Phalloplasty Risks

It is important to note that most phalloplasty procedures require multiple surgical visits as well as some revisions, can be quite painful, require significant recovery time, and often leave large areas of visible scarring. Because of the nature of using skin grafts, there is always a risk of tissue death and loss of part or all of the penis. Other potential complications include the extrusion of testicular implants, the formation of a stricture (an abnormal narrowing; blockage) or fistula (an abnormal connection; leakage) in the newly constructed urethral passage, and infection. There may also be damage to the nerves of the donor area, resulting in numbness or loss of function. Erotic sensation may be changed or diminished. And the results may not be as aesthetically pleasing as one might like them to be. Also, one must consider the usual risks of any surgery, including bleeding, infection, problems from anesthesia, blood clots, or death (rare).
Phalloplasty procedures also tend to be very expensive (between $50,000 to $150,000) and are not typically covered by insurance.
However, if one desires an average-sized penis that looks acceptable in the locker room, through which he can urinate, and with which he can engage in penetrative sex, a phalloplasty is certainly a way to achieve that end. Additionally, many trans men do not feel complete without a penis, and so may pursue a phalloplasty with that in mind. It is often reported by trans men that the forearm free flap phalloplasty provides the most realistic-looking penis of the options currently available, if you are willing to accept the surgical risks and the forearm scarring.

Scrotoplasty

In general, the creation of the scrotum is usually accomplished by hollowing out the labia majora, inserting solid silicone implants, and eventually joining the labia to create a single scrotal sac (similar to the procedure used in metoidioplasty). However, other techniques are sometimes employed to create a scrotum, such as the creation of a scrotal sac from donor tissue from the abdomen or thigh. Sometimes fat is harvested from the pubic mound and transplanted into the constructed sac rather than using implants, though often this does not produce adequate size and symmetry.

Phalloplasty

Phalloplasty involves the construction of a penis using donor skin from other areas of the body. Depending on the type of phalloplasty procedure, skin is typically taken from the abdomen, groin/leg, and/or forearm and grafted onto the pubic area. Phalloplasty often involves a urethral lengthening procedure so that the patient can urinate through the penis. Erections are usually achieved with either a malleable rod implanted permanently or inserted temporarily in the penis, or with an implanted pump device.
Phalloplasty techniques vary widely from surgeon to surgeon. Be sure to research carefully the surgeons you are considering in order to get an exact account of the procedure as they perform it. Summarized below are a number of terms and procedures related to phalloplasty. Keep in mind that these descriptions are generalized and are meant as a introduction to the topic; this list is not necessarily exhaustive.
Gillies technique
This refers to one of the earliest types of phalloplasty, in which a flap of abdominal skin is rolled into a tube to create a flaccid penis. Over the years, this procedure was improved to include a urethral extension by utilizing a second section of abdominal skin wrapped "raw side out" to form a "tube within a tube," nested inside the constructed phallus. This method usually produces a penis that is not erotically sensate (i.e., does not have feeling) and is often not very realistic in appearance. Usually, a flexible rod must be inserted into the penis in order to achieve an erection.
Suitcase handle
In order to help prevent tissue death in the penis, the Gilles procedure was improved by the development of the "suitcase handle" technique, where the rolled flap is left attached to the abdomen at the top and bottom (like the handle of a suitcase) for a number of weeks in order to ensure a proper blood supply. In a second stage operation, the flap (handle) is detached from the top end, and that end is brought down to graft onto the genital area. It is again allowed to develop a proper blood supply over a period of time. In a third operative stage, the other end is detached from the abdomen, leaving the new penis to hang naturally from its grafted place in the genital area. Variations of the suitcase handle technique are used in the pedicled flap procedures described below.
Pedicled pubic flap phalloplasty
In this procedure, the penis is constructed from an tubed pedicled flap running from the pubic area to just underneath the belly-button. (The term "pedicle" here refers to the fact that the flap of donor skin is left attached to the body, as described in the suitcase handle technique, in order to improve proper blood supply and prevent tissue death). This procedure may also utilize grafted skin from the thigh area to wrap around the outside of the pedicle, mimicking the loose outer skin of the penis. A urethral extension may by created using tissue from the labia or vaginal wall, or simply from creating an "inside-out" inner tube from the donor area. This operation is usually performed in several stages in order to ensure proper blood supply to the pedicled flap. The clitoris is usually left intact near the base of the penis; the exact placement of the base of the penis with regard to the clitoris should be discussed with the surgeon. This method usually produces a penis that is not erotically sensate. The aesthetic appearance of the penis is also sometimes unrealistic. Usually, a flexible rod must be inserted into the penis or an implanted pump device used in order to achieve an erection.
Because the donor skin used in this type of phalloplasty is typically hairy, some patients may choose to undergo electrolysis in the donor areas for a period of months to help minimize hair growth on the new penis. Indeed, some surgeons require electrolysis of the donor areas before they will proceed with the procedure. If electrolysis is not chosen, the patient will have to periodically shave the skin of the penis or use depilatory cream.
Pedicled groin flap phalloplasty
This procedure is similar to the pedicled pubic procedure listed above, except that it employs a skin flap that runs sideways outward from the groin area (usually around the area where the upper thigh meets the pelvic bone). A urethral extension may by created using tissue from the labia or vaginal wall, or simply from creating an "inside-out" inner tube from the donor area. This operation is usually performed in several stages in order to ensure proper blood supply to the pedicled flap. The clitoris is usually left intact near the base of the penis; the exact placement of the base of the penis with regard to the clitoris should be discussed with the surgeon. This method usually produces a penis that is not erotically sensate. The aesthetic appearance of the penis is also sometimes unrealistic. Usually, a flexible rod must be inserted into the penis or an implanted pump device used in order to achieve an erection.
Because the donor skin used in this type of phalloplasty can be hairy, some patients may choose to undergo electrolysis in the donor areas for a period of months to help minimize hair growth on the new penis. Indeed, some surgeons require electrolysis of the donor areas before they will proceed with the procedure. If electrolysis is not chosen, the patient will have to periodically shave the skin of the penis or use depilatory cream.
Free tissue flap transfer (FTFT)
The FTFT procedure is a more recent and improved approach to phalloplasty which uses a flap of skin and tissue from the groin, thigh, or forearm area. In FTFT, a skin flap is removed completely from the donor area and transferred, with its existing nerves and blood vessels intact, to the groin area. There the flap's nerves and blood vessels are connected microsurgically to the nerves and blood vessels of the groin. This is done with the aim of the new penis becoming erotically sensate, while also helping to ensure proper blood supply to the penis.
Forearm free flap phalloplasty
This procedure is considered by many to produce a more realistic-looking, more erotically sensate phallus than other phalloplasty procedures. This is due to the nature of the skin of the forearm (areas on the underside of the forearm are of good consistency and often are fairly hairless) as well as the nerves and blood vessels that are able to be harvested with that skin. The main drawback to the procedure is that it leaves a very large scarred area on the forearm, and there is some risk of damage to the overall function and feeling of the arm. The donor area on the arm is usually covered with skin from the thigh or groin, leaving a secondary scar in that area as well.
The forearm skin is shaped into the new penis and grafted into place on the groin, where the nerves and blood vessels are microsurgically connected. Some surgeons will connect the brachial nerve of the forearm to the pudendal nerve of the clitoris (with the goal being erotic sensation in the penis). A urethra is typically created using tissue from the labia or the vaginal wall, or with a section of relatively hairless skin from the forearm donor site, shaped into an inverted tube. The clitoris is usually left intact near the base of the penis; the exact placement of the base of the penis with regard to the clitoris should be discussed with the surgeon. Usually, a flexible rod must be inserted into the penis or an implanted pump device used in order to achieve an erection.
Because the donor skin on the forearm can be hairy (depending on the patient and the area from which the skin is taken), some patients may choose to undergo electrolysis in the donor areas for a period of months to help minimize hair growth on the new penis. Indeed, some surgeons require electrolysis of the donor areas before they will proceed with the procedure. If electrolysis is not chosen, the patient may have to periodically shave the skin of the penis or use depilatory cream.
Modified forearm free flap phalloplasty
In order to address the issue of major scarring on the forearm, some surgeons have combined the benefits of forearm free tissue flap transfer with other methods such as the pedicled groin flap. A surgeon may choose to create the main shaft of the phallus from a non-sensate source such as a pedicled groin flap, but in a later surgical stage, use sensate tissue from the forearm to create the head of the penis. In another approach to minimize scarring, tissue expanders may be inserted into the forearm and used over a period of months so that when the tissue is harvested from the forearm, the donor area can be closed without an additional skin graft. Such options should be carefully researched and discussed with the surgeons you are considering.