Phalloplasty (also called penoplasty) is the construction or reconstruction of a

penis A penis (; : penises or penes) is a sex organ through which male and hermaphrodite animals expel semen during copulation (zoology), copulation, and through which male placental mammals and marsupials also Urination, urinate. The term ''pen ...

or the artificial modification of the penis by

surgery Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery s ...

. The term is also occasionally used to refer to

penis enlargement Penis enlargement, or male enhancement, is any technique aimed to increase the size of a human penis. Some methods aim to increase total length, others the shaft's girth, and yet others the glans and foreskin size. Techniques include surgery, ...

History

Russian surgeon Nikolaj Bogoraz performed the first reconstruction of a total penis using rib cartilage in a reconstructed phallus made from a tubed abdominal flap in 1936. The first

gender-affirming surgery Gender-affirming surgery (GAS) is a surgical procedure, or series of procedures, that alters a person's physical appearance and sexual characteristics to resemble those associated with their gender identity. The phrase is most often associated ...

for a

trans man A trans man or transgender man is a man who was assigned female at birth. Trans men have a male gender identity, and many trans men undergo medical and social transition to alter their appearance in a way that aligns with their gender identi ...

was performed in 1946 by Sir

Harold Gillies Sir Harold Delf Gillies (17 June 1882 – 10 September 1960) was a New Zealand otolaryngologist and father of modern plastic surgery for the techniques he devised to repair the faces of wounded soldiers returning from World War I. Early life ...

on fellow physician

Michael Dillon Laurence Michael Dillon (1 May 1915 – 15 May 1962) was a British doctor, author, Buddhist monk and the first known Trans man, transgender man to undergo a phalloplasty. Born in Ladbroke Estate, Ladbroke Gardens, Kensington, he and his elder ...

, documented in Pagan Kennedy's book ''The First Man-Made Man''. Gillies' technique remained the standard one for decades. Later improvements in

microsurgery Microsurgery is a general term for surgery requiring an operating microscope. The most obvious developments have been procedures developed to allow anastomosis of successively smaller blood vessels and nerves (typically 1 mm in diameter) whi ...

made more techniques available.

Indications

A complete construction or reconstruction of a penis can be performed on patients who: * Have congenital anomalies such as

micropenis A micropenis or microphallus is an unusually small Human penis, penis. A common criterion is a dorsal (measured on top) Human penis size, penile length of at least 2.5 standard deviations smaller than the mean human penis size for age. A micr ...

epispadias Epispadias is a birth defect in which the urethra fails to fully develop, resulting in urine leaving the body from an abnormal site. In males, this may be an opening on the upper aspect of the penis, and in females when the urethra develops too ...

, and

hypospadias Hypospadias is a common malformation in fetal development of the penis in which the urethra does not open from its usual location on the head of the penis. It is the second-most common birth defect of the male reproductive system, affecting about ...

* Have lost their penis * Desire

as part of their

gender transition Gender transition is the process of affirming and expressing one's internal sense of gender, rather than the sex assigned to them at birth. It is a recommended course of treatment for individuals experiencing gender dysphoria, providing impro ...

Techniques and related procedures

There are different techniques for phalloplasty. Construction of a new penis (sometimes called a neophallus or neopenis) typically involves taking a tissue flap from a donor site (such as the forearm). Extending the

urethra The urethra (: urethras or urethrae) is the tube that connects the urinary bladder to the urinary meatus, through which Placentalia, placental mammals Urination, urinate and Ejaculation, ejaculate. The external urethral sphincter is a striated ...

through the length of the neophallus is often another goal of phalloplasty. For gender-affirming surgeries that include urethral lengthening, vaginectomy is recommended due to the reduction in complication rate, but not required. Temporary lengthening can also be gained by a procedure that releases the suspensory ligament where it is 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. However, scar formation can cause the penis to retract. Therefore, the

American Urological Association The American Urological Association (AUA) is a professional association in the United States for urology professionals. It has its headquarters at the William P. Didusch Center for Urologic History in Maryland. AUA works with many international o ...

"considers the division of the suspensory ligament of the penis for increasing penile length in adults to be a procedure which has not been shown to be safe or efficacious."

Penile implants

Phalloplasty requires an implanted

penile prosthesis A penile implant is an Implant (Medicine), implanted device intended for the treatment of erectile dysfunction, Peyronie's disease, ischemic priapism, deformity and any traumatic injury of the penis, and for phalloplasty or metoidioplasty, inclu ...

to achieve an erection. Penile prostheses are implanted devices intended to restore the erectile rigidity in

cisgender The word ''cisgender'' (often shortened to ''cis''; sometimes ''cissexual'') describes a person whose gender identity corresponds to their sex assigned at birth, i.e., someone who is not ''transgender''. The prefix '' cis-'' is Latin and ...

men and to build a neophallus (new penis) in

transgender A transgender (often shortened to trans) person has a gender identity different from that typically associated with the sex they were sex assignment, assigned at birth. The opposite of ''transgender'' is ''cisgender'', which describes perso ...

men. Penile implants have been used in phalloplasty surgeries both in cisgender and transgender patients since 1970s. There are two main types of penile implants – malleable (also known as non-inflatable or semi-rigid) and inflatable implants. Both types have a pair of cylinders implanted into the penis, replacing the non-erectile tissue in cisgender men and serving as the core for the neophallus in the phalloplasty procedure. The cylinder of the inflatable implant is filled with sterile

saline solution Saline (also known as saline solution) is a mixture of sodium chloride (salt) and water. It has a number of uses in medicine including cleaning wounds, removal and storage of contact lenses, and help with dry eyes. By injection into a vein, i ...

. Pumping saline into the chambers of this cylinder produces an erection. The glans of the penis, however, remains unaffected. In sex reassignment surgeries, a new penis is formed with the use of a penile implant surrounded with a tissue flap. The pump unit of inflatable penile implants resembles a human testicle and can serve as an artificial testicle for concomitant

scrotoplasty Scrotoplasty, also known as oscheoplasty, is a type of surgery to create or repair the scrotum. Scientific research for male genital plastic surgery such as scrotoplasty began to develop in the early 1900s. The development of testicular implants ...

. For gender-affirming surgeries, if no scrotoplasty was performed the pump unit can be placed within the existing labia. Initially, standard penile implants were used in phalloplasty procedures. However, since there is no corpus cavernosum in the penis undergoing phalloplasty, and the fact that standard penile implants were designed to be implanted in corpus cavernosum, there were many adverse outcomes. Since 2015,

Zephyr Surgical Implants Zephyr Surgical Implants (ZSI) is a Swiss-based medical device manufacturer that produces and distributes artificial urinary sphincters and penile implants worldwide. ZSI products are used in the management of moderate-to-severe urinary incontin ...

proposes malleable and inflatable penile implants particularly designed for phalloplasty surgeries. Implantation procedures are usually done in a separate surgery to allow time for proper healing.

Explanation of techniques

Radial forearm flap

Radial forearm flap, also referred to as RFF, uses a free flap from the forearm to create a neophallus. Existing clitoral tissue may be buried at the base of the neophallus or left exposed. Hair removal on a portion of the donor site is required for urethral lengthening and a split thickness graft is taken from the thigh to cover the graft site on the forearm. Nerves from the flap and the tissue it has been attached to can be connected via microsurgery and sensation outcomes are positive for the majority of patients.

Anterolateral thigh flap

Anterolateral thigh flap, also referred to as ALT, uses a graft from the thigh to form the neophallus. It can be done as a free flap procedure, as a pedicled flap, or as a delayed flap where the non-main blood supply is severed prior to the surgery to give the tissue time to adapt to the new blood supply. Sensation outcomes for nerve hook up have been found to be equivalent to RFF. The resulting scarring is easier to conceal than RFF due to the location on the upper thigh. Depending on the thickness of the individual's skin and the amount of sub-cutaneous fat present, the neophallus may require debulking procedures to remove excess girth. Phalloplasty-Artificial male genitals on grey background

Phalloplasty-Artificial male genitals on grey background

Musculocutaneous latissimus dorsi flap

This phalloplasty method uses a flap from the

latissimus dorsi The latissimus dorsi () is a large, flat muscle on the back that stretches to the sides, behind the arm, and is partly covered by the trapezius on the back near the midline. The word latissimus dorsi (plural: ''latissimi dorsi'') comes from L ...

muscle. The technique is also referred to as MLD. The nerve harvested from this location is a motor nerve, which provides less tactile sensation than RFF or ALT techniques, though erogenous sensation is still present from the existing clitoral tissue. The resulting scar is much thinner than RFF or ALT, forming a Y shape starting beneath the arm and extending down the side of the torso. The donor site often requires little to no hair removal.

Abdominal flap

Abdominal phalloplasty, or supra-pubic phalloplasty, makes use of a graft from the abdomen. The first recorded gender-affirming phalloplasty by Sir Harold Gillies utilized an abdominal flap to create a tube-in-tube neophallus. If nerve hook up or urethral lengthening are desired, a graft can be harvested from a small section of the forearm similar to RFF. Scarring is thin and easily hidden beneath clothing and hair removal of the graft site is not required, though it may still be pursued for aesthetic purposes.

Flap from the side of the chest

The disadvantages include: * Uses a motor nerve so erogenous sensation cannot be achieved, only tactile sensation. * It can pull the nipple to the side causing it to be off the usual location.

Subcutaneous soft silicone implant

This phalloplasty procedure involves the insertion of a subcutaneous soft silicone implant under the penile skin.

No-touch surgical technique

The no-touch surgical technique for

implantation is a surgical procedure developed by J. Francois Eid for the implantation of a

penile implant A penile implant is an Implant (Medicine), implanted device intended for the treatment of erectile dysfunction, Peyronie's disease, ischemic priapism, deformity and any traumatic injury of the penis, and for phalloplasty or metoidioplasty, inclu ...

. Implantation through the use of the "No-Touch" technique minimizes the risk of infection. As advancements in the design and manufacturing process of the IPP improved its mechanical survival, infection has emerged as the leading cause of implant failure. Although relatively infrequent (varying from .06% to 8.9%) infection of a penile prosthesis results in serious medical consequences for patients, requiring complete removal of the device and permanent loss of penile size and anatomy. Bacterial contamination of the device can occur during the surgery, and is caused by allowing direct or indirect contact of the prosthesis with the patient's skin. Over 70% of infections occur due to the skin

microbiome A microbiome () is the community of microorganisms that can usually be found living together in any given habitat. It was defined more precisely in 1988 by Whipps ''et al.'' as "a characteristic microbial community occupying a reasonably wel ...

's microorganisms including ''

Staphylococcus epidermidis ''Staphylococcus epidermidis'' is a Gram-positive bacterium, and one of over 40 species belonging to the genus ''Staphylococcus''. It is part of the human flora, normal human microbiota, typically the skin flora, skin microbiota, and less commonl ...

'', ''

Staphylococcus aureus ''Staphylococcus aureus'' is a Gram-positive spherically shaped bacterium, a member of the Bacillota, and is a usual member of the microbiota of the body, frequently found in the upper respiratory tract and on the skin. It is often posi ...

'', ''

Streptococcus ''Streptococcus'' is a genus of gram-positive spherical bacteria that belongs to the family Streptococcaceae, within the order Lactobacillales (lactic acid bacteria), in the phylum Bacillota. Cell division in streptococci occurs along a sing ...

'' and ''

Candida albicans ''Candida albicans'' is an opportunistic pathogenic yeast that is a common member of the human gut flora. It can also survive outside the human body. It is detected in the gastrointestinal tract and mouth in 40–60% of healthy adults. It is usu ...

''. Traditional strategies to combat infections aim at decreasing skin colony count such as scrubbing skin preparation with alcohol and chlorhexidine or kill bacteria once the implant is contaminated by skin flora such as intravenous antibiotics, antibiotic irrigation and antibiotic-coated implants. The "No-Touch" technique is unique in that it aims to prevent bacterial contamination of the prosthesis by completely eliminating contact of the device with the skin. Paired with the antibiotic-coated implant, the "No Touch" technique decreases infection to a rate of 0.46%, opposing the traditional method which has an infection rate of 5%. The use of an antibiotic-coated implant and a no-touch surgical technique with skin preparation measures and peri-operative antibiotic use has been found to be of high importance in the prevention of infection among penile implants. Eid developed the technique in 2006 on the hypothesis that eliminating any contact between the prosthesis and the skin, either directly or indirectly via surgical instruments or gloves, should reduce the incidence of contamination of the device with skin flora responsible for infection.

Procedure

Three days prior to the procedure, a patient is placed on oral

fluoroquinolones Quinolone antibiotics constitute a large group of broad-spectrum antibiotic, broad-spectrum bacteriocidals that share a bicyclic molecule, bicyclic core structure related to the substance 4-Quinolone, 4-quinolone. They are used in human and ve ...

, a grouping of antibacterial drugs. During this time, the patient scrubs the lower abdomen and genitals daily with

chlorhexidine Chlorhexidine is a disinfectant and antiseptic which is used for skin disinfection before surgery and to disinfect surgical instruments. It is also used for cleaning wounds, preventing dental plaque, treating yeast infections of the mouth, and ...

soap. On the day of the surgery,

vancomycin Vancomycin is a glycopeptide antibiotic medication used to treat certain bacterial infections. It is administered intravenously ( injection into a vein) to treat complicated skin infections, bloodstream infections, endocarditis, bone an ...

and

gentamicin Gentamicin is an aminoglycoside antibiotic used to treat several types of bacterial infections. This may include bone infections, endocarditis, pelvic inflammatory disease, meningitis, pneumonia, urinary tract infections, and sepsis amo ...

are administered intravenously one to two hours prior to the procedure. The lower abdomen and genitals are shaved, scrubbed for five minutes with a chlorhexidine sponge and prepped with chorhexidine/alcohol applicator. The area is then draped with a surgical drape and a Vi Drape over the genitalia. Before the incision is made, a Foley catheter is inserted in the bladder through the urethra. A scrotal incision is made on the penoscrotal raphe and carried down through the subcutaneous tissue to the

Buck's fascia Buck's fascia (deep fascia of the penis, Gallaudet's fascia or fascia of the penis) is a layer of deep fascia covering the three erectile bodies of the penis. Structure Buck's fascia is continuous with the external spermatic fascia in the scro ...

. A Scott retractor, a flexible device that holds open the skin of the surgical site, is applied to the area. Up until this stage of the surgery, the process has been consistent with the sanitary practices associated with standard surgical sterility. At this stage of the "No-Touch" technique, after the incision has been made, all instruments, including surgical gloves, that have touched skin are discarded. A loose drape is then deployed over the entire surgical field and secured at the periphery with adhesive strips. A small opening in the drape is then made overlying the incision and yellow hooks utilized to secure the edges of the opening to the edges of the incision, completely covering and isolating the patient's skin. At this point, new instruments and equipment are replaced and the entire prosthesis is inserted through the small opening of the loose drape. The loose drape allows for manipulation of the penis and scrotum required for this procedure without touching the skin. Implantation of the device continues with an incision and dilation of corpora, sizing and placing the penile cylinders, and placement of the pump in the scrotum and the reservoir in the retropubic space. Saline is used throughout the implantation for irrigation. Once the corporotomies are closed and all of the tubing and components of the prosthesis covered with a layer of Buck's fascia, subcutaneous tissues are closed and the "No-Touch" drape is removed and the skin closed.

Future

Penis transplantation Penis transplantation is a surgical transplant procedure in which a penis is transplanted to a patient. The penis may be an allograft from a human donor, or it may be grown artificially, though the latter has not yet been transplanted onto a hu ...

could also become a standardized method.

References

Sources

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) *
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, 6 July 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. {{refend

External links

FemaletoMale.org , Information about Phalloplasty

Video: Minimally Invasive Penile Implant Surgery to correct erectile disfunction

No-touch technique
Masculinizing surgery Genital modification and mutilation Male genital modification Male genital surgery Human penis Plastic surgery Surgical procedures and techniques