Phalloplasty: Phalloplasty as a gender-affirming operation – Medical explanation and aftercare

Introduction: Phalloplasty, often referred to as phalloplasty, is a complex operation and a major surgical procedure for the construction or reconstruction of a penis (neopenis or penoid). For many people, it represents a crucial step, whether as part of gender-affirming surgery (genital reconstruction) or for restoration following injuries or in cases of congenital malformations. This glossary entry on 4beauty provides you with a medically sound overview of phalloplasty surgery, the methods used, possible outcomes and important aspects such as risks and complications, as well as aftercare and covering the costs of follow-up treatment. Penile reconstruction aims to align the external genitalia with the individual’s gender identity and to affirm that identity.

What is a phalloplasty? The operation in detail

Phalloplasty – a reconstructive surgical procedure involving the formation or construction of a penis, also known as a penoid or neophallus; internationally referred to as phalloplasty – is one of the most extensive surgical procedures in reconstructive surgery and urology. The main aim of this operation is to create an aesthetically pleasing and functional penoid. Phalloplasty thus refers to a complex penoid reconstruction. Depending on individual wishes and circumstances, this may include the ability to urinate whilst standing, sexual sensation (connection of nerves and blood vessels) and the ability to penetrate during sexual intercourse (usually by means of a penile prosthesis or erectile prosthesis).

Indications: Who is a candidate for phalloplasty surgery?

A phalloplasty is performed surgically for a variety of reasons:

• Gender-affirming surgery (genital reassignment surgery): The most common indication for transgender men (FTM) or non-binary people who wish to undergo masculinising genital surgery. It is often a central part of the transition process, serving to affirm one’s gender identity.
• Congenital malformations: For example, in cases of aphallia (absence of the penis) or a pronounced micropenis.
• Loss or damage to the penis: Following accidents, burns, cancer surgery or other medical conditions requiring surgical reconstruction of the genitals.

The decision to undergo phalloplasty is a very personal one and requires comprehensive counselling from a specialist, as well as, as a rule, a psychological assessment and, in many cases, prior hormone therapy, particularly in the context of gender-affirming surgery.

Surgical techniques used in phalloplasty: penile reconstruction

There are various techniques for reconstructing a penis, which differ primarily in terms of the donor site for the skin flap (tissue graft).

Basic principle: Flap surgery and microsurgery

The basic principle of phalloplasty is based on the transplantation of the patient’s own tissue (skin flaps, fat, veins and nerves) from a donor site to the genital area. This requires microsurgical techniques to connect the fine blood vessels and nerves of the skin flap to the corresponding structures in the recipient area. This is crucial for the survival of the graft, good blood supply and subsequent sensitivity. A well-perfused skin flap is the basis for success.

An overview of common techniques: advantages and disadvantages

• Radial forearm free flap phalloplasty (RFFF – Radial Forearm Free Flap):
  • Sampling from the non-dominant forearm.
  • Advantages: Relatively thin, malleable tissue; good sensitivity can often be achieved; simultaneous lengthening of the urethra is possible.
  • Disadvantages: Visible scar on the forearm; requires healthy blood vessels.
• ALT phalloplasty (Anterolateral Thigh Flap):
  • Sampling from the outer thigh.
  • Advantages: The scar is usually less visible than on the forearm; potentially greater volume is possible.
  • Disadvantages: The tissue may be thicker; sensitivity may vary; hair may be present on the skin flap.
• Other options: Less commonly, other techniques such as the latissimus dorsi flap (from the back muscle) are used.

The choice of method depends on the patient’s anatomical characteristics, the objectives (to achieve the desired results) and the experience of the surgical team. An experienced surgeon will explain the advantages and disadvantages of each method.

The multi-stage surgical process involved in gender-affirming surgery

A phalloplasty operation is not usually a one-off procedure, but rather a multi-stage process that is often carried out in several stages and can take anywhere from months to years. Typical stages include:

1. Penile reconstruction Formation of the corpus cavernosum (phallus) from the selected skin flap.
2. Urethral reconstruction (urethroplasty) Creation of a new urethra (urethral lengthening) with a new urethral opening at the tip of the penis, enabling the patient to urinate whilst standing.
3. Glansplasty Cosmetic reshaping of the glans.
4. Scrotal plastic surgery Creation of a scrotum, often using tissue from the labia majora.
5. Insertion of testicular implants Testicular prostheses at a later date, once the scrotum has healed.
6. Fitting of a penile prosthesis (penile implant) Enables an erection for sexual penetration; a surgical procedure may also be required at a later stage, once healing is complete. A hydraulic pump is often required for the implant to function.

What results can be expected following phalloplasty surgery?

The results of a phalloplasty vary greatly from person to person. The functional and aesthetic goals sought are:

• Urination: The ability to urinate whilst standing is usually achieved.
• Sensitivity: A certain degree of tactile and, to some extent, erogenous sensitivity in the penoid is possible due to the connection of nerves and blood vessels.
• Sexual function: Sexual intercourse is possible with a penile prosthesis.
• Aesthetic appearance: Modern techniques aim to ensure that the reshaped penis looks as natural as possible.

Risks and possible complications of the surgical procedure

Phalloplasty is a complex operation and, like any major operation, carries general risks. In addition, there are specific complications:

• Urethral complications: Fistulas or urethral strictures are very common and may require further surgical intervention.
• Flap loss/necrosis: Partial or complete loss of the transplanted skin flap due to inadequate blood supply (rare, but serious).
• Infections: Both at the donor site and on the penoid.
• Scarring: Visible scars are inevitable.
• Problems with implants: dislocation, infection or mechanical failure of testicular or penile prostheses. Complications also include sensory disturbances.

It is essential that the treating surgeon or urologist provides comprehensive information about all potential risks and complications in order to prevent complications or detect them at an early stage.

Financial considerations and the importance of insurance against follow-on costs

Coverage of the costs for phalloplasty surgery and the treatment of complications can be complex. Insurance covering follow-up costs can provide financial security in the event that further treatment is required following the initial surgical procedure. This is an important part of planning post-operative care. The actual medical aftercare following the operation extends over many weeks after the procedure and involves regular check-ups to ensure the best possible results and to be able to respond promptly to any complications that may arise.

Questions and answers about phalloplasty surgery