Phalloplasty is a gender-affirming surgery primarily sought by transgender men (FTM or female-to-male) or non-binary individuals who wish to construct a penis. It can also be performed on cisgender men who have lost their penis due to trauma, cancer, or congenital conditions. This complex surgical procedure involves creating a neophallus (a new penis) using tissue from other parts of the body, such as the forearm, thigh, or back, to construct a penis that looks and functions as naturally as possible.

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Purpose and Importance

For many transgender men and non-binary individuals, the presence of male genitalia can be an important factor in relieving gender dysphoria. Phalloplasty enables the creation of a penis that allows the individual to feel more congruent with their gender identity. Additionally, phalloplasty can provide sexual function, enabling the individual to engage in penetrative intercourse and, in some cases, urinate while standing, which is a significant aspect of male embodiment for many trans men.

While not every transgender person opts for genital reconstruction, phalloplasty offers those who do an opportunity to align their body with their gender identity more completely.

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Procedure

Phalloplasty is a highly intricate surgery, typically completed in multiple stages over several months. The procedure involves various steps, including the construction of the penis, urethral extension, and in some cases, the placement of erectile devices. Here is an overview of the process:

1. Harvesting Tissue:

   • The surgeon harvests a flap of skin, tissue, and sometimes nerves and blood vessels from a donor site on the body (commonly the forearm, thigh, or back). The choice of the donor site depends on the patient’s preferences, desired appearance, and surgical feasibility.

   • The donor tissue is then shaped into the form of a penis.

2. Construction of the Neophallus:

   • The harvested tissue is used to construct the shaft and head of the penis. In some cases, surgeons may use microsurgical techniques to connect nerves from the donor site to ensure the neophallus has sensation.

   • A separate graft of skin may be used to construct the scrotum, which can later have testicular implants placed if desired.

3. Urethral Lengthening:

   • One of the most complex aspects of phalloplasty is the extension of the urethra to allow for urination through the penis. This involves creating a new urethra from tissue, which is connected to the existing urethra. This stage can carry risks of complications, including urethral strictures or fistulas, which may require revision surgeries.

4. Erectile Devices (Optional):

   • Since the constructed penis does not naturally have erectile function, some patients choose to have a penile prosthesis implanted in a later stage of surgery. This device allows for erections sufficient for penetrative intercourse. Common prosthesis options include inflatable devices or semi-rigid rods.

5. Testicular Implants (Optional):

   • For those who want to enhance the scrotum’s appearance, silicone testicular implants can be inserted to provide a more realistic male genital appearance.

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Recovery

The recovery process following phalloplasty is long and can be challenging, given the complexity of the surgery. Some key aspects include:

• Hospitalization: After the initial surgery, patients typically remain in the hospital for several days to a week to monitor for complications like infection or tissue rejection.

• Donor Site Healing: The donor site (e.g., forearm or thigh) will need time to heal, and it may leave a noticeable scar. Skin grafts from another area of the body are often used to cover the donor site.

• Follow-Up Surgeries: Additional procedures, such as urethral revisions or the placement of erectile devices, are typically required, with intervals of months between surgeries.

• Daily Activities: Patients will need to limit physical activity, especially strenuous exercise, lifting, and sexual activity, for several weeks or months post-surgery to ensure proper healing.

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Risks and Complications

Due to its complexity, phalloplasty carries several potential risks and complications, including:

• Urethral Complications: Urethral strictures (narrowing) or fistulas (abnormal connections) are common and may require additional corrective surgeries.

• Loss of Sensation: While efforts are made to preserve and connect nerves, there is no guarantee of sensation in the neophallus.

• Scarring: Significant scarring can occur both at the donor site and the area where the penis is constructed.

• Implant Issues: In cases where penile prostheses are used, they may malfunction or cause infections, necessitating removal or replacement.

• Aesthetic Concerns: The appearance and size of the penis may not meet the patient’s expectations, and revisions may be needed.

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Mental Health and Emotional Impact

Phalloplasty can have a profound emotional and psychological impact. For many transgender men and non-binary individuals, having male genitalia plays a key role in reducing gender dysphoria and improving self-esteem. Being able to urinate while standing and engage in sexual activity with male anatomy can significantly enhance one’s quality of life. However, the decision to undergo phalloplasty is deeply personal, and not all transgender men choose this path. Some are satisfied with other forms of transition, such as hormone therapy or top surgery, and may not feel the need for genital reconstruction.

It’s important to note that counseling and mental health support are typically recommended before and after surgery. Phalloplasty is a long, emotionally challenging process that involves multiple surgeries and an extended recovery period. Having a support system and professional guidance can help individuals navigate the psychological and emotional aspects of the surgery.

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Conclusion

Phalloplasty is a complex and transformative surgery that allows transgender men and non-binary individuals to achieve a penis and, in many cases, urinary and sexual function. While it carries significant risks and requires a long recovery, it offers the potential for physical and psychological relief from gender dysphoria. For those who undergo the surgery, phalloplasty can be a life-changing step toward bodily congruence and improved quality of life.