Phalloplasty
Phalloplasty is the surgical construction of a penis from the body's own tissue, in several surgical stages, generally undertaken by biological females living as trans men. It is technically one of the most complex plastic-surgical pathways in existence, with a high complication rate and a high number of necessary follow-up operations. The end result is not a functional penis in a biological sense — there is no spontaneous erection, no sperm production, no reproductive capacity — but a neopenis with variable cosmetic and functional outcomes.
Techniques and donor sites
The most used technique is the radial forearm free flap (RFF). A large piece of skin and subcutaneous tissue is taken from the forearm, including blood vessels and nerves, and connected to the pubic area. An alternative is the anterolateral thigh flap (ALT) or a back flap (MLD). Each method leaves a large scar at the donor site — with RFF that is a conspicuous, lifelong-visible scar on the forearm that is regularly recognised as a phalloplasty scar.
Donor-site morbidity
Removing a large piece of tissue from arm or thigh is not a minor procedure. Possible consequences include: permanent reduction of strength and sensation in the arm or leg, limited hand function (with RFF), chronic pain at the donor site, sensitivity to temperature or pressure, lymphatic problems and a cosmetically very visible scar. With the ALT technique the scar is less visible but the removed tissue is larger; with RFF the scar is highly visible.
High complication and re-operation rates
Phalloplasty has one of the highest complication rates within surgery. From large series it follows that:
- Urethral strictures (narrowings in the constructed urethra) occur in roughly a third to half of patients and almost always require follow-up surgery.
- Urethral fistulas (leakage in which urine escapes through the skin) are likewise common; repair is difficult and often requires multiple procedures.
- Flap necrosis (partial or total death of the constructed shaft) is a feared complication, the total loss of the neopenis being one possible consequence.
- Infections, haematomas, wound dehiscence occur frequently.
- Erectile prostheses, required for penetrative sex, have a high failure rate and must be replaced regularly.
- Re-operations: it is normal for a patient to undergo several correction, urethral reconstruction and prosthesis placement procedures after the initial construction. Three to six operations is not exceptional.
Stages and duration
A phalloplasty pathway generally consists of two to four planned surgical stages, with recovery intervals in between. Including revisions, the complete pathway can take four to six years or longer. That is a considerable claim on the patient's life.
Sensation and sexuality
Tactile and erogenous sensation is attempted to be restored by connecting nerves in the flap to nerves in the pubic region. Results are variable. Some patients report good sensation, others little or none. Sexual function almost always requires an erectile prosthesis; spontaneous erection is biologically impossible.
Infertility and irreversibility
The procedure usually goes together with (or follows) hysterectomy and possibly oophorectomy, with definitive loss of fertility. Phalloplasty itself is irreversible: the neopenis can be removed, but the original anatomy cannot be restored.
Metoidioplasty as a less invasive alternative
Metoidioplasty makes use of the clitoris enlarged by testosterone. The result is a small penis with its own sensation, generally without the possibility of penetrative sex. Complication rates are considerably lower than with phalloplasty, and there is no donor-site morbidity. For those whose primary goal is standing urination, this can suffice.
Reimbursement
Performed in the Netherlands at Amsterdam UMC, reimbursed from the basic insurance within the gender care pathway. Waiting times are substantial. See also Waiting times and care pathway, Detransition and Cass Review.