Further Methods of Phalloplasty

As we have known that phalloplasty is a medical surgery to construct, reconstruct, or modify a person’s penis, phalloplasty is mostly performed with skin graft. There are six further methods of phalloplasty, explained below:

Graft from the arm

Graft from arm is actually the easiest method to perform phalloplasty, but it leaves scar on arm—which can not be hidden. Moreover, the function of the arm may be worse if it does not heal properly. A full scale metoidioplasty can be performed several months earlier before phalloplasty. This is to decrease the complications possibilities after the surgery.

Below is the most common steps of this method of phalloplasty. Some variations may apply, but mostly below is the general approaches:

• After the patient is prepared, the surgery starts by marking the forearm with the size of the graft. The graft is then taken. In case the graft is too large, another graft from other parts of the body may be used to reconstruct the arm.
• The graft skin is then separated to see the veins and several antebrachial nerves. This is performed very carefully.
• The urethra and the phallus will be joined at this step, if both requires construction at the same time. If they don’t, the glans is formed.
• To let the joining of the graft and the existing tissues joined easily, a part of vein around the patient’s groin is used.
• The vein is placed to the femoral artery very carefully.
• The flap and the vein to the femoral artery are then joined.
• The ligament and clitoral hood is removed, while the nerve bundle is being untouched for some moments. Some surgeons make an alternative of leaving the clitoral tissue as it is after metoidioplasty.
• Some part of the flap is then placed as the nerve bundles are joined.
• If there is an urethral extension required, the urethra is joined with a catherer. It will be kept in place for two until four weeks recovery. The skin sometimes need to be sealed and the scrotum is also made up.

Moreover, if the urethra extension is required until the top of the glands of the new penis, a mixture of saline and epinephrine is injected to the labia minora. It is then opened up, and the layers are separated. The layers are then closed around a catheter and sewed up.

Sometimes, in an urethral extension, a mucosal flap from inside the vagina may be used. This requires a separate surgery.

Graft from the side of the chest

Graft from chest is actually not an old method. This is one of the biggest advancement in phalloplasty. Some advantages of this methods are good appearance, no prominent scar, lower potential of complications, and no need of hair removal. This method of phalloplasty requires three parts, spanning over six to nine months. The steps are:

• The surgery starts (after the patient is prepped) with the side of the chest marked for graft size.
• After the patient is prepared, the surgery starts by marking the side of the chest with the size of the graft. The graft is then taken.
• The graft skin is then separated to see the veins and several thoracodorsal nerves.
• With the graft still attached to the blood supply from the vein, the graft is rolled to shape a rough penis.
• To let the joining of the graft and the existing tissues joined easily, a part of vein around the patient’s groin is used.
• The vein is placed to the femoral artery very carefully.
• The flap and the vein to the femoral artery are then joined.
• The ligament and clitoral hood is removed, while the nerve bundle is being untouched for some moments.
• Some part of the flap is then placed as the nerve bundles are joined.
• The new penis is protected from any contact to other muscles and skins during the beginning recovery period. This step requires a constructed dressing to keep away any potential complications of blood supply
• Urethral extension is then started after three months pass.
• The new penis is separated and an oral mucosa graft is laid onto the cavity and extended to the urethra. Both are then joined to let urination while standing.
• A catheter is placed for several weeks to allow for proper healing
• For recovery, a catherer is used for some weeks. After three until six months, the erection device can be placed.

Graft from leg

This method is akin to that of forearm graft, except that the scar of the donor will be easily hidden by socks or pants. The remaining steps are similar to as in the forearm graft method, including the removal of permanent hair before the operation. Sometimes, the graft from the leg may be combined with forearm graft to reshape the glans penis.

Pubic area flap

Graft is taken from the skin around the pelvic bone, across the abdomen around the stomach. There will be a big horizontal scar, making it a little bit unaesthetic. Moreover, the grafts are usually seen unnatural and less permanent to keep an erecticle implant for a further term. Hair removal is necessary before proceeding this method.

Gillies technique

This method of phalloplasty is actually the first phalloplasty method ever used. An abdominal skin is rolled, making a form of tube, to simulate a natural penis. Urethral extenion is performed in another part of the skin, creating a tube within a tube. A flexible rod is required to implant erectile. A more improved method of Gillies technique includes an inclusion of a blood supply pedicle to avoid dead tissue before being transplanted to the groin.

Abdominal muscle

This last method of phalloplasty is rarely undergone. There are three minimum steps in this method, including implantating an expansion balloon to help grafting the necessary skin parts. Finally, the grafts will be a little bit unnatural, and less likely to keep the implanted erectile in a further term.

A Brief Information about Phalloplasty

Phalloplasty is a medical term of constructing, reconstructing, or modifying a person’s penis due to medical condition or cosmetic purposes (also known as penis enlargement). A phalloplasty is usually performed to patients with genitalia deformities like micropenis or hypospadias, patients who lost their penis, or female to male transsexual patients. First phalloplasty ever recorded in history was performed with the aim of female to male sex reassignment surgery, undergone by a trans man, Michael Dillon, in 1946. Dr. Harold Gillies, the surgeon, documented the technique in Pagan Kennedy’s book “The First Man-Made Man”.

Basic Methods of Phalloplasty

Surgeons have four different methods in performing phalloplasty. Basically, these methods include a graft of tissue and skin from donor and an extention of the urethra. Phalloplasty can create a penis up to 7 inches long (approximately 14-18 cm) and 5.9 inches (approximately 11-15 cm) in circumference.

Phalloplasty is simpler for real male (or termed as cis men) than for trans men, because there is no significant requirement of urethra extension. In trans men, the urethra finishes close to the vaginal opening and, therefore, needs to be significantly extended. The urethra extension is the most difficult phase of phalloplasty. In trans men, phalloplasty is also followed by scrotoplasty. Scrotoplasty is a construction of scrotum, where testicles are located. Scrotoplasty can be done by using labia majora or vulva. Then prosthetic testicles can be inserted in the scrotum after scrotoplasty is done.

The success of a phalloplasty can not be measured just by whether the penis has been constructed/reconstructed or not, but by whether the penis could perform similar functions like natural penis. For instance, could it achieve an errection and sexual penetration? In this case, an implanted erectile prosthesis is required in every phalloplasty. Some kinds of this implanted erectile prosthesis include malleable rod-like medical devices—that allow the penis to erect or be flaccid. Still, in this case, the success rate of erectile prosthesis implantation in trans men is lower than that in cis men. But, surgeons usually use their experience in sex reassignment surgery to trick the implantation to lower down the potential risk.

Former methods of this implantation require a bone graft as part of the phalloplasty. Studies from Germany and Turkey have given proof that these reconstructions can hold the stiffness without any further complications. However, in this case, the penis will not have the ability to become flaccide without breaking the bone graft apart.

In penis enlargement, phalloplasty is sometimes performed by cutting the suspensory ligament that hold the penis near to the upper skin. It allows the penis to grow toward the outside of the body instead of upward. This is done by doing a horizontal incision around the pubic bone region, where the pubic hair will help covering the incision part. After all, the penis is free from any incisions.

There is still research in progress about synthesizing corpus cavernosa, or the erectile tissue, performed on rabbits in laboratory. This is done to dig more about eventual use in patients who require phalloplasty. The last report of this research tells that the rabbits give response to sexual stimulation, just like to the tissue of male rabbit which is not any parts of the research.

Patient Satisfaction

Approximately 90% of the patients undergoing phalloplasty is satisfied, while only 9% of them complain about the sensitivity of their new penis. Meanwhile, 51% of them are able to do sexual penetration without pains or difficulties. Moreover, 40% of these patients are able to apply for a job they can not apply for when they were still female. There is 27% of them who needs temporary use of anti-depressants, while 93% (or mostly) of them said that they were happy with their new penises.