Phalloplasty
What does phalloplasty involve? How to prepare and what to expect after the operation? Below, you can read about the procedure, the risks involved in the operation, the period after the operation and any subsequent, corrective operations (i.e. secondary corrections). The animations will give you more insight into the operation procedure itself.
About the phalloplasty
Phalloplasty is a surgical procedure to create a penis (phallus), using tissue from elsewhere on your body, such as from your arm, leg or flank. The technique used depends on your physical characteristics and your wishes.
The phallus can be created either with or without urethral extension. The phalloplasty with urethral extension is more likely to cause complications, and such an extension does not guarantee that you will be able to urinate standing up.
In order to be considered for a phalloplasty, you must be fully informed and will need to comply with a number of preconditions. More information on the preparation for a phalloplasty can be found here. Clarifying information can be found in Amsterdam UMC's animation video.
The operation
The phalloplasty is performed by both a plastic surgeon and a urologist. The phallus shaft and the urethral extension can be made in different ways. The duration of the operation depends on the technique — from over 3 hours for a simple technique, to over 6 hours for one that is more complicated.
Note that the details of the surgical procedure may differ for any Dutch care facility. It is, therefore, important to check the exact procudure with the institute where you are having surgery.Creating the scrotum
The scrotum is made in a similar way for both types of phalloplasty (i.e. with and without urethral extension). The clitoris and inner and outer labia are cut free. In the case of a phalloplasty with urethral extension, the urethra is lengthened slightly using the inner labia. This step is skipped in the case of a phalloplasty without urethral extension, because the urethra will ultimately be positioned under the scrotum. Then, the outer labia and the skin of the mons pubis are brought together and sutured to make the scrotum. Now the genital area is ready for connecting the phallus.
Follow-up and operation techniques
The operations are performed by both a plastic surgeon and a urologist. The urologist places a urinary catheter, which is a drain that is inserted through the urethra. In the case of a urethral extension, you will also receive a bladder catheter that is inserted through the abdomen, in addition to the urinary catheter. The subsequent steps of the operation depend on the technique chosen.
The following operation techniques can be used:
- Phalloplasty without urethral extension – donor skin from the forearm (FRFF)
- Phalloplasty without urethral extension – donor skin from the upper leg (ALT)
- Phalloplasty without urethral extension – donor skin from the flank (SCIP)
- Phalloplasty with urethral extension – donor skin from the forearm (urethra and shaft)
- Phalloplasty with urethral extension – donor skin from the upper leg (shaft) and the forearm (urethra)
- Phalloplasty with urethral extension – donor skin from the flank (shaft), multiple options for the urethra
1. Phalloplasty without urethral extension — donor skin from the forearm (FRFF)
With this technique, skin is taken from the forearm and used for making the shaft of the phallus.
While the urologist is creating the scrotum, the plastic surgeon is working on your forearm, where a skin area of about 13 x 13 cm is marked (see figure), which will become the donor skin for the phallus.
This area contains an important blood vessel, an artery and two nerves. This ensures that the donor skin remains perfused and sensitive. The skin is detached from the forearm and transferred to the genital area. Using a microscope, the blood vessels of the donor skin are connected to those in the groin. The nerve is then connected to one of the two nerves of the clitoris to create feeling in the penis. The skin is subsequently formed in the shape of a penis and sutured in place.
A thin layer of skin is taken from your thigh to close the wound on the forearm.
Scars
This technique results in a large, recognisable scar on the arm from which the skin was taken.
2. Phalloplasty without urethral extension — donor skin from the upper leg (ALT)
With this technique, the skin from the upper leg is used for creating the shaft of the phallus.
While the urologist is creating the scrotum, the plastic surgeon is working on your upper leg, where a skin area of about 13 x 13 cm is marked (see figure), which will become the donor skin for the phallus.
The donor skin contains a vein, an artery and two nerves, which keep the skin perfused and sensitive. The skin is then rolled up and sutured to form a phallus, which is subsequently moved, underneath the leg muscles, to the genital area. The blood vessels remain intact. Then, the nerve from the donor skin is connected to one of the two nerves of the clitoris to create feeling in the penis. The skin is subsequently formed in the shape of a penis and sutured in place.
Scars
A thin layer of skin is taken from the other upper leg and used for closing the leg wound. This technique results in a large scar on the upper leg from which the donor skin was removed, but this will fade over time as the wound is only superficial.
3. Phalloplasty without urethral extension — donor skin from the flank (SCIP)
With this technique, the skin is taken from the flank and used for creating the shaft of the phallus.
While the urologist is creating the scrotum, the plastic surgeon is working on your flank, where a skin area of about 13 x 13 cm is marked, which will become the donor skin for the phallus. The area contains a vein, an artery and two nerves. This ensures that the donor skin remains perfused and sensitive. Then, the donor skin with nerves and blood vessels is detached from the flank, sparing the nerves.
The skin is transferred to the genital area, rolled up to form a phallus. The blood vessels remain intact. Then, the nerve from the donor skin is connected to one of the two nerves of the clitoris to create feeling in the penis. The skin is subsequently formed in the shape of a penis and sutured in place. Lastly, the wound on the flank is sutured.
Scars
This technique results in a large scar on the flank from which the donor skin was removed. This scar will fall into the natural folds of the flank, making it less conspicuous.
4. Phalloplasty with urethral extension — donor skin from the forearm
With this operation, both the urethra and the shaft of the penis will be created from skin of the forearm. The phalloplasty with urethral extension and donor skin from the forearm is the most widely used technique, worldwide.
This operation is performed by two plastic surgeons and a urologist. While the urologist is creating the scrotum, the plastic surgeons are working on your forearms. On one forearm, a skin area of 3 x 17 cm is marked for the urethra. On the other forearm, an area of about 13 x 13 cm is marked (see figure), which will become the donor skin for the phallus. This area contains an important blood vessel, an artery and two nerves. This ensures that the donor skin remains perfused and sensitive.
The first part of the donor skin (the so-called free flap) is wrapped around the urinary catheter to create a urethra. The remainder of the free flap is rolled around the created urethra, transferred to the genital area and sutured to form the penis.
Using a microscope, the blood vessels of the donor skin are connected to those in the groin. The nerve is then connected to one of the two nerves of the clitoris to create feeling in the penis. The skin is subsequently formed into the shape of a penis and sutured in place.
The wound from the donor skin for the urethra is sutured and wound from the donor skin for the phallus is closed using skin taken from the upper leg.
Scars
This technique results in a large, recognisable scar on the forearm from where the donor skin was taken, as well as a smaller scar on the other arm, from where a thin layer of skin was removed.
- Phalloplasty with urethral extension — donor skin from the upper leg (shaft) and forearm (urethra)
With this phalloplasty, the urethra is created using skin from your forearm and the shaft is made using the skin from your upper leg.
This operation is carried out by two plastic surgeons and a urologist. While the urologist is creating the scrotum, the plastic surgeons work on the upper leg and the forearm. On the upper leg, a skin area of about 13 x 13 cm is marked (see figure), which will become the donor skin for the phallus. On the forearm a skin area of 3 x 17 cm is marked for the urethra.
The donor skin contains a vein, an artery and two nerves, which keep the skin perfused and sensitive. The entire flap of skin from the upper leg is then detached from the underlying tissue. The free flap from the forearm is sutured around the urinary catheter to create a urethra. The skin taken from the upper leg is subsequently rolled around the urethra, moved to the genital area and sutured to form the penis. Then, the nerve of the donor skin from the upper leg is connected to one of the two nerves of the clitoris to create feeling in the penis. The skin is formed into a penis and sutured in place.
The wound on the forearm is sutured, and the wound on the upper leg is closed using skin taken from the other leg.
Scars
This technique results in a large scar on the upper leg from where the donor skin was removed, which will, however, fade over time as the wound is only superficial. You will also have a smaller scar on the forearm from where a thin layer of skin was removed to close the other wound.
6. Phalloplasty with urethral extension — donor skin from, amongst other things, the flank (shaft)
In this phalloplasty, the shaft of the penis is created using donor skin from your flank. The urethra can be created in different ways: from skin of your forearm, from tissue of the labia minora or from the other flank.
The operation is performed by two plastic surgeons and a urologist. While the urologist is creating the scrotum, the plastic surgeons are working on your flank, where a skin area of about 13 x 13 cm is marked, which will become the donor skin for the phallus. The skin for the urethra can be obtained from the forearm, the labia minora or the other flank (depending on your wishes and physical characteristics).
The donor skin contains a vein, an artery and two nerves, which keep the skin perfused and sensitive. The entire skin area from the flank is detached from the underlying tissue. The skin for the urethra is sutured around the urinary catheter to create a urethra. The skin from the flank is then rolled around the urethra, transferred to the genital area and sutured to form the penis. Then, the nerve from the donor skin is connected to one of the two nerves of the clitoris to create feeling in the penis. The skin is subsequently formed in the shape of a penis and sutured in place, after which the wound on your flank is sutured.
Scars
This technique results in a large scar on one or both of your flanks, where skin was removed. The scar will fall into the natural folds of the flank, making it less noticeable. You may also have a smaller scar elsewhere, where skin was removed to create the urethra.
Aftercare
After the operation, you will have regular check-ups at the plastic surgeon and urologist. The plastic surgeon will check the appearance and wounds on the penis. The urologist will continue to monitor your urethra and urinary function after surgery both with and without urethral extension. The urologist will do so using urine samples and questionnaires. If any complications occur, you will need to go to hospital more often. You should care for catheters and wounds as explained by the nurse.
It is often advised to wait until the wounds are completely closed before swimming, taking a bath or going to the sauna. This often takes 4 to 6 weeks. This is to prevent the stitches from dissolving too early and you getting infections in the wound. Brief showers are allowed. You are not allowed to exercise or lift heavy objects for six weeks, as this may cause bleeding or the build-up of excessive fluid. In addition, you will need to wear tight underwear/net briefs for six weeks so that the penis will hang down neat and straight.
You are strongly advised not to smoke for at least three months after the operation. You should care for catheters and wounds as explained by the nurse.
Clarifying information about aftercare, results, and complications can be found in this animation video from Amsterdam UMC.
Complications and risks during and after the operation
Medical complications may arise during or after the procedure, even though the operation was performed correctly. The risk of complications depends on your health and the technique used. The techniques that involve creating a urethra have a higher risk of complications. A phalloplasty with urethral extension has a 50% risk of complications; without urethral extension, the risk is 5%.
- Haemorrhage. This usually occurs immediately after the operation. Depending on the severity of the bleeding, a second operation may be necessary to stop it.
- Wounds opening up again. Wounds may open, for example, because sutures come apart prematurely. You must take good care of your wounds, as re-suturing is not possible.
- Wound dehiscence (badly healing wounds). Particularly around the sutures, wound healing can become impaired. This often happens to smokers, but sometimes also to non-smokers. This type of wound will generally heal by itself, but it can take a long time. Rinse the wounds regularly with lukewarm tap water and pat the area dry.
- Necrosis (dying tissue). If there is insufficient perfusion in part or all of the skin, tissue will die off. Smokers have an increased risk of this type of complication. Sometimes, this can already be observed during the operation, in which case the surgeon will improve the circulation. In some cases, this occurs not until after the operation. It will usually heal by itself, but sometimes another operation is required.
- Infection. Although the procedure is done in a clean and sterile way, there is always a chance of bacteria entering the wound . This can also happen later, once you are at home. Therefore, it is important that you take good care of your wounds. If the skin around the wound becomes warm and red, if the wound starts to fester or if you get a fever, this may be an indication of the wound being infected and you should contact the plastic surgeon.
- Urination problems (narrowing of the urethra). Narrowing of the urethra (stenosis) may make it difficult to urinate. Stenoses are treated by regularly stretching the urethra, over a number of weeks or months, which is done at the outpatient clinic or by yourself. Sometimes, surgery will be required. The risk of stenosis in cases without urethral extension is 5%, whereas with urethral extension, this is more than 50%.
- Urination problems (fistula). The extended urethra may find an opening to the outside, causing urine to leak out of this opening. This is called a fistula. Sometimes, the opening will heal on its own, but it can also require surgery to correct this situation. Without urethral extension, the risk of a fistula is 5%, whereas with such an extension, this risk is over 50%.
- Urination problems (leakage). Even after a successful urethral extension, leakage is common. The outpatient clinic can provide information and give you instructions on how to massage the urine out of the urethra.
- Loss of feeling/orgasm. Whether you will have feeling in the entire phallus cannot be guaranteed. Both the nerve from the skin and from the former clitoris will need to regrow after the surgery. This process will take anything from months to years and is difficult to predict. Important factors here are your age and smoking behaviour. Your clitoris will be positioned deeper under the skin, which may mean that it will be more difficult or even impossible for you to have an orgasm. However, this complication occurs relatively seldomly.
NB Infection or bleeding can also occur at the location from which the donor skin was taken (on the forearm, upper leg or flank).
End result and secondary corrections
End result
Overall, the end result will be different for everyone, which is why you cannot request a certain appearance of your penis, in advance of the operation. This appearance will be partly determined by your current genitals and the thickness of your donor skin.
You will have scars after the operation. The production of scar tissue varies from person to person, from skin type to operation technique. People and their skin all heal in their own way. Scars will heal less well in overweight people and smokers than in non-smokers with a healthy body weight.
Secondary corrections
There may be various reasons why you are not completely satisfied with the appearance or function of the genitals after the operation. You are advised to wait at least a year for any secondary corrections.
Prosthetics
After genital surgery for masculinisation, prosthetics can be placed. After a phalloplasty, prosthetic testicles and erectile devices can be placed.
Sexuality
Once your penis has healed sufficiently, you will be able to have sex. The guideline for this is three months after the operation; we advise you to discuss this during the follow-up examinations with the plastic surgeon.
Sexual arousal and orgasms can be different from before a phalloplasty. The clitoris is buried under the skin which means it is more difficult to stimulate. Most people are able to experience sexual arousal and orgasm after a phalloplasty, both when masturbating and with a partner. Penetration is hardly ever possible, but certain aids can be used, such as erectile devices.
Familiarising yourself
However, your sexual life depends not only on a phalloplasty, but also on many psychological and biological factors. Becoming familiar with your penis (sexually speaking) and learning to use it in a pleasurable way are important challenges after genital surgery.
Some trans men are sexually satisfied without an erectile device, whereas others are more satisfied with such devices. It is important that you discover what gives you sexual pleasure and that you discuss this with your potential partner/partners. Should you opt for an erectile device then it is important that you are aware of the related risks of complications (e.g. wear and tear and repair surgery). Discuss this with your physician.
This text was edited on 14-10-2022
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Prosthetics after genital surgery
After genital surgery for masculinisation, prosthetics can be placed. Prosthetic testicles are possible after metoidioplasty and phalloplasty. Erectile devices are possible after phalloplasty.
