What is phalloplasty?

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

Indications for the procedure

Indications for phalloplasty in men include:

• injuries and injuries of the penis , including its crushing and complete loss (traumatic amputation), burns, infringement with subsequent tissue necrosis, etc.;
• penectomy transferred for medical reasons (in particular, with malignant neoplasms of the urethra or penis);
• penis skin defects that are not amenable 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 albuginea 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 dissatisfied with the appearance of their genitals - most likely due to  dysmorphophobia  - decide on drastic measures: with the help of plastic surgery, increase the "dimensions" of the penis. However, in most men there is no medical indication 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, in detail in the material -  Operation ligamentotomy . And the publication is devoted to the technique of penis enlargement in volume -  Operation to thicken the penis .

Sex reassignment phalloplasty, referred to by the American Society of Plastic Surgeons (ASPS) as gender reassignment surgery, also involves plastic surgery, but in this case, as in traumatic amputation and after penectomy, it is a total phalloplasty. In the course of 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. The essential difference between such an operation when  changing sex  from female to male (female to male or FtM) is that it does not restore the original male anatomy, 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 the artificial modification of the penis through surgical intervention is not the only masculinizing surgical procedure that is used during the sexual transformation of women with gender dysphoria,  a gender identity disorder, diagnosed and confirmed by a council of psychiatrists .

Preparation

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

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

Hair is removed from the skin to be transplanted and from the genital area with laser hair removal.

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

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 system, his allergic status and determines drugs for premedication and anesthesia itself.

Mandatory conditions for phalloplasty during FtM sex reassignment: taking male sex hormone preparations (within 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 scalped injury to the penis, a burn with significant loss (necrosis) of the skin, removal of an abscess or excision of tissues 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 pedunculated 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 surface of the thigh and full-thickness flaps taken from the inguinal region. The flap is attached with interrupted absorbable sutures and covered with a support bandage; the area where the skin was taken is closed with an occlusive or vacuum dressing.

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

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

The material for the new penis in total phalloplasty is:

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

Total phalloplasty is performed in several stages; first, a skin graft is taken with the appropriate treatment and a new penis is formed, which is transferred to the pubis and sewn into the incision made. During the 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 lengthened to the base of the penis by the tissues of the labia minora.

At the donor site (the place where the flap was taken), dermoplasty is performed with a split skin flap. For the outflow of urine, a Foley urethral catheter is placed, the sewn graft is lifted a few centimeters from the abdominal wall with a special bandage.

At the following stages, the formation of the head of the penis, the 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, this is not all done in one operation: at least three months pass between the stages, and a complete phalloplasty can take up to two years.

Phalloplasty with prosthetics

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

Two types of penile prostheses can be used: semi-rigid rod devices and inflatable devices. The first type is a silicone rod with a flexible but rigid core; rigidity does not allow "transferring" neopenis to a relaxed state and, moreover, constant pressure on the skin, leading to erosion.

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

Contraindications to the procedure

Surgery to reconstruct or correct the penis is contraindicated in:

• 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 diseases.

Phalloplasty in men has age restrictions: it is not performed after 60 years. And phalloplasty when changing sex is not performed on patients under the age of 18.

Consequences after the procedure

Immediately after phalloplasty surgery, patients feel pain, including in the place where the skin flap was taken from. There are such consequences of surgery as nausea after prolonged general anesthesia, reporting of soft tissues and hematomas in the area of the surgical wound, bleeding, burning and hematuria during urination.

But the list, which includes complications after phalloplasty, is longer, and surgeons and other specialists have included in it:

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

Care after the procedure

Care after the procedure requires hygiene and maximum limitation of physical activity.

On 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 with 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 inguinal region.

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 (vessel Doppler). The condition of the donor site of the skin is checked, if necessary, the bandage is changed.

After five days, it is allowed to walk a little, after putting on supportive underwear. The first time after surgery, urination occurs through the suprapubic catheter, and the area around it during the first week after leaving the hospital should be cleaned with a sponge. It is allowed to take a shower only after two weeks: both the penis and the donor site on the forearm, thigh, etc. Must be kept dry, so they should be covered from water. Bathing and swimming in the pool is prohibited. [4]

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

The penis must be maintained in an elevated position (including lying in bed) and pressure on it must be avoided, therefore, it is impossible to bend the body in the belt at an angle of more than 90 °. Weight lifting is also contraindicated.

And only a doctor, after examination and consultation, can allow the operated patient to try to have sexual contact - always using a condom. When can this happen? The recovery period - rehabilitation after the procedure, especially when phalloplasty was performed during a sex change - can last about two years.

Analyzing the feedback of their patients regarding the real results of phalloplasty - functional and aesthetic - and the problems that arise with its complications, experts remind that urogenital plastic surgery has not yet been able to restore the  physiology of sexual function , despite the constant improvement of the techniques of this surgical intervention and the accumulated clinical experience.