Phalloplasty

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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 transman Michael Dillon in 1946 by Dr. Harold Gillies, which is documented in Pagan Kennedy's book The First Man-Made Man.

Contents

[edit] Indications

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

  • Patients with congenital anomalies such as micropenis, epispadias, and hypospadias
  • FtM transsexual patients
  • Cisgendered men who have lost their penis through minor to serious iatrogenic, accidental or intentional penile trauma injuries (or total emasculation).

There are four different techniques for phalloplasty. All of the techniques involve using a free graft of tissue that is removed from its original place, rolled up, with the urethra extended in some fashion, and grafted to its new place between the thighs. A penis of up to 7 inches (14-18 cm) long with a circumference up to 5.9 inches (11-15 cm) can be created with any of the methods in this article.

The basic procedures have similarities (except in extreme cases of micro/macropenis), although surgery on cisgendered men can be simpler, since the urethra still ends in the front of the genital area, whereas the urethra of transmen ends near the vaginal opening and has to be lengthened considerably. The lengthening of the urethra is a difficult part of total phalloplasty, and also the one where complications often occur.

With all types of phalloplasty in transmen, the labia majora (see vulva) are united 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.

An example of an implantable erectile prostheses
An example of an implantable erectile prostheses

Unlike metoidioplasty, phalloplasty requires an implanted erectile prosthesis to achieve an erection. (and enable sexual penetration) This is usually done in separate surgery for healing reasons. There are several types of erectile prostheses, ranging from malleable rod-like medical devices so the neo-penis can either stand up or hang down, to elaborate pumping systems. 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 a reconstructed penis have been poor. Good sensation of the reconstruction can help reduce the risk for the implant eventually eroding through the skin.

It is for this reason that living bone was first used inside the 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.

As of November, 2009, there is research being done on rabbits to synthesize corpus cavernosa (erectile tissue) in the lab for eventual use for patients requiring penile construction surgery. Of the rabbits used in the preliminary studies, 8 had biological response to sexual stimuli (from the synthetic erectile tissue) that was similar to the tissue of a (male) rabbit that was not part of the study. In the future, this would allow trans men a significantly improved end result (as part of) reassignment bottom surgery compared with phalloplasty techniques currently used today.

[edit] Techniques available

[edit] Graft from the arm

An example of an arm skin tissue donor site, partially dissected
An example of an arm skin tissue donor site, partially dissected

Of the four, an operation using the forearm as a donor site is most easy to perform, but results in a cosmetically undesirable scar on the exposed area of the arm. Arm function may be hampered as well if the donor site does not heal properly. Electrolysis and/or laser hair reduction is required for a relatively hair free 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 it. In addition, nerves from the graft and the tissue it has been attached to may connect after a while. This does not necessarily mean an ability to achieve genital orgasm after healing.

The following explanation of this technique has many similarities with the others, but the details, especially in construction of the glans, is what makes the difference at the moment due to lack of research in complete penile construction.

An example of a completed forearm skin graft
An example of a completed forearm skin graft
  • The surgery starts (after patient prep) with the forearm marked for graft size.
  • The graft skin is dissected to expose the blood supply veins, and the antebrachial cutaneous nerves. (the latter done carefully for later reattachment)
  • If the urethra is being constructed a the same time as the phallus, it is joined at this step otherwise the glans is shaped.
  • Going to the patients groin, a segment of vein is "borrowed" to allow easier joining of the graft with the preexisting tissues.
  • The above mentioned vein is carefully attached to the femoral artery.
  • The clitoral hood is cut away, and the nerve bundle is isolated for the time being.
  • The blood supply from the flap and the vein leading to the femeral artery are joined.
  • Now the flap it partially attached physically while the surgeon attempts to join the nerve bundles.
  • If the urethra was extended, it is joined now with the catheter remaining in place for healing purposes for about 2 weeks otherwise the skin is either 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 first injected full of a mixture of normal 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.
  • At this stage a mucosal flap from the vagina may be used to bridge the urethra with the extension.

Often, this is done in a separate procedure.

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 fill thickness skin graft.

[edit] Patient satisfaction and concerns

The overall aesthetic satisfaction rate for forearm phalloplasty is good (90%) in spite of it's shortcomings. The superficial (skin) sensation rate also fares well at 83% of patients who replied to a study. Unfortunately, only 9% had erogenous sensitivity in their neopenis and only about half (51%) were able to perform satisfactory during intercourse. (defined as 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. 40% claimed ability to apply for employment they were unable to achieve as legally female after surgery. Finally, while the complication rate high, overall sensation rate mixed at best, and aesthetics in the eye of the beholder, an overwhelming 93% of patients stated that after phalloplasty, they were happy with their genitals. (or in other words, felt they were complete as men)

[edit] 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.

[edit] 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 Flap) is, overall, a leap forward in the perceived outcome of phalloplasty. The advantages of this technique over the older forearm flap include:

  • Is hairless (little to no electrolysis needed)
  • Has satisfactory aesthetic appearance with more or less normal colored skin
  • Capable of both tactile and erogenous sensation (as with any form of phalloplasty, this does not necessarily mean ability to have a genital orgasm after healing)
  • Has a competent neo-urethra with a meatus at the top of the glans
  • Leaves a donor site scar that is not conspicuous
  • Has a lower occurrence of complications from either the initial surgery, or when after the erectile prosthesis in inserted

This is a four part surgery that takes place over a period of 9-18 months. The steps consist of:

  • Neophallus creation using MLD free flap (this is the initial stage)

After 3-6 months..

  • First stage urethroplasty: buccal mucosa inlay (a temporary urethra is formed in place)
  • Incorporation of penile remnants into neophlallus (this is an attempt to provide sensation)

After another 3-6 months...

  • Second stage urethroplasty: neourethral plate tubularization and joining with native urethra

This minor (but crucial) operation, joins the new urethra with the existing one to permanently allow urination while standing up. And finally, after another 3-6 months, a (technically) optional step is done to implant a device that allows an erection.

[edit] 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 long term. More studies are needed regarding function, aesthetics, and how to improve the technique.

[edit] Complications

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

A study of post-op men, shown 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 issues 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)

[edit] Alternatives

An option for transmen is metoidioplasty, where a small penis is created from the clitoris that has been enlarged by hormone replacement therapy.

[edit] See also

[edit] References

[edit] Discuss

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