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Surgery on the genitals may not sound desirable to many people, but if you’ve had an injury to your penis or you’re a transgender man, phalloplasty—penis construction—is a surgical option for which you’re probably very grateful. Phalloplasty is one of many gender-affirming surgeries available for transgender men and women seeking to align their bodies with their true gender identities. This article will explore what this complex surgery involves, how it works, what recovery is like, and how much it costs.
What is a phalloplasty?
Phalloplasty is the surgical construction of a penis using a person’s own skin and tissue. It can be done reconstructively after a traumatic injury or cancer. It can also be done as gender affirming surgery for a transgender man (also known as gender reassignment surgery, or “bottom surgery”). This can sound like an intimidating and confusing procedure, but most phalloplasty patients are happy with their surgeries, have greatly improved quality of life, and would undergo surgery again (Papdopulos, 2021).
There are several options within the phalloplasty procedure, and you can choose the combination that is right for you. You can opt for reconstruction of your urethra to enable you to urinate standing up, to have a scrotum created, to surgically implant a penile prosthesis so that you can have erections, and, for transgender men, to remove some or all of your female sexual organs (Chen, 2019).
Transition is different for everyone, and not all transgender men opt for a phalloplasty. Some choose to make social changes to live in a male gender role, undergo hormonal therapy alone, or change their bodies through cosmetic or chest surgery leave their genitalia as is. Some people choose to have a metoidioplasty, another method of creating a penis, and may later have a phalloplasty (Heston, 2019). You can choose the combination of options that are right for you and when you are ready.
There are two primary ways a penis is constructed for a phalloplasty: using tissue from the forearm or the thigh. There are advantages and disadvantages to each method, and you can discuss which is right for you with your healthcare provider.
There are two main techniques for phalloplasty surgery: radial forearm free-flap (RFFF) phalloplasty and anterolateral thigh (ALT) phalloplasty.
While choosing your preferred method, it’s essential to have a candid discussion with your healthcare providers about your goals and expectations for penis function, sexual arousal, and performance. Each method of phalloplasty has its pros and cons, and both come with some risk of complications. You can ensure a successful and satisfying experience by having a clear idea of what to expect from your phalloplasty (Garg, 2021).
What is dysphoria? How is it related to gender dysphoria?
Radial forearm free-flap (RFFF) phalloplasty
The most common method of phalloplasty is called the RFFF technique. The surgeon will remove tissue that includes blood vessels and nerves from the forearm, form this tissue into a penis using a ‘tube within a tube’ shape, and then surgically attach it to the patient. In the same surgery, the urethra is reconstructed to extend through the penis, a scrotum can be created from the labia, and a glans (or head) of the penis can be formed (Carter, 2020).
The RFFF method takes a substantial portion of skin from the forearm, which (rarely) can damage hand function and also results in an obvious and identifiable scar. That said, a seven-year follow-up study of transgender men who had undergone RFFF phalloplasty found that all patients had good and unimpaired forearm function, no pain in the scar, and good bone health. Over 75% felt satisfied with or neutral about their scar (Van Caenegem, 2013).
Before surgery, it’s important to permanently remove body hair on the forearm area from which the donor tissue will be taken. This is to prevent infection or problems with hair growing internally in the new penis. Hair removal can be done via electrolysis or laser hair removal, and although people sometimes have a small amount of hair regrowth, it isn’t usually an issue (Carter, 2020).
Despite the downside of forearm scarring, the RFFF method is usually the preferred method of phalloplasty. The skin of the forearm is more similar to genital skin, has a lot of nerves and blood supply, and usually creates a penis with good aesthetics, blood flow, and tactile sensation. It also can usually be completed in one surgery (unless there are follow-up surgeries needed for complications or cosmetics). However, the RFFF method isn’t an option for people with IV drug histories or past forearm damage. Fortunately, the ALT method is available in these cases (Chen, 2019).
Anterolateral thigh (ALT) phalloplasty
The anterolateral thigh (ALT) phalloplasty technique is similar to the RFFF method in that it uses a tube-within-a-tube construction; however, the donor tissue is instead taken from the thigh. Some people prefer this because it results in a more discreet scar than RFFF phalloplasty (the thigh being more easily covered than the forearm) (Chen, 2019).
ALT phalloplasty also has the possible advantage that penis size is larger and that thigh tissue tends to be thicker and firmer than forearm tissue. This means the penis created with the ALT method may be rigid enough to use for penetrative sex (though many patients still opt to receive a penile prosthesis for erections) (Carter, 2020).
Penis anatomy: how the parts come together
However, there are some downsides to the ALT method. Because thigh skin is relatively thicker and has fewer nerves and blood vessels, it can take more surgeries for an ALT phalloplasty to be completed (including surgeries to decrease penis size, reconstruct the urethra, and create a glans of the penis). There is also less tactile sensation in the penis than with RFFF phalloplasty, and there tend to be slightly more medical complications after the surgery (Ascha, 2019; Chen, 2019). Despite this, most men who receive an ALT phalloplasty feel satisfied with it and that it has improved their confidence and quality of life (van de Grift, 2019).
As with the RFFF method, before ALT phalloplasty, you’ll have to use electrolysis or laser hair removal to permanently remove body hair from the tissue donor site on your thigh. This will help prevent infection or problems with hair growing internally in the new penis (Carter, 2020).
How it works: steps of a phalloplasty
Phalloplasty usually includes multiple surgeries, some of which can be done simultaneously, while others need to be performed separately over months. You can choose the combination of surgical procedures that suits your personal needs and goals for transition.
There are several pre-surgical steps your doctor will discuss with you that will help promote good healing and recovery, including quitting smoking and getting to a healthy body weight.
Oophorectomy & hysterectomy
Some transgender men choose to have some or all of their female sex organs removed, though it isn’t required for having a phalloplasty. This can include removal and closing of the vagina and labia (called a vaginectomy), removal of the ovaries (called an oophorectomy), and removal of the uterus (called a hysterectomy) (Heston, 2019).
If you are having your ovaries and/or uterus removed, it needs to be in a separate surgery before the phalloplasty surgery to allow full healing. Beforehand, be sure to talk to your healthcare provider about any thoughts or goals you may have about having biological children in the future. If you want to remove these organs while still having the option to have biological children in the future, there are several fertility preservation options like egg freezing (Garg, 2021).
IVF egg retrieval: process, recovery, cost, results
Phallus creation, vaginectomy, & urethroplasty
The phallus is created during the primary surgery. This is also when a transgender man can choose to have the vagina removed or reduced.
During this surgery or a follow-up surgery (as is sometimes necessary with ALT phalloplasty), transgender men can also choose whether to have a lengthened urethra or to leave the urethra as it is. Urethral lengthening allows for standing urination. Leaving the urethra as-is involves keeping your vaginal opening and continuing to sit with urination. A benefit to this is that the phalloplasty procedure is simpler and involves fewer post-surgery risks and complications since the urethra won’t be altered. However, standing urination is often a priority for transgender men, in which case urethral reconstruction is an option (Heston, 2019).
Scrotoplasty & glansplasty
During the phalloplasty or in a follow-up surgery, a transgender man can choose to have a scrotum created (scrotoplasty). This involves using the labia to create a scrotal pouch beneath the penis. The clitoris can be “buried” within this scrotum, or moved between it and the penis, to allow clitoral sensation and the possibility of orgasm. A glans, or head of the penis, may also be created during the phalloplasty or in a follow-up surgery (Chen, 2019).
After around 12 months, you can choose to have testicular implants and a penile prosthesis implanted in your new penis. This allows for erectile function and sexual penetration (Heston, 2019).
Recovery from phalloplasty
Phalloplasty is a complex surgery and recovery time can be long; it’s very helpful if a loved one can support you through this period. A five-day stay in the hospital is usually required, during which you will have a urethral catheter (which helps keep the reconstructed urethra open), and a suprapubic catheter (to drain your urine while the urethra heals). Trained clinicians will check on you frequently to make sure that the surgery was successful and there are no immediate complications.
Once you are discharged from the hospital, there is a 4–12 week recovery period at home (Carter, 2020). It’s essential to make a postoperative care plan with your surgeon and whoever will help you at home, since phalloplasty recovery typically requires weekly follow-up visits for the first few months after surgery. You can expect to have difficulty moving, socializing, working, bathing, and being intimate during this time—but rest assured, most men make a full recovery without serious complications, and are very satisfied with the results (Heston, 2019).
What are penis implants or penile implants?
If all goes well, your urethral catheter will be removed after about a week, and the suprapubic catheter will be removed after three weeks. For at least the first month you should do nothing physically strenuous, like walking quickly, making big movements, or lifting heavy objects. It’s also important to keep your surgical area very clean and to keep the new penis at an angle away from the body for the first several weeks (Chen, 2019).
Phalloplasty is an increasingly common surgery, but it still comes with a high rate of complications, like any major surgery. Most patients who experience complications do so in the first few days in the hospital, but fortunately most are minor and easy to manage (like UTIs, skin issues, pain, and bleeding). About a third of patients experience a significant issue after surgery, such as urethral fistulas and urethral strictures (abnormal openings or narrowings in the new urethra that can cause problems with urinating) (Ascha, 2018). These usually require follow-up surgery. Other possible complications include tissue death of the new penis, wound breakdown, and lack of sensation (Santucci, 2018).
This unfortunate possibility of urethral complications, and the potential inability to urinate with the new penis, do not happen most of the time but are a real risk in such a complex surgery. There are ways to help prevent and manage it, and most men who choose urethral reconstruction are eventually able to urinate from their penis. Still, it’s one of the important considerations you should discuss with your healthcare provider ahead of time (Heston, 2019).
Despite the risks of the surgery, most transgender men are very satisfied with their phalloplasty and would choose to undergo surgery again (Papadopulos, 2021). Most are satisfied with the aesthetic appearance of their new penis and experience increased self-confidence, improved body image, a greater sense of well-being about their gender identity, and a feeling of affirmation of masculinity. Most also experience greater sexual enjoyment (Heston, 2019; van de Grift, 2019).
Each person will experience different levels of tactile sensation, ability to be sexually aroused, erectile function, and ability to orgasm after phalloplasty. This can depend on which particular surgical options are chosen, whether a penile prosthesis was implanted, and how successfully the person recovered from each surgery. However, rates of sexual satisfaction still tend to be high, especially if a person has a clear understanding ahead of time of the possible outcomes of phalloplasty surgery (Garg, 2021).
Testosterone replacement therapy (TRT)
Cost can be a major concern for people considering phalloplasty. It is an immensely expensive surgery if paid for out of pocket (generally in the realm of several tens of thousands of dollars), and extra costs can pile up like unexpected issues during surgery, hospital fees, and surgeries to correct complications.
Fortunately, thanks to the Affordable Care Act and to growing medical consensus that gender transition care is a medical necessity for many transgender individuals, more US health insurance companies are now beginning to cover transition care (Baker, 2017). 95% of US insurance companies cover phalloplasty, and 60% cover penile prosthesis (Cohen, 2019).
A hidden cost of phalloplasty is the issue of distance to qualified providers. Phalloplasty is still a relatively rare procedure in the US, and a person may have to travel a substantial distance to seek care and must pay for food and accommodation for several weeks.
Phalloplasty is a big step and comes with a lot of risks, but for many transgender men, it is a worthwhile and satisfying choice that allows them to lead fuller, more authentic lives, with improved confidence and well-being.
- Ascha, M., Massie, J. P., Morrison, S. D., Crane, C. N., & Chen, M. L. (2018). Outcomes of single stage phalloplasty by pedicled anterolateral thigh flap versus radial forearm free flap in gender confirming surgery. Journal of Urology, 199(1):206-214. doi: 10.1016/j.juro.2017.07.084. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28765066/
- Baker, K. E. (2017). The future of transgender coverage. The New England Journal of Medicine, 11;376(19):1801-1804. doi: 10.1056/NEJMp1702427. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28402247/
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- Cohen, W. A., Sangalang, A. M., Dalena, M. M., Ayyala, H. S., & Keith, J. D. (2019). Navigating insurance policies in the United States for gender-affirming surgery. Plastic and Reconstructive Surgery, 7(12), e2564. doi: 10.1097/GOX.0000000000002564. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7288898/
- Garg, G., Elshimy, G., & Marwaha, R. (2021). Gender dysphoria. [Updated July 20, 2021]. In: StatPearls [Internet]. Retrieved on Jan. 31, 2022 from https://www.ncbi.nlm.nih.gov/books/NBK532313/
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- World Professional Association for Transgender Health. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People [7th Version]. Retrieved from https://www.wpath.org/publications/soc