Phalloplasty is a type of “bottom surgery” that creates a penis using tissue from your donor site. Phalloplasty often requires 3 or more surgeries to complete. These surgeries are typically 3 to 6 months apart. Penises created by phalloplasty are often within the average adult male size. There will be a large and permanent scar on your donor site after phalloplasty.
Types of phalloplasty
- Forearm-flap phalloplasty: This surgery is often called radial forearm flap phalloplasty (RFF). This surgery offers a better chance of developing sensation in the penis. Many patients choose to have the flap taken from their non-dominant forearm. Your primary care provider can perform a clinical Allen's test to determine if your forearm may be a candidate for forearm-flap phalloplasty before you start hair removal. You will need to remove the hair on your forearm between your elbow and wrist.
- Thigh-flap phalloplasty: This surgery is often called anterolateral thigh phalloplasty (ALT). This surgery offers a better chance of increased penis length and girth and a more hidden donor site but may have a higher complication rate than forearm-flap phalloplasty. Minimal body fat on the thigh is needed to be a good candidate and many people are not eligible for thigh-flap phalloplasty.
- Combined forearm and thigh flap phalloplasty: This surgery uses tissue from the forearm to create the urethra (pee tube) and tissue from the thigh to create the penis shaft. This surgery may have a higher complication rate than forearm-flap phalloplasty but it creates a smaller area of scarring on the forearm than forearm-flap phalloplasty. Combined flap phalloplasty creates less penile girth than thigh-flap phalloplasty, where the urethra is created by the tube-within-a-tube method.
- Closure of the vagina: Closure of the vagina is often called a vaginectomy, or colpectomy with colpocleisis. Closure of the vagina is optional for patients who do not want urethral lengthening.
Your surgeon will answer your questions about surgery and provide you more information about the risks associated with phalloplasty during your consultation.
How do I prepare for phalloplasty while I am waiting for a consultation?
While you wait for your consultation, there are several things you might need to do to prepare for phalloplasty.
Hair removal
Hair removal is an important aspect of preparing for phalloplasty, and is required if you want to be able to pee through your penis. Body hair needs to be permanently removed from the skin that will be used to create your urethra (pee tube). Hair removal can take more than 18 months for some people. Hair removal needs to be completed before you can schedule the surgery that will lengthen the urethra. It is important to start laser hair removal or electrolysis to remove the hair from your arm as soon as possible.
Hysterectomy
A hysterectomy removes your uterus. You will need to have your uterus, uterine (fallopian) tubes, and cervix removed at least 3 months before you have the surgery to close the vagina. An oophorectomy (surgery to remove the ovaries) is not necessary for many people unless desired.
Nicotine cessation
We require you to abstain from nicotine consumption, including tobacco and e-nicotine products, for at least 6 weeks prior to surgery and 6 weeks after surgery. This is because nicotine constricts the blood vessels and decreases blood flow to body tissues. Nicotine users may have a higher risk of complications, including delayed healing of wounds and skin graft failure.
Some patients may choose to work with their primary care provider and the Koop Tobacco Treatment Center at Dartmouth Hitchcock Medical Center to receive support in quitting nicotine products to help them prepare for surgery.
Diabetes management
For individuals who are diabetic or are at-risk for diabetes, it is important to have A1C levels checked and confirmed before you have surgery. We ask that you have an A1C of 7% or lower prior to surgery. Having uncontrolled blood glucose levels can lead to higher rates of infection and there are risks associated with poor healing of the surgical site.
Body mass index (BMI)
We recognize that bodies come in all sorts of shapes and sizes and that weight is not the ultimate deciding factor for overall health. Generally speaking, a BMI of 35 or less is desirable for optimal surgical recovery. Having a BMI above 35 can lead to higher rates of complications, specifically with regard to blood clotting and tissue healing.
Some patients may choose to work with their primary care provider and the Weight and Wellness Program to address weight and related conditions to help them prepare for surgery. However, each person is unique and BMI is not always a reliable indicator of overall health.
WPATH letters of surgical readiness
Many insurance providers will require you to provide 2 letters from mental health providers as per the World Professional Association for Transgender Health’s (WPATH's) seventh edition of their Standards of Care guidelines.
- They may want one of the letters to come from a provider who you have an established and ongoing relationship with. This provider is usually a therapist or psychiatrist who you have regular appointments with.
- A second letter is often required from a provider who has screened you for your eligibility for surgery, but that you do not continue to see on a regular basis.
It is important for you to contact your insurance provider to confirm what their requirements are for covering gender-affirming genital surgery.