Phalloplasty in FTM Transition: Methods, Staging, Function, and Recovery

Phalloplasty is one of the complex and sensitive surgeries for gender affirmation. The goal of this procedure is to create a male penis with natural function and appearance for FTM trans individuals. This operation gives them the physical body that aligns with their gender identity. As a result, it not only causes physical changes but also affects their psychological and social quality of life. If you or someone close to you intends to undergo this procedure, stay with us to fully familiarize yourself with the methods, stages, and costs of phalloplasty.

What is Phalloplasty?

As mentioned in the introduction, Phalloplasty is a reconstructive surgery in which a male penis is created from the individual's own tissue. This procedure is an important step in the female-to-male transition and is part of gender affirmation surgery. The surgery involves various stages such as urethral lengthening, glans creation, testicle creation (scrotoplasty), and implant placement, which must be performed by specialized and experienced physicians in this field. This surgery is usually performed in several stages to ensure tissue health and reduce risks.

Metoidioplasty vs. Phalloplasty

In gender affirmation methods, besides phalloplasty, Metoidioplasty can also be used. This method is considered a less invasive alternative to phalloplasty. In this procedure, the clitoris is subjected to hormone therapy to enlarge. Then, release and repositioning stages are performed so that it can function as a smaller penis. This method is less invasive than phalloplasty, but the size of the penis is smaller than natural, and it has limitations. In contrast, phalloplasty uses skin flaps to create a larger penis with a more natural appearance and function. The resulting penis in this method will have capabilities such as standing urination and implant placement for erection. The choice between both methods depends on various factors such as the patient's priority, complications, appearance, and the number of stages.

In What Cases is Phalloplasty Performed?

Generally, this procedure is performed for FTM trans individuals as one of the important stages of the gender confirmation process. In other medical cases, such as congenital penile defect, injury, or loss of penile tissue, this surgery may also be performed at the doctor's discretion.

Types of Phalloplasty (Choosing the Right Method)

In phalloplasty surgery, various body tissues can be used to create the new penis, depending on factors such as the patient's physical condition, priority for scar appearance, vascular and nervous system status, and fat thickness. Currently, doctors use several different methods for performing phalloplasty:

Radial Forearm Free Flap (RFF)

In this method, skin and subcutaneous tissue from the forearm are used to construct the shaft and urethra of the penis. This is a free flap method, meaning the blood vessels and nerves are connected at the new site. The aesthetic result of this method is good and natural, and sensation can be achieved. Disadvantages of this method include a visible scar on the forearm, a long surgery time, the risk of flap necrosis, and the need for a skin graft to repair the donor site.

Anterolateral Thigh Flap (ALT)

In this method, tissue is taken from the front and outer thigh area and designed and used to form the neophallus. The volume of tissue removed in this method is sufficient for creating a large penis, and the scar is less visible. The risk of fistula and urethral stenosis is higher in this method compared to others. Other disadvantages include more difficult shaping due to greater fat thickness and less sensation in the new penis.

Abdominal Flap

As the name suggests, tissue from the skin and fat of the abdomen is used to construct the shaft and urethra of the new penis. The scar in this method is covered by clothing, and the volume is sufficient for creating a large penis. Since this method is not widely used, the surgeon's experience in using it may be less. In this method, fat thickness also makes shaping difficult, and the probability of necrosis and vascular problems is higher.

Groin Flap

In the groin flap, tissue is taken from this area. If you do not want the scar to be visible on the forearm or front of the thigh, this method is a suitable option. However, the volume of tissue removed in this method is limited, and the potential for innervation and sensation in the neophallus is lower.

Pedicled Flaps

This is one of the specialized methods in phalloplasty because the flap is removed in a way that its vascular pedicle is preserved and connected to local vessels. As a result, sensation in the new penis will be well achieved in this method. This surgery is complex and long and must be performed by a physician with specialization and experience in this field. In this method, the design of the new penis will have more limitations in size and shape. Below is a comparative table of the methods.

Stages of Phalloplasty Surgery

Phalloplasty surgery is considered a complex procedure. This operation will be performed in multiple stages.

Before Surgery

Before the operation, the individual must undergo the necessary medical tests to evaluate general health, vascular and nervous status in the donor area, imaging, and blood analysis to ensure the person is ready for it. If the donor tissue is hairy, laser or hair removal may be required to prevent hair growth in the new penis. If requested by the person and confirmed by the physician, hysterectomy (uterus removal) or vaginectomy (vagina removal) may be performed. Also, the specialist physician and the medical staff must thoroughly discuss the penis size, urethral design, innervation, and implant with the person and provide the necessary consultation.

During Surgery

Each stage of the phalloplasty procedure is performed after the person is anesthetized by harvesting the flap from the donor area, such as the forearm, thigh, or abdomen. The removed tissue is constructed into the shaft of the new penis. In some methods, skin is also used to construct the urethra. In a free flap, the donor's blood vessels (artery and vein) and nerves are connected to the local blood vessels and nerves of the genital area to establish blood flow and sensation. In the final stage, if planned in advance, the construction or connection of the urethra is performed so that the neophallus can allow for standing urination.

After Surgery

After the operation, the flap site and donor area must be well dressed. In some cases, a Foley or suprapubic catheter is used for urine drainage for the first few days. Following the surgery, the person needs to be hospitalized for a few days so the surgical team can regularly monitor the flap's status for blood supply. After discharge, the patient is given instructions for washing, activity restrictions, physiotherapy, and wound care, which must be fully followed.

Approximate Duration of Surgery Based on the Selected Method

The duration of the surgery varies depending on the type of procedure, the person's condition, and the surgeon's expertise and experience. Generally, this surgery approximately requires about 470 minutes (nearly 8 hours).

Length of Stay and Discharge Tips

Based on data from reputable centers such as Johns Hopkins, after the first stage of phalloplasty, the patient must stay in the hospital for four to five days. Discharge usually occurs after the removal of the suprapubic or Foley catheter.

Sexual Function After Phalloplasty

Sexual function after phalloplasty can be examined in three parts: sensation, erection and sexual intercourse, and standing urination. With nerve connection, the possibility of having tactile and erotic sensation exists in men after the operation. For having an erection, a penile implant or prosthesis will usually be required after the surgery. Also, with urethral lengthening, standing urination will be possible for many individuals.

Why is Urethral Lengthening Performed?

The ability to urinate while standing is a major priority for many trans men. Urethral lengthening is the most important step for achieving the ability to urinate while standing. Urethral lengthening also helps create a more natural shape for the penis.

Common Complications of Urethral Lengthening

Urethral lengthening is a critical part of phalloplasty that may also have complications. Fistula is one of the complications of urethral lengthening. A fistula creates an abnormal passage between the urethra and the skin. Neo-urethral stricture (narrowing) is another complication of urethral lengthening that may require reconstructive surgery. Statistics show that the rate of fistula or stricture after the operation is about 49 percent.

What is Scrotoplasty and Testicular Creation?

Another stage of phalloplasty is the creation of the scrotum or Scrotoplasty in trans men. In this stage, the necessary tissue is harvested from areas such as the skin of the vagina and transferred to the genital area in the shape of a scrotum. After the creation of the scrotum, testicular prostheses can be placed inside it to give the genitalia a more natural appearance.

Stages of Scrotum Creation and Testicular Prosthesis Placement

Initially, the scrotum is constructed with tissue. In some cases, this procedure may be performed as a separate operation. After healing, the testicular prosthesis is placed. This is usually done in the third stage, after the initial placement of the penis and its healing. Post-operative monitoring is performed for infection, necrosis, and the status of the prosthesis.

Advantages of Phalloplasty

Phalloplasty brings many advantages for trans men, both physically and psychologically:

• Possibility of creating a larger penis with a natural appearance
• Ability to urinate while standing
• Capability for erection implant placement
• Possibility of tactile and erotic sensation due to innervation
• Improvement in psychological and sexual quality of life

Complications of Phalloplasty

Like any major surgery, this procedure will have complications in addition to its advantages:

• Urinary fistula
• Urethral stricture (narrowing)
• Flap necrosis (death of part of the tissue)
• Infection
• Vascular thrombosis in a free flap
• Scarring at the donor site

Warning Signs After Surgery

If you observe any of the following after phalloplasty, immediately contact your surgeon or surgical team:

• Severe pain, swelling, or color change of the flap
• Abnormal or foul-smelling discharge from the wound
• Fever or signs of infection
• Urinary problems such as blockage, urine leakage, or fistula
• Pain or issues with the catheter

Physiotherapy and Care Protocol for the Donor Site

The donor site requires special care after tissue removal for reconstruction. For example:

• Physiotherapy to maintain range of motion and prevent restrictive scarring
• Wound care, dressing changes, monitoring of healing
• Gentle exercises prescribed by the doctor to prevent reduced blood flow and fibrous tissue formation
• Neurological evaluation for nerve sensation after the operation

Success Rate of Phalloplasty

Despite its complexity, phalloplasty surgery has a high success rate. In a large study examining 269 individuals with forearm and groin flaps, a success rate of about 97% was observed. Also, according to meta-analysis, the patient satisfaction rate after the operation is about 90%.

What to Expect After Phalloplasty?

Individuals have expectations about the size, appearance, and function of their penis after the operation. The size and diameter of the constructed penis depend on various factors such as the surgeon's design, the type of flap, the patient's tissue, and other factors. Generally, the forearm flap allows for the construction of a longer penis. The appearance of the constructed penis will be largely natural, especially after the testicular prosthesis. Also, functionally, if the urethra is lengthened, the ability to urinate while standing, tactile sensation, and erection with an implant will be possible.

Types of Implants and Their Function

After initial healing, some individuals use an implant for erection. Implants have different types:

• Two-piece: Includes a cylinder within the neophallus shaft along with a pump in the scrotum or at the base of the penis.
• Three-piece: Includes a cylinder, a pump, and a reservoir, offering a very natural erection but requiring a complex surgery.
• Silicone implant: Depending on the brand, design, durability, and complexity, it varies.

Cost of Phalloplasty in Iran and Comparison with Other Countries

Phalloplasty is considered an expensive operation due to its complexity. In Iran, the cost of the operation varies from about 400 to 900 million Tomans. The cost of phalloplasty in other countries is around $35,000 to $50,000, which is significantly higher compared to the cost in Iran.

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This article reviews phalloplasty, one of the important surgeries in male gender reassignment surgery (FTM), and explains the different methods of constructing a penis from body tissue (such as the forearm, thigh, or abdomen). It also describes the surgical steps, urethral creation, nerve connection, and the possibility of using implants for erection and standing urination. The article also discusses the advantages, limitations, possible complications, and postoperative care so that the reader has a complete view of this complex process and its effects.

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Frequently Asked Questions

Does sensation return after phalloplasty?

Yes, in many cases, with nerve connection, tactile and erotic sensation returns. Statistics show that about 88% of individuals have experienced the return of sensations.

Is ejaculation possible after phalloplasty?

Phalloplasty itself does not cause ejaculation or semen discharge because it is not sperm-producing.

Does menstruation continue after phalloplasty?

If the ovaries have not been removed, menstruation may continue. Otherwise, menstruation will stop with the removal of the uterus and ovaries.

How many centimeters does phalloplasty usually add?

The final size depends on factors such as the method, flap dimensions, and the surgeon's design, and a fixed number for the size cannot be stated.

When can an implant be installed?

The erectile implant is usually placed in the next stage of phalloplasty, after the complete healing of the flap and the confirmation of its health, which is about six to twelve months later.

Does orgasm occur after phalloplasty?

Many individuals have experienced orgasm after phalloplasty, especially if the nerve connection has been successful.

How long does it take for the penis to have normal function?

It may take 12 months or more, depending on the stages of surgery and tissue repair.