the upper arm, leg or abdomen. The arm flap operation is easier to perform but requires an implant and has a cosmetically undesirable scar on the exposed area of the arm. The lower leg operation takes along with the skin a piece of the small bone of the leg. Like the appendix, humans can live fine without it. The scar in the leg is easily covered with a sock and hidden from view. These are the two operations which are used most commonly today in the world. They have normal skin on them and can have good cosmetic results. Skin grafted muscle flaps have fallen from popularity. The grafts have a less natural appearance and are less likely to maintain an implant long term.

Good references for these issues may be found in the Journal of Plastic and Reconstructive Surgery by the authors, Papadapoulos and Biemer, Sengezer, Sadove and McRoberts, and Hage.

Belgrade University School of Medicine admits in the British Journal of Urology, Volume 100, Issue 4, that the four stages of this total phalloplasty method of penile reconstruction over a period of 9–18 months is one of the most demanding tasks in genital reconstructive surgery but the benefits for patients are great.

It satisfies the 12 major aesthetic and functional goals of modern penile reconstruction — a penis that: 1) is large, with substantial volume; 2) enables safe insertion of a prosthesis; 3) is hairless; 4) has satisfactory aesthetic appearance; 5) has normally colored skin; 6) has both penile tactile and erogenous sensation; 7) has a competent neo-urethra with a meatus at the top of the glans; 8) can have sexual intercourse; 9) leaves no conspicuous, disfiguring scars at the donor site; 10) has very low occurrence of disease or other complication; 11) achieves patient satisfaction; and 12) improves quality of life.

Not a major medical goal, but important to many patients, total phalloplasty using the MLD flap enables the person to urinate standing up. This is true of all modern operations. Suitable candidates for this surgery which creates a penis up to 7 inches (18 cm) long with a circumference up to 5.9 inches (15 cm) include: 1) patients with congenital anomalies such as micropenis, epispadias, and hypospadias; 2) FtM transsexual patients; and 3) victims of minor to serious iatrogenic, accidental or intentional penile trauma injuries (or total emasculation) caused by motor vehicle accidents (but not plane crashes), child abuse, animal bites, gun shots, burns, electrocution or self-mutilation.

For transmen getting a procedure not using the MLD flap, the urethra up to this point is formed by many doctors from the inner labia. Often, this is done in a separate procedure; sometimes a full-scale metoidioplasty is done a few months before the actual phalloplasty to prevent complications or make intervention easier when they occur.

Sensation is retained through the clitoris which is at the base of the neo-phallus; also, often a large nerve in the graft is connected to nerves either from the clitoris or other nearby nerves. In addition, nerves from the graft and the tissue it has been attached to usually connect after a while, thereby allowing additional sensation.

The forearm and leg flaps are the most common surgical techniques for total phalloplasty today. They remain the state of the day for both function and aesthetics. Muscle Flap procedures need long term publications of their function and aesthetics before making extreme claims of their popularity and superiority.

Abdominal fatty tissue
Another option for transmen is metoidioplasty, where a small penis is created from the clitoris that has been enlarged by hormone replacement therapy.