Phalloplasty: Procedure, Benefits, Risks, Recovery and Alternatives

Phalloplasty is a complex and life-changing surgical procedure that creates or reconstructs a penis (phallus). It is most commonly performed for transgender men seeking gender-affirming surgery, but is also used in cisgender men with congenital or acquired penile insufficiency. As surgical techniques and patient care have evolved, so have the options, outcomes, and expectations for those considering phalloplasty. This article provides a comprehensive, evidence-based overview of the procedure, its benefits, risks, the recovery journey, and available alternatives.

Phalloplasty: The Procedure

Phalloplasty is a highly individualized and technically demanding surgery. It generally involves constructing a neophallus using tissue flaps from other parts of the body. The goals are to create a penis with a natural appearance, sensation, and, when possible, the ability to urinate while standing and engage in sexual activity. The procedure can be single-stage or multi-stage, depending on patient needs and surgical technique.

Technique	Donor Site/Flap	Key Features	Sources
Radial Forearm	Forearm	"Gold standard", sensation, standing urination	5 8 14
ALT Flap	Anterolateral Thigh	Less donor site scarring, good bulk, sensation	4 5
Fibular Flap	Fibula (lower leg)	Includes bone for rigidity, sensation possible	2 5
Metaidoioplasty	Clitoris (enlarged)	Minimally invasive, small phallus, limited penetration	15 16

Table 1: Common Phalloplasty Techniques and Features

Surgical Techniques Explained

• Radial Forearm Free Flap (RFFF):

  • The most established technique, using skin, nerves, and blood vessels from the forearm to sculpt the neophallus.
  • Offers reliable tactile and some erogenous sensation after nerve connection (coaptation).
  • Enables urethral lengthening for standing urination and implantation of erectile devices for penetrative sex 5 8 14.
  • Leaves a noticeable scar on the forearm.

• Anterolateral Thigh (ALT) Flap:

  • Uses tissue from the thigh, reducing visible scarring in more noticeable areas.
  • Provides good tissue bulk and can be sensate.
  • Suitable for patients with adequate thigh tissue 4 5.

• Fibular Osteocutaneous Flap:

  • Involves taking bone and skin from the lower leg, providing inherent rigidity.
  • Often chosen for patients who desire a neophallus with natural firmness.
  • Can be combined with nerve coaptation for sensation 2 5.

• Metaidoioplasty:

  • An alternative, less invasive procedure utilizing an enlarged clitoris (enlarged via hormone therapy) to form a small phallus.
  • Less scarring and fewer stages, but limited in size and sexual function 15 16.

Key Steps in Phalloplasty

• Donor Tissue Harvest: Tissue flap is taken from the chosen site.
• Neophallus Construction: The tissue is shaped and connected to blood vessels and nerves.
• Urethral Lengthening: Allows for urination while standing; not every patient chooses this option 2 9.
• Implantation of Erectile Device: Optional, often performed in a later stage for sexual function 3 12.
• Glansplasty: Creation of the glans (penis head) for a natural appearance.
• Scrotoplasty: Construction of a scrotum with or without testicular implants.

The choice of technique and steps depends on the patient’s anatomy, goals, and preferences. Some patients may opt for phalloplasty without urethral lengthening to reduce complications, accepting that they will not be able to urinate standing up 17.

Benefits and Effectiveness of Phalloplasty

Phalloplasty can have profound effects on physical function, psychological well-being, and quality of life. Its effectiveness is measured by functional, aesthetic, and psychosocial outcomes, as well as patient satisfaction.

Benefit	Description	Outcome Highlights	Sources
Functional	Standing urination, sexual activity, tactile sensation	88-94% achieve urination and sensation; most can orgasm	8 11 12 13 14
Psychosocial	Gender dysphoria relief, confidence, improved self-esteem	High satisfaction and improved well-being	1 5 8
Aesthetic	Natural appearance, minimal visible scarring	High satisfaction with appearance	4 8 13
Patient Satisfaction	Overall contentment with results	90-91% report being satisfied	1 8 13

Table 2: Benefits and Effectiveness of Phalloplasty

Functional Outcomes

• Urination: Most patients who undergo urethral lengthening can void while standing (84–92%) 8 11 12 13. Those who choose not to have urethral reconstruction avoid many complications but must urinate sitting down 17.
• Sexual Function: Sensation (both tactile and erogenous) is achieved in the majority (88–94%) of patients with nerve-connected flaps, especially RFFF and ALT 8 12 13 14. Most patients (97–98%) can achieve orgasm 12 14.
• Penetrative Sex: Many opt for erectile device implantation to enable penetrative intercourse. Satisfaction with these devices varies 3 12 18.

Psychosocial and Aesthetic Benefits

• Gender Dysphoria Relief: Phalloplasty is associated with significant improvements in gender dysphoria, confidence, and sexual self-esteem 1 5 8.
• Aesthetic Outcomes: High rates of satisfaction with the appearance of the neophallus are reported, especially with advanced techniques 4 8 13.

Patient Satisfaction

• Most patients are satisfied with their surgical results (90–91%), both functionally and psychologically 1 8 13.
• Satisfaction is higher with primary (single-stage) urethroplasty than with staged procedures 7.

Risks and Side Effects of Phalloplasty

While phalloplasty offers substantial benefits, it is also associated with significant risks and potential complications. Understanding these is crucial for informed decision-making.

Complication	Incidence / Nature	Impact on Patient	Sources
Urethral Fistula	25–34% (trans males); up to 49% overall	May require revision surgery	8 10 11 12 13
Urethral Stricture	20–25%	Difficulty urinating, may require surgery	8 10 11 12 13
Flap Complications	8–11% (partial necrosis, failure)	May need additional surgery	7 11 12
Prosthesis Issues	11–28% (erosion, infection, malfunction)	May need device removal/replacement	3 12 13 18
General	Infection, hematoma, scarring, loss of sensation	Varies	1 5 11 12

Table 3: Common Risks and Complications of Phalloplasty

Urethral Complications

• Fistula: An abnormal connection between the urethra and the skin, causing urine leakage.
• Stricture: Narrowing of the urethra, leading to difficulty urinating.
• Urethral complications are the most common and may require multiple revision surgeries 8 10 11 12 13.
• Risks are higher in trans men than cis men, and with staged urethroplasty versus primary single-stage repair 7 13.

Flap-Related Complications

• Partial Flap Necrosis: Loss of some tissue due to inadequate blood supply, seen in 8–11% of cases 7 11 12.
• Graft Failure: Rare, but may necessitate reoperation.

Erectile Device Complications

• Infection, Erosion, Malfunction: Prosthetic devices can fail, erode through tissue, or become infected (11–28% incidence) 3 12 13 18.
• Many patients have concerns about the risks, need for further surgery, and cost of prosthetic devices 18.

Other Risks

• General Surgical Risks: Infection, hematoma, blood loss, scarring at donor site, loss of sensation, and dissatisfaction with results 1 5 11 12.
• Psychological Impact: While most report improved well-being, some may experience disappointment if expectations are not met, especially regarding size and function 6 15.

Recovery and Aftercare of Phalloplasty

The journey to recovery after phalloplasty is lengthy and demands patience, support, and attentive aftercare. Recovery timelines and experiences vary based on surgical technique, individual health, and the occurrence of complications.

Recovery Phase	Focus	Typical Duration	Sources
Hospital Stay	Monitoring, wound care	7–14 days	5 8 11 12
Initial Healing	Flap integration, catheter care	4–6 weeks	5 11 12
Rehab/Follow-up	Mobility, sensation, prosthesis	Months to 1 year	8 12 14
Revisions	Address complications, refinements	Varies (months–years)	10 11 12 13

Table 4: Recovery and Aftercare Timeline for Phalloplasty

Immediate Postoperative Period

• Hospitalization: Lasts about 1–2 weeks for monitoring blood flow to the flap, pain management, and wound care 5 11 12.
• Catheterization: Urinary catheter remains in place for several weeks to protect the new urethra and allow healing.

Early Recovery

• Healing: Most patients require 4–6 weeks for initial healing of the donor and recipient sites.
• Limited Activity: Patients are advised to avoid strenuous activity to promote proper integration of the new tissue 5 11 12.
• Wound Care: Daily wound checks, cleaning, and sometimes negative pressure wound therapy.

Long-Term Aftercare

• Rehabilitation: Sensation and function continue to improve over months. Regular follow-up is essential to monitor for complications and assess nerve regeneration 8 12 14.
• Prosthesis Placement: If desired, erectile devices are usually implanted in a later stage, typically 6–12 months after initial surgery 3 12.
• Additional Procedures: Some may need revision surgeries for urethral or flap complications 10 11 13.
• Psychological Support: Counseling can aid mental health and adjustment during recovery.

Patient Experience

• Sensation: Sensory recovery is gradual, often taking months to years. Most regain tactile and some erogenous sensation 14.
• Urination and Sexual Function: Ability to urinate standing and sexual function are restored for most, but may require additional interventions 8 11 12 13.
• Quality of Life: Despite the demanding recovery, most patients report improved quality of life and satisfaction with their outcomes 1 8 13.

Alternatives of Phalloplasty

Phalloplasty is not the only option for those seeking genital gender-affirming surgery or penile reconstruction. Several alternatives exist, each with its own benefits and limitations.

Alternative	Description	Key Benefits	Sources
Metoidioplasty	Uses hormonally enlarged clitoris	One-stage, minimal scarring, preserves sensation	15 16
Phalloplasty w/o UL	Phalloplasty without urethral lengthening	Fewer complications, normal appearance	17
Augmentation Phalloplasty	Cosmetic enhancement of existing penis	Modest size increase, improved self-esteem	6
Penile Prosthesis	Devices for erectile function	Non-surgical alternatives available	18

Table 5: Key Alternatives to Phalloplasty

Metoidioplasty

• What It Is: A one-stage procedure that uses the hormonally enlarged clitoris to construct a small phallus.
• Advantages: Less invasive, no large donor site scars, preserves natural sensation, fewer complications.
• Limitations: Results in a small phallus, generally not suitable for penetrative sex 15 16.

Phalloplasty Without Urethral Lengthening

• What It Is: Neophallus is created without extending the urethra through it.
• Advantages: Greatly reduced risk of urethral complications, still allows for natural appearance and scrotoplasty.
• Limitations: Patient must urinate sitting down; some may find this a significant drawback.
• Patient Preferences: Many value reduced complications over the ability to urinate standing 17.

Augmentation Phalloplasty

• What It Is: Cosmetic procedures to increase length or girth of an existing penis, mainly for men with penile dysmorphophobia.
• Advantages: Modest improvements in size, high satisfaction in selected patients.
• Limitations: Not suitable for those lacking a penis or seeking gender affirmation 6.

Penile Prosthesis and Non-Surgical Options

• Internal Prosthesis: Can be implanted in a neophallus for sexual function, but many have concerns about risks and failure 3 18.
• External Devices: Some patients explore non-surgical devices for erections, especially if concerned about implant complications 18.

Conclusion

Phalloplasty is a transformative procedure that offers many individuals the chance to align their bodies with their identities and goals. It is complex, with remarkable benefits and significant risks, and should be approached with comprehensive information and support.

Key takeaways:

• Multiple Techniques: Options include RFFF, ALT, fibular flap, and metoidioplasty, each with unique advantages 4 5 8 15 16.
• High Satisfaction: Most patients achieve standing urination, sensation, and improved well-being 1 8 12 13 14.
• Risks Remain: Urethral complications and prosthesis issues are common; staged procedures and certain techniques increase risks 7 8 10 11 12 13 18.
• Recovery Is Lengthy: Healing can take months to years, often requiring multiple surgeries and ongoing aftercare 5 11 12 14.
• Alternatives Exist: Metoidioplasty, phalloplasty without urethral lengthening, and augmentation procedures may better suit some individuals 6 15 16 17.
• Shared Decision-Making Is Crucial: Every patient’s priorities and anatomy are unique; thorough counseling and personalized planning are essential for optimal outcomes.

If you are considering phalloplasty or related procedures, consult with an experienced multidisciplinary surgical team to discuss your goals, options, and the journey ahead.