Note that in this article biological terms regarding sex organs will be discussed.
Phalloplasty (also called Phallo) is a procedure meant for people who were assigned female at birth, usually trans men. This is one of the two main bottom surgery methods for AFABs.
For reading about the other main method, see Metoidioplasty.
In phalloplasty, a “donor area” from elsewhere in the body is used to construct a penis.
There are a few donor areas that can be used, which are: the forearm (RFF phalloplasty), the thigh (ALT phalloplasty), and the upper back (MLD phalloplasty).
To construct the penis, a piece of tissue is taken from the donor area including skin, fat, nerves, and blood vessels. The penis is then connected to the nerves of the existing organ so that there can be erotic and tactile sensation. It is possible to add a procedure for creating a urethra, as well as creating a scrotum.
Surgery Characteristics
- Sexual sensation is retained after the procedure, though the risk of losing partial or full sensation is higher than with the metoidioplasty method.
- After phalloplasty there remain scars in the donor area (the forearm, thigh, upper back).
- The penis length after surgery will usually be between 13-21cm, with a thickness of 5-7cm. The size varies according to the patient’s anatomy and the donor area used.
- Phalloplasty does not create an organ that erects spontaneously from sexual stimulation, and it is necessary to utilize a device for erection.
- Phalloplasty can be suitable for penetration of a partner, but an erectile device is necessary.
- You cannot do metoidioplasty surgery after phalloplasty.
- After the organ is created, there is no ejaculation after an orgasm.
Surgery Stages
Phalloplasty is usually split into two surgeries.
The first surgery can include (at the patient’s discretion):
- Construction of the penis and connection to nerves and blood supply
- Creation of a cap for the organ
- Creation of a urethra
The second surgery usually includes:
- Creation of a scrotum
- Implementation of an erectile device
- Corrections if necessary
It is not necessary to undergo all procedures, you can choose between them.
There are some clinics that perform the surgery in 4 procedures instead of 2, to avoid potential complications. At certain clinics, it is possible to split it into a larger number of procedures according to the patient’s wishes.
Different Phalloplasty Methods
RFF Phalloplasty
In this method, the forearm (usually the weaker arm) is used as the donor area for constructing the penis.
To cover the donor area, a skin graft will be taken from the thigh or stomach.
Thanks to the connection of two central forearm nerves to the nerves in the existing sex organ, it is possible to have relatively strong tactile and erotic sensation in RFF phalloplasty, compared to the other methods.
ALT Phalloplasty
In this method, the thigh (usually the weaker leg) is used as the donor area for constructing the penis.
In this method as well, a central nerve in the thigh is connected to the nerves in the existing sex organ, to obtain tactile and erotic sensation. ALT phalloplasty is considered a method that retains erotic and tactile sensation at relatively high rates, though less so than with RFF phalloplasty due to lesser sensitivity in the thigh in comparison with the forearm. What makes ALT phalloplasty unique is the ability to choose the length of the organ, from 10cm up to even 21cm, depending on anatomy. Additionally, this method is suitable for those with a lower BMI, as the thigh typically has a thicker layer of fat.
MLD Phalloplasty
In this method, the upper back is used as the donor area for constructing the penis.
In this method as well, a central nerve is connected to the nerves in the existing sex organ, to obtain tactile and erotic sensation. MLD phalloplasty is also considered a method that retains erotic and tactile sensation, though less than the other two methods due to the lesser sensitivity of the upper back in comparison with the forearm and thigh.
Phalloplasty Surgery Risks
Along with standard surgery risks, there are potential complications that are unique to phalloplasty surgery:
Fistula / Stricture
A fistula is a hole in the urethra, which can cause leaks or urination disorders.
The fistula usually heals on its own, but sometimes surgical intervention is necessary to fix it.
Stricture is the narrowing of the urethra due to unsymmetrical healing of the internal scar.
The rate of complications with the urethra is relatively high in phalloplasty surgeries, and according to research, the percentages are 24.2% for the RFF method and 32.8% for the ALT method.
Partial or Full Loss of the Organ
According to research, the chance of partial or full loss is 3.4% for the RFF method and 7.8% for the ALT method.
Implant Rejection
A potential complication, where the body rejects the silicone testicular implants / erectile device. This complication may require additional surgery to fix it. In this case, surgery is necessary to remove the implants, and after 6 months of recovery, it is possible to try to implant again.
Related Procedures Available as Part of Phalloplasty (Optional)
Erectile Device
Implantation of an erectile device inside the penis so that it can erect. The erection is not spontaneous (by sexual stimulation), it is manual. The device must be replaced every 10 to 20 years, but the exact number depends on the type of device and is based on older device models.
There are two types of erectile devices:
- Semi-rigid rod – an erectile device made of metal wires wrapped in medical-grade silicon, the device is placed inside the organ and is connected to the pelvic bone. Erection occurs when the device is moved to its erect position. With this erectile device, the penis will always be partially erect, as the device is always rigid even when not erect.
- Pump – an erectile device made of an implant, a manual pump, and a water reservoir.
The water reservoir is implanted in the abdominal cavity and the water flows to and from the device. The device itself is placed inside the penis and is filled with water with a manual pump located in the testicle. When water flows to the device, it expands and the erection is created.
Vaginectomy
Removal of all parts of the vagina. Information about this procedure can be found on Wikipedia.
Urethra Lengthening (UL)
Lengthening of the urethra, allowing for urination while standing.
Scrotoplasty and Testicular Implants
There are two main methods for creating a scrotum:
- In the common method, VY scrotoplasty, a scrotum is created using the vaginal lip skin. Silicon testicles are implanted in the scrotum. The result is one scrotum that bulges from the body.
- In the second method, no surgery is done to create a scrotum, and round silicone implants (at a size of choice) are inserted into the outer lips themselves. The procedure itself is simpler, and the result is a scrotum made up of two smaller “bags”, which bulge from the body less.
The silicone implants cannot burst or rip naturally, even if a lot of pressure is applied to them.
Recovery
As with any surgical procedure, the recovery process varies from person to person and depends on the specific procedure performed.
For the first and second phalloplasty surgeries, the recovery time is usually around 6 weeks. However, the length of recovery can vary from person to person and depends on the specific procedures performed, as well as how successful it was. During recovery, you are not allowed to lift more than 5 kilograms for one to three months after surgery.
Additionally, most surgeons recommend waiting at least six months between the surgeries for better recovery. Recovery time will be estimated individually by the surgeon, at consultation before surgery.
How to Undergo Surgery
The surgery is performed at specialized clinics in various countries around the world. For a list of surgeons.
In Israel, you can receive approval for the surgery through the Committee for Gender Reassignment, while the surgery itself is possible abroad (for example in Germany, the USA, or Serbia) with HMO funding. It is important to take into account that not all HMOs work with some countries, so they may not approve surgery in certain countries. If there is a need for a specific country (for example if a specific procedure is performed there and nowhere else), bring the specific recommendation from the Committee for Gender Reassignment so the HMO approves the funding.
As these surgeries are not regularly performed in Israel, the support network in the case of corrections or complications occurring near the surgery is more limited than abroad. This is another reason to undergo surgery abroad with experienced and recommended surgeons.
In the past, there were attempts to bring a surgeon to Israel but it was unsuccessful; therefore as of today, there is no expectation of another invitation of a surgeon from abroad. Information is available through the Committee for Gender Reassignment in Tel Hashomer.
It is possible to undergo surgery with private funding, or with funding from private health insurance if it exists and the surgery is covered by the policy.
The price range of phalloplasty is between $130,000-$230,000.
For Further Reading
- Research comparing surgery results for the different methods
- Wikipedia article about phalloplasty
- The Ministry of Health medical director’s recommendations about bottom surgery abroad