Phalloplasty

Phalloplasty refers to the construction (or reconstruction) of a penis or, sometimes, artificial modification of the penis by surgery, often for cosmetic purposes. It is also occasionally used to refer to penis enlargement.

The first phalloplasty done for the purposes of sexual reassignment was performed on trans man Michael Dillon in 1946 by Dr. Harold Gillies, which is documented in Pagan Kennedy's book The First Man-Made Man.

Indications

A complete construction or reconstruction of a penis is done on:

• Patients with congenital anomalies such as micropenis, epispadias, and hypospadias,
• Patients who have lost their penis,
• Female-to-Male transsexual patients.

Techniques and related procedures

There are four different techniques for phalloplasty. All of the techniques involve taking a graft of tissue from a donor site and extending the urethra. A penis of up to 7 inches (14–18cm) long with a circumference up to 5.9 inches (11–15cm) can be created with each of the methods.

Surgery on cisgender men is more simple than on trans men, because the urethra requires less lengthening. The urethra of a trans man ends near the vaginal opening and has to be lengthened considerably. The lengthening of the urethra is when most complications occur.

With all types of phalloplasty in trans men, scrotoplasty can be performed using the labia majora (vulva) to form a scrotum where prosthetic testicles can be inserted. If vaginectomy, hysterectomy and/or oophorectomy have not been performed, they can be done at the same time.

Unlike metoidioplasty, phalloplasty requires an implanted erectile prosthesis to achieve an erection (and enable sexual penetration). This is usually done in a separate surgery to allow time for healing. There are several types of erectile prostheses, including malleable rod-like medical devices that allow the neo-penis to either stand up or hang down. 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 constructed penii are less than the success rates of reconstruction in cisgender men. Good sensation in the reconstructed penis can help reduce the risk of the implant eventually eroding through the skin.^[1]

Earlier techniques used a bone graft as part of reconstruction. Long-term follow-up studies from Germany and Turkey of more than 10 years proved that these reconstructions maintain their stiffness without late complications. Unfortunately, it results in a penis that has no ability to become flaccid again without breaking the internal bone graft.

Lengthening can also achieved by a procedure that releases the suspensory ligament where it's attached to the pubic bone, thereby allowing the penis to be advanced toward the outside of the body. The procedure is performed through a discreet horizontal incision located in the pubic region where the pubic hair will help conceal the incision site. No incision is made on the penis itself.

As of November 2009, there is research in progress to synthesize corpus cavernosa (erectile tissue) in the lab on rabbits for eventual use in patients requiring penile construction surgery. Of the rabbits used in the preliminary studies, 8 had biological responses to sexual stimuli that was similar to the tissue of a male rabbit that was not part of the study.^[2]

Phalloplasty techniques explained

Graft from the arm

An operation using the forearm as a donor site is the easiest to perform, but results in a cosmetically undesirable scar on the exposed area of the arm. Arm function may be hampered if the donor site does not heal properly. Electrolysis and/or laser hair reduction is required for a relatively hairless neophallus.

Sometimes a full-scale metoidioplasty is done a few months before the actual phalloplasty to reduce the possibility of complications after phalloplasty. Sensation is retained through the clitoral tissue at the base of the neophallus, and surgeons will often attempt to graft nerves together from the clitoris or nearby. Nerves from the graft and the tissue it has been attached to may eventually connect. This does not necessarily guarantee the ability to achieve genital orgasm after healing, as the most important task of nerve reconnection is to ensure the penis is able to sense injury.

The following explanation of this technique has many similarities to other approaches, but the construction of the glans differs.

• The surgery starts (after the patient is prepped) with the forearm marked for graft size. After the graft is taken, another graft may be used to reconstruct the arm (resulting in a secondary scar).
• The graft skin is dissected to expose the veins and antebrachial cutaneous nerves. (the latter done carefully for later reattachment)
• If the urethra is being constructed at the same time as the phallus, it is joined at this step. If not, the glans is shaped. Sometimes glansplasty is done in a separate surgical stage after urethral extension.
• A segment of vein going to the patient's groin is "borrowed" to allow easier joining of the graft with the preexisting tissues.
• The vein is carefully attached to the femoral artery.
• The blood supplies from the flap and the vein leading to the femoral artery are joined.
• The clitoral hood and ligament is cut away, and the nerve bundle is isolated for the time being. Important: while this assumes the clitoral tissue is assimilated (buried) into the penis base, some surgeons give the option of leaving it as-is in a post metoidioplasty like state.
• The flap is partially attached physically while the surgeon attempts to join the nerve bundles.
• If the urethra was extended, it is now joined with a catheter that will remain in place for healing purposes for two to four weeks. Otherwise, the skin is sutured up and/or the scrotum is fabricated.

If the patient chooses to have the urethra extended to the glans of the neophallus, it is formed by the following steps:

• The labia minora is injected with a mixture of saline and epinephrine.
• It is then split open and layers separated using sharp and blunt dissection.
• The layers are wrapped around a catheter and stitched.
• A mucosal flap from the vagina may be used to bridge the urethra with the extension. This is often done in a separate procedure. Alternative graft locations include the mouth/cheeks or experimentally, the intestines. If the labia minora is not used during construction of the urethral extension, (or in the chance there is enough material remaining) it can be used during glansplasty to provide for better results compared with a full thickness skin graft.

Patient satisfaction and concerns

The overall aesthetic satisfaction rate for forearm phalloplasty is 90% in spite of its shortcomings. 83% of patients who replied to a study reported good superficial (skin) sensation. Only 9% had erogenous sensitivity in their neopenis, and only 51% were able to perform satisfactorily during intercourse (defined as being able to penetrate their partner successfully without difficulty or pain).

Post-op depression which required temporary use of anti-depressants were noted by 27% of those who replied, with one suicide attempt not related to the surgery outcome. After surgery, 40% were able to apply for employment positions that they were unable to fill when they were legally female. 93% of patients stated that after phalloplasty, they were happy with their genitals.

Graft from the side of the chest

A relatively new technique involving a graft from the side of the chest under the armpit (known as a musculocutaneous latissimus dorsi free transfer flap) is a step forward in phalloplasty. The advantages of this technique over the older forearm flap technique include:

• Hairlessness (little to no electrolysis needed)
• Aesthetic appearance of normally colored skin (the glans may be tattooed to proper color)
• Capable of tactile sensation (as with any form of phalloplasty, this does not necessarily mean the ability to have a genital orgasm after healing, as the erogenous zone is limited to the base of the penis)
• Leaves an inconspicuous scar
• Has a lower occurrence of complications from both the initial surgery and the erectile prosthesis insertion

This is a three part surgery that takes place over a period of six to nine months. The steps consist of:

Neophallus creation using MLD free flap

• The surgery starts (after the patient is prepped) with the side of the chest marked for graft size.
• The graft skin is dissected to expose the veins and the thoracodorsal nerves.
• The graft, while still attached to the blood supply, is formed to a rough phallus shape by rolling the edges together.
• A segment of vein going to the patient's groin is "borrowed" to allow easier joining of the graft with the preexisting tissues.
• The vein is carefully attached to the femoral artery.
• The blood supplies from the flap and the vein leading to the femeral artery are joined.
• The clitoral hood and ligament are cut away and the nerve bundle is isolated.
• The flap is partially attached physically while the surgeon attempts to join the nerve bundles.

During initial recovery, the neophallus is protected from contact with other tissues with a specially constructed dressing as to avoid blood supply complications.

After three months, urethroplasty (urethral extension) is performed.

• The neophallus is dissected and a buccal (oral) mucosa graft inlaid into the created cavity and extended to the native urethra and joined to permanently allow urination while standing
• A catheter is placed for several weeks to allow for proper healing

After another three to six months, a device that allows an erection can be inserted.

Graft from the leg

The lower leg operation is similar to forearm graft with the exception that the donor scar is easily covered with a sock and/or pants and hidden from view. Other details are same as forearm graft, especially the need for permanent hair removal before the operation. A graft from the leg or another area where the scar is less noticeable may be combined with free forearm graft to sculpt the glans penis.

Pubic area flap

The graft location is around the pelvic bone, usually running across the abdomen under the belly button. As such, there is a large horizontal scar that may not be aesthetically acceptable. The grafts have a less natural appearance and may not maintain an erectile implant long term. Electrolysis is required before surgery with the alternative being clearing of hair via shaving, or chemical depilatory.

Gillies technique

This technique was pioneered by Sir Harold Delf Gillies as one of the first competent phalloplasty techniques. It was simply a flap of abdominal skin rolled into a tube to simulate a penis, with urethral extension being another section of skin to create a "tube within a tube." Early erectile implants consisted of a flexible rod. A later improvement involved the inclusion of a blood supply pedicle which was left in place to prevent tissue death before it was transplanted to the groin. Most latter techniques involve tissues with attached pedicle.

Abdominal muscle

Skin grafted muscle flaps have fallen from popularity. This procedure is a minimum of 3 steps and involves implantation of an expansion balloon to facilitate the amount of skin needed for grafting. The grafts have a less natural appearance and are less likely to maintain an implant erectile long term.

Future

In the future, bioengineering may be used to create fully functional penises. ^[3]

Common complications

As phalloplasty has improved over the decades, the risks and complications from surgery have been reduced. However, there is still a possibility of a need for revision surgery to repair incorrect healing.

A study of post-op men showed that on average, 25% had one or more serious complications of the neopenis. The ones reported consisted of:

• Loss of the phallus from either disease or blood supply issues
• Cephalic vein thrombosis (blood clot)
• Arterial ischaemia (shortage of blood supply)
• Infection
• Distal limited necrosis (death of parts of the penis)
• Haematoma (bruise)

In the same study, chances of complications of the extended urethra were higher, averaging 55%. The most common complications reported were:

• Urinary fistula (hole) requiring perineal urethrostomy
• Urinary fistula (hole) with conservative treatment
• Urinary retention (from stenosis or narrowing of the new urethra)
• (Erectile) prosthesis change (from complications)
• (Erectile) prosthesis explantation (removal of the prosthesis without replacement)

See also

Medicine portal

• Sex reassignment
• List of transgender-related topics
• Penis transplantation
• Foreskin restoration

References

1. ^ Erectile Implants in Female-to-Male Transsexuals: Our Experience in 129 Patients by Piet B. Hoebeke, Karel Decaestecker, Matthias Beysens, Yasmin Opdenakker, Nicolaas Lumen and Stan M. Monstrey (European Urology, February 2010)
2. ^ Bioengineered corporal tissue for structural and functional restoration of the penis by Kuo-Liang Chen, Daniel Eberli, James J. Yoo, and Anthony Atala (Proceedings of the National Academy of Sciences, Vol. 106 No. 45, November 9, 2009)
3. ^ Chen KL, Eberli D, Yoo JJ, Atala A (November 2009). "Regenerative Medicine Special Feature: Bioengineered corporal tissue for structural and functional restoration of the penis". Proceedings of the National Academy of Sciences of the United States of America 107 (8): 3346–50. doi:10.1073/pnas.0909367106. PMC 2840474. PMID 19915140. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2840474. 

• Total Phalloplasty Using a Musculocutaneous Latissimus Dorsi Flap by Sava V. Perovic, Rados Djinovic (British Journal of Urology, Reconstructive Urology, Volume 100 Issue 4, Sep 2007)
• New Technique of Total Phalloplasty With Reinnervated Latissimus Dorsi Myocutaneous Free Flap in Female-to-Male Transsexuals by Vesely, Jiri; Hyza, Petr; Ranno, Raul; Cigna, Emanuele; Monni, Nicola; al etc. (Annals of Plastic Surgery, Volume 58 Issue 5, May 2007)
• Simultaneous Penis and Perineum Reconstruction Using a Combined Latissimus Dorsi-Scapular Free Flap with Intraoperative Penile Skin Expansion by Rohrich, Rod J.; Allen, Terry; Lester, Fred; Young, Jonathan P.; Katz, Scott L. (Journal of Plastic and Reconstructive Surgery, Volume 99 Issue 4, April 1997)
• Neophalloplasty in Female-to-Male Transsexuals with the Island Tensor Fasciae Latae Flap by Santanelli, Fabio M.D., Ph.D.; Scuderi, Nicolò (Journal of Plastic and Reconstructive Surgery, Volume 105 Issue 6, May 2000)
• A New Surgical Procedure for Phallic Reconstruction: Istanbul Flap by Mutaf, Mehmet (Journal of Plastic and Reconstructive Surgery, Volume 105 Issue 4, April 2000)
• One-Stage Reconstruction of the Penis with Composite Iliac Crest and Lateral Groin Skin Flap by Sun, Guang-ci M.D.; Huang, Jin-jing (Annals of Plastic Surgery, Volume 15 Issue 6, December 1985)
• A Novel Single-Flap Technique for Total Penile Reconstruction: The Pedicled Anterolateral Thigh Flap by Lee, Gordon K.; Lim, Angeline F.; Bird, Erin (Journal of Plastic and Reconstructive Surgery, Volume 124 Issue 1, July 2009)
• Penile Reconstruction by the Free Scapular Flap and Malleable Penis Prosthesis by Yang, Mingyong; Zhao, Muxin; Li, Senkai; Li, Yangqun (Journal of Plastic and Reconstructive Surgery, Volume 59 Issue 1, July 2007)
• Hage, J. Joris. Peniplastica Totalis to Reassignment Surgery of the External Genitalia in Female-to-Male Transsexuals. ISBN 9053831150. 
• Long-Term Follow-Up of Total Penile Reconstruction with Sensate Osteocutaneous Free Fibula Flap in 18 Biological Male Patients by Sengezer, Mustafa; Öztürk, Serdar; Deveci, Mustafa; Odabasi, Zeki (Journal of Plastic and Reconstructive Surgery, Volume 114 Issue 2, August 2004)
• Long-Term Fate of the Bony Component in Neophallus Construction with Free Osteofasciocutaneous Forearm or Fibula Flap in 18 Female-to-Male Transsexuals by Papadopulos, Nikolaos A.; Schaff, Juergen; Biemer, Edgar (Journal of Plastic and Reconstructive Surgery, Volume 109 Issue 3, March 2002)
• Use of forearm free-flap phalloplasty in bladder exstrophy adults by Marc-Olivier Timsit, Pierre Mouriquand, Alain Ruffion, Alain Bouillot, Diala Dembelé, Arnaud Mejean, Fanny Lalloue, Albert Leriche and Nicolas Morel-Journel (BJU International, Volume 103 Issue 10, Dec 2008)
• Phalloplasty for female transsexuals with sensate free forearm flap by Rong-Hwang Fang, Jin-Teh Lin, Shiuh Ma (Microsurgery, Volume 15 Issue 5, Oct 2005)
• Long-term outcome of forearm flee-flap phalloplasty in the treatment of transsexualism by Albert Leriche, Marc-Olivier Timsit, Nicolas Morel-Journel, André Bouillot, Diala Dembele and Alain Ruffion (BJU International, Volume 101 Issue 10, Jan 2008)
• Penile Reconstruction: Is the Radial Forearm Flap Really the Standard Technique? by Monstrey, Stan; Hoebeke, Piet; Selvaggi, Gennaro; al etc. (Journal of Plastic and Reconstructive Surgery, Volume 124 Issue 2, August 2009)
• Addressing the ideal requirements by free flap phalloplasty: Some reflections on refinements of technique by J. Joris Hage, Floris H. De Graaf (Microsurgery, Volume 14 Issue 9, Oct 2005)
• Total Phallic Construction in Female to Male Transsexuals by Giulio Garaffa, Nim A. Christopher, David J. Ralph (Current Urology, Vol. 3, No. 3, 2009)

• Gender Reassigment by Dan Greenwald and Wayne Stadelmann (eMedicine Journal, Volume 2 Number 7, July 6, 2001)
• Gender Identity Disorders: Diagnostic and Surgical Aspects by Michael Sohn, and Hartmut Bosinski, MD (Journal of Sexual Medicine, Volume 4 Issue 5, Aug 2007)
• Glans sculpting in phalloplasty — experiences in female-to-male transsexuals by Rong-Hwang Fang, Yi-Sheng Kaoa, Shiuh Ma, Jin-Teh Lin (Journal of Plastic, Reconstructive & Aesthetic Surgery, Volume 51, Issue 5, July 1998)
• Severe Penile Injuries: Etiology, Management and Outcomes by Sava V. Perovic, Urologia Polska (Polish Journal of Urology) 2005/58/3, ISSN 0500-7208.

External links

• Video: Minimally Invasive Penile Implant Surgery (note: while this is being performed on a cismale, the procedure is similar during phalloplasty)