Phalloplasty Options

There are many different phalloplasty operations to create a new penis used for transmen and each offers specific advantages and disadvantages.  Here’s an overview of four major ones types of gender affirming phalloplasty.

The Radial Forearm Free Flap Phalloplasty (RFFF)

Probably the most common phalloplasty is the radial forearm free flap. With this, the nondominant forearm skin, nerves and and blood vessels are used to create a new penis. In the RFFF, the urethra is created by creating a tube from skin and the then wrapping the penile skin over this to create the outside of the penis.  Surgery is technically complicated but the operation creates a normal sized penis with some sensation and the ability to urinate standing up through the tip of the penis.  At another stage of the operation, a penile implant can be placed to allow penetrative sex. One disadvantage of this surgery is that it leads to a large scar over the forearm.  This area is often covered by another skin graft, usually from the thighs, which in turn leaves another area of scar there.  With time, the penis may also shrink and become smaller.

Anterior Lateral Tight (ALT) Flap

The Anterior Lateral Thigh flap uses skin and underlying tissue from the thigh to create a new penis. It is a local flap – meaning the blood supply is not transected in the creation of the flap but the skin is rotated in place to create a new phallus.  There is some sensation and a tubularized urethra can be created at the time of the surgery. It is also possible to place a penile prosthesis in a second stage to permit penetrative sex.  The ALT is only appropriate in a patient with the right anatomy. If there is too much fat in the subcutaneous tissues then the penis will be become “coke-can” like and too thick.  It also leaves a substantial scar in the thigh that may require a skin graft to cover. Sensation is not as well developed as a RFFF.

Lattismus Dorsi Free (LDF) Flap

The LDF utilized a combination of skin and muscle from the side of the chest wall as a free flap  to create a new phallus.  A large phallus can be created with normal girth and a tubularized urethra that permits standing while urinating.  The scar tissue from the donor site is substantially less than the ALT or the RFF and patients have some sensation in the penis but not as much as the RFF.  In a second stage, a penile implant can be placed to permit penetrative sex and, unlike the RFFF, there is often enough thickness to implant two cylinders of the prosthesis.  The LDF does require the right patient – if there is too much fat in the skin at the donor site it can be difficult to close the edges of the donor site together and the patient might be left with too thick a penis.

Suprapubic Phalloplasty

The suprapubic phalloplasty involves using skin and fat in the lower abdomen to create a new phallus.  This is the most straightforward phalloplasty option and offers the fastest recovery for patients. It provides a nice sized penis with normal thickness and the ability to place a penile prosthesis at a later stage. Donor site morbidity is minimal particularly when compared to other types of gender affirming phallopasties.  Patient selection is important with this operation – if there is too much fat then it can be difficult to close the site from where the penis was harvested. The suprapubic phalloplasty does not typically construct a urethra in the first stage but it can be constructed to permit standing while urinating in later stages.