What is phalloplasty?

Phalloplasty is the correction and/or reconstruction of the male penis by surgical intervention. The need for this plastic surgery may arise for various reasons.

Indications for the procedure

Indications for which phalloplasty is performed in men include:

• damage and injury to the penis, including its crushing and complete loss (traumatic amputation), burns, strangulation with subsequent tissue necrosis, etc.;
• penectomy performed for medical reasons (in particular, for malignant neoplasms of the urethra or penis);
• penile skin defects that do not respond to conservative therapy;
• abnormal location of the external opening of the urethra - epispadias or hypospadias;
• congenital deviation (curvature of the penis) or deformation caused by the formation of fibrous plaques inside the protein membrane of the spongy and cavernous bodies (Peyronie's disease);
• congenital anatomical anomalies: agenesis of the penis, micropenis, hidden penis;
• penoscrotal lymphedema - elephantism or elephantiasis of the penis.

In addition, some men who doubt their sexual abilities or are simply unhappy with the appearance of their genitals – most likely due to dysmorphophobia – decide to take drastic measures: to increase the “size” of the penis with the help of plastic surgery. However, most men do not have medical indications for such an operation, and in such cases phalloplasty is aesthetic, and its purpose is to increase self-esteem. [ 1 ]

How surgeons make the penis longer is described in detail in the article – Ligamentotomy operation. And the publication – Penis thickening operation – is devoted to the technique of penis enlargement.

Phalloplasty for gender reassignment, which the American Society of Plastic Surgeons (ASPS) calls gender confirmation surgery, also involves plastic surgery, but in this case – as with traumatic amputation and after penectomy – it is total phalloplasty. During such a comprehensive surgical intervention, an artificial penis is created for a transgender man (that is, a woman who feels like a man) by transplanting tissue from his own body (autograft), similar in appearance and function to a natural one. A significant difference in such surgery for gender reassignment from female to male (female to male or FtM) is that the original male anatomy is not restored, but phalloplasty is performed in women with the creation of a neophallus – a non-existent external genital organ. It should be borne in mind that artificial modification of the penis through surgical intervention is not the only masculinizing surgical procedure that is resorted to during the sexual transformation of women with gender dysphoria - a disorder of sexual identity - diagnosed and confirmed by a psychiatric council.

Preparation

Regardless of the indications for phalloplasty in men and the chosen technique, preparation is required, in particular, preoperative examination: ECG, ultrasound of the penis, Dopplerography of its vessels, and before surgery for hypospadias - echography of the urethra.

In addition to a general blood test and coagulogram, blood tests for STDs, HIV, hepatitis C, as well as a comprehensive metabolic panel, which includes more than a dozen blood tests, including sugar levels, electrolytes, albumin, urea nitrogen, creatinine, alkaline phosphatase, C-reactive protein, etc. are required.

Hair is removed from the skin transplant area and the genital area using laser hair removal.

Bowel preparation is also required: two days before the operation, fried and spicy foods, red meat, legumes, coarse plant fiber, and alcohol are excluded from the diet; a day before the operation, magnesium citrate solution or Bisacodyl laxative tablets (up to 20 mg) are taken orally, and in the afternoon, solid food intake is stopped and a cleansing enema is done.

Penile plastic surgery is a long operation performed under general anesthesia, and an anesthesiologist takes part in the preparation for it. He finds out the state of the patient's cardiovascular and respiratory systems, his allergy status and determines the drugs for premedication and the anesthesia itself.

Mandatory conditions for phalloplasty for FtM gender reassignment: taking male sex hormones (for 12 months), performing a hysterectomy (removal of the uterus), vaginectomy (removal of the vagina) and oophorectomy (removal of the ovaries), as well as subcutaneous mastectomy (removal of the mammary glands) - at least three to five months before the surgical creation of the neophallus.

Technique What is phalloplasty?

After a scalp injury to the penis, a burn with significant loss (necrosis) of skin, removal of an abscess or excision of tissue in case of elephantiasis of the penis, phalloplasty with skin replacement is required, for which the classical technique of autodermoplasty is used. In this case, both pedicled skin flaps (from the scrotum, lower abdomen or inner thigh) and free skin grafts are used: in the form of split-thickness flaps from the inner thigh and full-thickness flaps taken from the groin area. The flap is attached with interrupted absorbable sutures and covered with a supporting bandage; the area where the skin was taken is covered with an occlusive or vacuum bandage.

In phalloplasty performed in cases of hypospadias, the penile shaft is straightened; the lumen of the urethra section passing through the penis is corrected; the external opening of the urethra (urinary meatus) is moved to the apical point of the head; and skin defects are closed with an autograft.

In case of curvature of the penis due to fibrous changes in its protein sheath (tunika albuginea), the technique of flap plastic surgery of the body of the penis (corpus penis) is used - corporoplasty, plastic surgery with transverse plication, shortening of t. albuginea on the contralateral side. All details are in the publication Peyronie's Disease.

The material used for the new penis in total phalloplasty is:

• free radial forearm skin flap (with thin dermis, optimal subcutaneous fat layer and sufficient innervation); blood vessels and nerves are sutured using microsurgery; the urethra for standing urination is formed simultaneously - using the tube-in-tube method;
• skin flap (with legs) of the anterolateral thigh - without blood vessels and nerves (a urethra for standing urination can be formed and a penile implant can be placed);
• a rectangular flap of skin from the suprapubic part of the abdominal cavity (without the urethra passing through the neophallus, i.e. urination occurs in a sitting position);
• free flap of the musculocutaneous latissimus dorsi muscle with the thoracic vessels and thoracodorsal nerve.

Total phalloplasty is performed in several stages; first, a skin graft is taken with appropriate treatment and a new penis is formed, which is transferred to the pubis and sewn into the incision made. In a female-to-male operation, the urethra can either be left in its native position, or brought out (in the form of a perineal urostomy), or extended to the base of the penis with tissues of the labia minora.

At the donor site (the site of the flap), dermoplasty is performed using a split skin flap. A Foley catheter is inserted to drain urine, and the sewn-in transplant is raised several centimeters from the abdominal wall using a special bandage.

The next stages involve the formation of the head of the penis, restoration or creation of the scrotum (scrotoplasty), the newly created urethra is connected to the bladder; the last stage is the placement of the penis prosthesis and testicles. Of course, all this is not done in one operation: at least three months pass between stages, and the complete phalloplasty can take up to two years.

Phalloplasty with prosthetics

For additional density and axial stability of the neophallus shaft formed from a skin autograft, phalloplasty with prosthetics is performed, which is the implantation of a penile endoprosthesis during a separate surgical intervention. [ 2 ]

There are two types of penile prostheses that can be used: semi-rigid rod devices and inflatable ones. The first type is a silicone rod with a flexible but rigid core; the rigidity does not allow the neopenis to be “translated” into a relaxed state and, in addition, constantly presses on the skin, leading to erosion.

The basis of hydraulic inflatable penile prostheses is an inflatable cylindrical chamber (placed in the reconstructed penis), a pump (implanted in the scrotum and activated by manual compression) and a fluid-filled reservoir (which is sewn into the abdominal cavity). [ 3 ]

Contraindications to the procedure

Penile reconstructive or corrective surgery is contraindicated in the following cases:

• acute inflammation or exacerbation of a chronic inflammatory process (any localization);
• STDs, AIDS or hepatitis C;
• fever;
• poor blood clotting;
• diabetes;
• overweight (body mass index ˃30);
• systemic autoimmune and skin diseases;
• mental disorders and illnesses.

Phalloplasty in men has age restrictions: it is not performed after 60 years. And phalloplasty for gender reassignment is not performed on patients under 18 years of age.

Consequences after the procedure

Immediately after phalloplasty surgery, patients feel pain, including in the area where the skin flap was taken. Consequences of surgery include nausea after prolonged general anesthesia, soft tissue bruising and hematomas in the area of the surgical wound, bleeding, burning, and hematuria during urination.

But the list of complications after phalloplasty is longer, and surgeons and other specialists have included the following:

• bleeding;
• bacterial infection requiring antibiotics;
• problems with the blood supply to the neophallus, which can lead to partial or complete necrosis of the transplant;
• pain in the pelvic area;
• damage to the bladder or rectum;
• formation of painful subcutaneous granulomas;
• vein thrombosis;
• loss of sensation during urination (requiring constant use of a urethral catheter);
• recurrent urinary tract infections;
• formation of urethral fistulas (fistulas) requiring urethrostomy;
• urinary leakage after catheter removal and stress urinary incontinence;
• urinary dysfunction due to urethral stricture of the new penis;
• lack of sensation of the transplanted penis and erection;
• large scars at the site where the skin flap was taken.

Care after the procedure

Post-procedure care requires maintaining hygiene and maximum limitation of physical activity.

During the first day after the operation, patients do not receive food, then - in order not to overload the intestines - a diet without fiber is prescribed (for a couple of weeks). Postoperative pain is controlled by analgesics, compression stockings are used to prevent thrombosis in the veins of the legs, and acetylsalicylic acid (Aspirin) is prescribed to prevent thrombosis of the veins of the groin area.

During the first three days, body temperature is constantly monitored, as well as the level of blood flow and the condition of the blood vessels supplying the penis (vascular Doppler sonography). The condition of the donor skin area is checked, and the bandage is changed if necessary.

After five days, you are allowed to walk a little, after putting on supportive underwear. For the first time after the operation, urination occurs through a suprapubic catheter, and the area around it should be cleaned with a sponge during the first week after leaving the hospital. Showering is allowed only after two weeks: both the penis and the donor area on the forearm, thigh, etc. must be kept dry, so they should be protected from water. Taking a bath or swimming in a pool is prohibited. [ 4 ]

During corporoplasty, which corrects the shape of the penis, surgeons recommend applying Bacitracin, Baneocin or Argosulfan ointment to the incisions and sutures (twice a day).

The penis should be kept in an elevated position (including when lying in bed) and pressure on it should be avoided, so the body should not be bent at the waist at an angle greater than 90°. Lifting weights is also contraindicated.

And only a doctor after examination and consultation can allow the operated patient to try to have sexual intercourse - necessarily with the use of a condom. When can this happen? The recovery period - rehabilitation after the procedure, especially when phalloplasty was performed for gender reassignment - can last about two years.

Analyzing the feedback from their patients regarding the actual results of phalloplasty – functional and aesthetic – and the problems that arise from its complications, specialists remind us that urogenital plastic surgery has not yet succeeded in restoring the physiology of sexual function, despite the constant improvement of the techniques of this surgical intervention and the accumulated clinical experience.