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Formation of the Phallus

Radial Artery Phalloplasty (Forearm free flap phalloplasty)

We have been performing this surgery since 1996 using the original technique as described by Chang in 1984. The forearm flap has the thinnest skin, reasonable fat content and is not usually hairy on the urethral segment. In addition it has the most reliable anatomy when compared to all the other free flap techniques and is fairly easy to harvest. This is the procedure of choice if standing and voiding from the tip, cosmesis and sensation are the prime requirements.

The main disadvantage for patients is the cosmetic appearance of the skin graft on the forearm where tissue has been taken to construct the phallus. 

It is important to appreciate that actual problems with the function of the hand and arm are extremely uncommon and always have been in our series of patients.  We are aware however that the appearance of the arm after surgery is extremely important to our patients and much effort has gone into improving this aspect.  Modern dressing techniques using silicone, absorbable monofilament sutures and fewer dressing changes combined with careful attention to graft placement has resulted in significant improvements in the cosmetic appearance of the arm following surgery.

Operative technique

A flap from the urethral segment of the forearm skin is formed into a skin-lined tube that will eventually be the neo-urethra (Figure 4).  This tube is then rolled up like a Swiss Roll within a larger flap which has the skin on the outside. This tube within a tube is then transplanted to the pubic area and microsurgical anastomoses made to connect the artery, veins and nerves. The radial artery from the arm is transplanted to provide a blood supply to the phallus via the inferior epigastric artery from the lower abdominal muscles. The lower neo-urethral opening is placed to the side of the clitoris ready to be connected to the native urethral opening in the future.

Donor site defect

We use lower buttock skin crease full thickness grafts for the forearm grafts instead of using groin skin, axillary skin or abdominal skin. The scar from buttock skin is easily hidden and the hair quality is fairly fine and appropriate for most forearms.

If a patient has no spare skin anywhere then we take split thickness skin graft from the thigh to cover the forearm. Split thickness skin graft is hairless, very sensitive to sunlight damage and also contracts more which may impair arm function. However we have not had many seriously significant problems with our patients in the long term. Full thickness skin does grow hair, is thicker, stretches more and looks and feels better. In addition it takes tattoo ink better if patients want to tattoo the graft. We suggest waiting a year for the scar to stabilise before starting a tattoo. We recommend that patients avoid sunlight exposure to the skin grafts for about two years. It is also important to use skin moisturisers as often as possible to hydrate the grafted skin and maintain pliability

The standard forearm skin length measurement of the phallus is 14 cm but if the forearm is of small size then we make a smaller phallus (12-13 cm) to aid skin closure, increase usable radial artery length and reduce forearm morbidity. This gives a very acceptable cosmetic result. The length and girth of the phallus once made depends on the weight of the fat and skin elasticity so patients end up with range of sizes (some bigger, some smaller).  We aim for a girth of about 13 cm which leaves enough space for the erectile device. We connect normal sensory as well as erogenous nerves to the phallus and about 90% of our patients to date have at least some touch/sexual sensation in the phallus. The forearm flap usually has 3 nerves that come with it and is therefore more likely to develop sensation than any other kind of phalloplasty. Nerves do grow slowly and it can take a couple of years for sensation to appear.

Operative technique

A rectangular shaped skin flap (14 cm long by 12 cm wide) is raised from the lower abdominal skin but still in continuity with the clitoral and pubic area. If there has been a transverse hysterectomy scar then we mark out the proposed flap, raise it and then put it back on the abdomen and wait for at least six weeks. This is to make sure that there is sufficient blood supply for a phallus to survive. The rectangular skin flap is folded in a tubular fashion to form the phallus.

Abdominal skin is mobilised and brought down to cover the defect. We use lateral hip skin flaps rotated in to help close the skin defect, which reduces the risk of the phallus being tethered upwards. The scar does go right across the abdomen but usually can be hidden by underpants. The main complaint from patients is that they lose their pubic hair using this technique.
If there is difficulty closing the skin defect then we initially allow the phallus to ride high (ie: pointing upwards) and then use groin crease skin flaps to drop the phallus down at a later stage, giving more pubic hair.   This problem is more likely to arise in patients with little abdominal fat.

These phalluses can also be rather large particularly in girth and we have had to deliberately reduce the girth and even length in some patients to allow comfortable sexual intercourse with their partner.  They have less sensation than the radial artery phalloplasties when compared with the radial artery phalloplasties. They have no distal phallus sensation (feeling towards the tip) because all the nerves get cut during the flap elevation.

Anterolateral thigh flap phalloplasty (ALT)

This type of phalloplasty is made from the skin and fat on the front and side of the thigh. Very few patients are suitable for this method as it requires that the subcutaneous fat on the thigh be not too thick. In addition if a neo-urethra is required then the urethral segment must not be hairy. In general terms, the skin itself is also much thicker/coarser than that of the forearm.

For ALT phalloplasty with urethra the flap design and construction is the same as for the forearm technique: a tube within a tube. The flap skin length dimension is usually 14-16 cm as there is more available skin on the thigh compared to the forearm. Usually the feeding artery and veins are very long and arise from near the hip joint and it is therefore possible to tunnel the whole flap under the quadriceps muscle to the groin without disconnecting and reconnecting the blood vessels (pedicled flap). There is however only a single nerve with this flap so even with a nerve hook-up, sensation is not as good as with the forearm flap method. 

The large donor site defect is covered with a split skin graft from the other thigh and is not particularly cosmetic but can be covered with a long pair of shorts quite easily. We do not offer this type of phalloplasty if the patient has significant knee problems as these may get worse post-operatively. In any case the thigh muscles tend to bulge quite a bit afterwards but the split skin graft shrinks considerably as it matures and tends to hold the muscles back in place. The quadriceps muscles are deliberately cut to release the feeding artery and vein but are sutured back together at the end of the procedure. Healing takes place in much the same was as a bad sports muscle tear/injury would do. Patients are able to mobilise within a couple of days.

For ALT phalloplasty without urethra, a smaller width flap is taken and the hairiness does not matter as that can be dealt with later. This option is sometimes chosen if a patient wants a potentially sensate phallus but has little abdominal fat, cannot use the forearm and is happy to void sitting down.

Metoidioplasty (Mini-phallus)

This operation is selected by those who need to void standing but are not interested in phallus size or having penetrative sexual intercourse. Sometimes they just want the appearance of a small penis and scrotum and are happy to void sitting. It is not a common choice in our group of patients and in our experience about 25% of patients having this operation later regret not having had a larger phallus constructed which allows them to have sexual intercourse.

Operative technique

The procedure involves bringing the urethral opening up to the tip of the clitoris rather than the side and the clitoris is formed into a pseudo-glans. The remaining non-hairy inner labial folds are excised and the hairy outer labial skin is dropped down to make the mini-phallus stick out more.  The neo-urethra is usually constructed in two stages with a buccal graft taken from the lining of the mouth grafted on first to form the lining of the new segment of urethra.  This is allowed to heal before the surgery is completed at a second stage about six months later. Laparoscopic hysterectomy and vaginectomy can be performed at the same time as the second stage.

If the patient does not need to void standing then the mini-phallus and scrotum are formed in one operation with laparoscopic hysterectomy and/or vaginectomy as required. The native urethral opening is then repositioned discretely just under the scrotum so no female-looking parts are retained.
Small testicular prostheses are inserted later if required. 

Best results are obtained when there is significant clitoral enlargement from long-term testosterone treatment. If the clitoris is small or the patient is overweight then this is not a recommended procedure. One of the problems is that the urethral width is quite narrow for technical reasons and voiding difficulties and strictures are not uncommon.

Hair removal

Once the hair removal has been completed we wait three months before listing you for surgery to ensure that the area remains suitable for surgery with no significant regrowth of hair.  Even if the hair removal is for cosmetic reasons we still will not operate within six weeks of the most recent session.  This is to avoid the possibility of the treatment interfering with the surgical outcome.

Hair removal for cosmetic reasons (i.e.: because you do not like the appearance of hair on the penis) is not normally funded by the NHS but can be undertaken either before surgery (when the areas concerned are relatively flat) or afterwards (when it can be seen exactly which hairs require removal). 
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