Last updated July 30, 2025 > [!important] This report was produced by Gemini Deep Research. It is for educational purposes only and should not be considered medical advice. - [[#Introduction]] - [[#Types of Phalloplasty Surgical Techniques]] - [[#Radial Forearm Flap (RFF) Phalloplasty]] - [[#Anterolateral Thigh Flap (ALT) Phalloplasty]] - [[#Other Phalloplasty Techniques]] - [[#Metoidioplasty and its Relation to Phalloplasty]] - [[#Pre-operative Preparation for Phalloplasty]] - [[#Medical and Psychological Evaluations]] - [[#Hormone Therapy Guidelines]] - [[#Smoking Cessation]] - [[#Hair Removal]] - [[#Other Lifestyle Adjustments]] - [[#The Phalloplasty Surgical Procedure]] - [[#Staging of Phalloplasty]] - [[#Detailed Explanation of Each Stage]] - [[#Anesthesia and Hospital Stay]] - [[#Post-operative Care and Recovery]] - [[#Immediate Post-operative Care]] - [[#Long-Term Aftercare]] - [[#Recovery Timeline]] - [[#Potential Risks and Complications of Phalloplasty]] - [[#General Surgical Risks]] - [[#Specific Phalloplasty Complications]] - [[#Management and Treatment of Complications]] - [[#Sensory Outcomes and Erectile Function After Phalloplasty]] - [[#Expected Sensory Return]] - [[#Achieving Erectile Function]] - [[#Realistic Expectations for Sensory and Functional Outcomes]] - [[#Financial Considerations for Phalloplasty]] - [[#Cost of Phalloplasty]] - [[#Insurance Coverage]] - [[#Resources for Financial Assistance]] - [[#Follow-up Care and Potential Revision Surgeries]] - [[#Typical Follow-up Schedule]] - [[#Reasons for Revision Surgeries]] - [[#What to Expect During Revision Procedures]] - [[#Conclusion]] ## Introduction Phalloplasty is a significant gender-affirming surgical procedure that constructs a penis for transgender men using tissue from another part of their body. This complex surgery may include vaginectomy (vaginal removal), urethral lengthening for standing urination, scrotoplasty (scrotum creation), glansplasty (penile head formation), and penile implant placement. The primary goal is aligning physical anatomy with gender identity. Recent decades have seen remarkable improvements in both functionality and aesthetics of the constructed penis, with over 97% of patients reporting high satisfaction with how the procedure meets their gender affirmation goals. Phalloplasty objectives for transgender men address multiple aspects of wellbeing. These include creating a natural-appearing penis, enabling both tactile and erogenous sensations, facilitating standing urination, and allowing penetrative sexual intercourse through penile prosthesis use. The surgery plays a crucial role in alleviating physical and emotional distress associated with gender dysphoria. Given this significant decision and the surgical complexity, comprehensive information access is essential for individuals considering phalloplasty and their support networks. A thorough understanding of techniques, potential outcomes, and the overall journey ensures informed consent and realistic expectations. ## **Types of Phalloplasty Surgical Techniques** Several surgical techniques are available for phalloplasty, each with its own set of advantages and disadvantages. The choice of technique often depends on individual factors, such as body type, desired outcomes, and surgeon expertise. ### **Radial Forearm Flap (RFF) Phalloplasty** Radial forearm flap (RFF) phalloplasty is currently the most commonly used technique for gender-affirming phalloplasty. Widely considered the gold standard, this approach uses a thin, flexible flap of skin and tissue from the forearm. This area is rich in nerves, which enables potential development of erogenous sensation. The forearm skin typically has less hair, making it ideal for single-stage urethral construction. The RFF procedure begins with careful mapping of the flap on the forearm. During surgery, the lateral and medial antebrachial cutaneous nerves in the flap are connected to the ilioinguinal and dorsal penile nerves in the groin, facilitating sensation in the new penis. The radial artery, which supplies blood to the flap, is connected to a groin artery such as the profunda femoris, lateral circumflex femoral, circumflex iliac, or inferior epigastric artery. Similarly, the accompanying veins and cephalic vein are connected to branches of the greater saphenous vein to ensure proper blood drainage. The donor site on the forearm is typically closed using a skin graft, often a split-thickness graft from the thigh or a full-thickness graft from the buttocks. To create the glans, surgeons remove the outer skin layer from the forearm flap tip and fold it inward. A full-thickness skin graft, frequently taken from the groin, is placed underneath to enhance appearance. A Foley catheter remains in place for at least two weeks to allow the new urethra to heal and reduce the risk of narrowing or fistula formation. RFF technique typically employs a "tube-within-a-tube" design, creating the phallus and urethra simultaneously. The forearm is the standard donor site for RFF phalloplasty. The skin in this region is thin and pliable with relatively little hair, making it particularly suitable for urethral reconstruction. However, the donor site requires a skin graft for closure. A significant consideration with this technique is the visible forearm scar, which can be difficult to conceal. Potential donor site complications include partial skin graft loss, decreased sensitivity, swelling, reduced hand range of motion (generally improvable with therapy), and decreased grip strength. The visibility of the forearm scar and potential hand function impacts are important factors for patients to consider. RFF phalloplasty offers excellent potential for developing erogenous sensation due to the highly innervated forearm flap. The surgical nerve connections enable potential recovery of tactile sensation in the constructed penis. Achieving erectile function typically requires a subsequent procedure to implant a penile prosthesis, usually performed 10 to 12 months after initial phalloplasty, once tactile sensation has returned. Forearm flaps generally provide better sensory outcomes compared to other donor sites. Importantly, the nerves responsible for orgasm are connected to the flap, helping preserve orgasmic ability for most individuals. While RFF offers good sensation potential, the need for a separate implant procedure for erections underscores the multi-stage nature of the overall process. RFF phalloplasty staging typically involves an initial stage using the tube-within-a-tube design for simultaneous phallus and urethra creation. This first stage often includes vaginectomy, penis construction with complete urethra, scrotoplasty, and glansplasty. A second stage, typically performed 6 to 12 months later, usually involves inserting both testicular and erectile prosthetics. Additional surgical stages may be necessary for aesthetic refinements or functional repairs. If procedures like glansplasty or implant placement are performed separately, the entire phalloplasty process can extend to 12 to 18 months. ### **Anterolateral Thigh Flap (ALT) Phalloplasty** Anterolateral thigh flap (ALT) phalloplasty is another common technique that utilizes skin, fat, and fascia harvested from the anterolateral aspect of the thigh. This method is frequently considered as an alternative to RFF phalloplasty. The ALT procedure involves harvesting a flap of tissue from the thinner, distal part of the thigh. The blood supply to this flap comes from the descending branch of the lateral femoral circumflex vessels. Sensation is provided by the lateral femoral cutaneous nerve, which is connected to one of the dorsal clitoral nerves during the surgery. Before the procedure, a multidetector CT scan (MDCT) is strongly recommended to thoroughly evaluate the blood supply and the thickness of the subcutaneous fat in the thigh, as these factors can significantly influence the suitability of the ALT flap for phalloplasty. Urethral lengthening in ALT phalloplasty can be achieved through various approaches, including vascularized, non-vascularized, and partial techniques. The ALT flap can be utilized either as a free flap procedure (completely detached and reconnected using microsurgery) or as a pedicled flap (one end remains attached to maintain blood supply). The donor site for ALT phalloplasty is located on the lateral thigh. The skin in this area is typically thicker and usually has hair, with a considerably thicker subcutaneous fat layer. A key advantage of the ALT technique is that the donor site can often be concealed under clothing. However, the site may require a skin graft for closure. Potential complications include infection, bleeding, abnormal nerve sensations (paresthesia), urethral issues such as fistula and stricture, partial flap loss, leg weakness, and adhesion formation. While the ALT donor site offers better concealment compared to the forearm, the thicker thigh tissue can present challenges for urethral reconstruction and may result in a bulkier neophallus. ALT phalloplasty can create a penis with sensation because the lateral femoral cutaneous nerve is included in the flap and connected to sensory nerves in the groin. However, some reports suggest that sensation achieved with ALT may be less intense compared to RFF phalloplasty. Similar to other techniques, achieving erectile function typically requires surgical implantation of a penile prosthesis in a subsequent stage. Thigh flaps can offer more options for penis length. Some individuals also report a degree of natural rigidity in the phallus created with the ALT technique. The staging of ALT phalloplasty varies depending on surgeon preferences and individual patient needs. A typical first stage often includes vaginectomy, phallus creation using the ALT flap, and scrotoplasty. Urethral lengthening may be performed during this initial stage or subsequently. Glansplasty (creation of the penile head) is often delayed until the second stage. Testicular implants usually occur in either the second or third stage, with the penile implant for erectile function typically placed in the final surgical stage. The entire process of ALT phalloplasty can take up to two years to complete, including various stages and healing periods. ### **Other Phalloplasty Techniques** Beyond RFF and ALT, several alternative phalloplasty techniques exist, each with distinct characteristics. Musculocutaneous Latissimus Dorsi Flap (MLD) phalloplasty uses skin and muscle from the back, offering the advantage of a scar that can be hidden under clothing. However, MLD typically provides less sensation than RFF, though the donor site usually doesn't require a skin graft. Abdominal Flap phalloplasty utilizes lower abdominal skin. As a pedicled flap, it remains partially attached to maintain blood supply. Without microsurgical nerve connections, sensation potential is limited. This approach is typically used for shaft-only phalloplasty, which doesn't allow for standing urination. Other techniques include Groin Flap phalloplasty, which uses skin from the groin area, and Fibular Flap phalloplasty, which incorporates skin, nerve, and sometimes bone from the lower leg. Combined Forearm and Thigh Flap phalloplasty uses forearm tissue for the urethra and thigh tissue for the penis shaft. While this creates a smaller forearm scar compared to standard RFF, it may have higher complication rates and typically produces less penile girth than a thigh flap alone. Pedicled Flap techniques keep the skin flap partially attached to the donor site to maintain blood supply. Most of these approaches (except Pedicled ALT) lack microsurgical nerve connections, limiting sensation. In contrast, Free Flap phalloplasty completely detaches the skin flap along with its blood supply, nerves, and sometimes muscle or bone before transferring it to the recipient site. Microsurgical connections restore circulation and sensation. The Delayed ALT Flap technique involves an initial surgery that severs the secondary blood supply to the upper thigh tissue while maintaining the main blood supply. The tissue remains in place for 4-6 months to adapt to the new blood supply before relocation during phalloplasty. This additional step is particularly beneficial for patients with thicker ALT flaps. This variety of techniques allows surgeons to customize the phalloplasty procedure according to each individual's specific needs and preferences, though each approach presents distinct advantages and disadvantages regarding sensation, scarring, and surgical complexity. ### **Metoidioplasty and its Relation to Phalloplasty** Metoidioplasty creates masculine-appearing genitalia with fewer surgical steps than phalloplasty. This procedure lengthens the skin of the labia and the area around the clitoris to form a small penis. Metoidioplasty uses the testosterone-enlarged clitoris as the main component of the new phallus, typically resulting in a length of about 4 to 6 centimeters. Patients generally experience a quicker recovery period and face fewer complications compared to phalloplasty. A significant advantage is that individuals typically retain full sensation and can achieve natural erections without requiring a penile implant. Many are also able to urinate while standing after the procedure. Individuals choose metoidioplasty for various reasons: preferring a less complex surgery, avoiding donor site tissue harvesting from arms or legs, prioritizing sexual sensation and natural erections, or concerns about extensive scarring associated with phalloplasty. For some transgender men, metoidioplasty serves as an initial step toward further genital masculinization. Some individuals later undergo phalloplasty to achieve additional length and girth. However, medical experts often suggest that if significant length and girth are primary goals, starting with phalloplasty might be more efficient, potentially resulting in fewer surgeries overall. Reasons for pursuing phalloplasty after metoidioplasty include wanting a larger phallus, seeking the ability to have penetrative intercourse, having initially chosen metoidioplasty as a stepping stone, or desiring to urinate while standing. All available phalloplasty techniques are considered feasible for individuals who have previously undergone metoidioplasty. Studies indicate that complication rates for secondary phalloplasty performed after metoidioplasty are comparable to those of primary phalloplasty procedures. Metoidioplasty offers a less invasive initial option providing immediate gender affirmation with preserved sensation, while phalloplasty offers the possibility of a larger phallus suitable for penetrative sex, either as a primary approach or as a subsequent procedure. ## **Pre-operative Preparation for Phalloplasty** Thorough preparation is essential for a successful phalloplasty and involves several key steps. ### **Medical and Psychological Evaluations** Prior to undergoing phalloplasty, individuals need comprehensive medical and psychological evaluations. Mental health assessments are often required for insurance coverage and are crucial for determining readiness for such significant surgery. Generally, patients are expected to meet the standards of care set forth by the World Professional Association for Transgender Health (WPATH). Surgeons also conduct thorough medical evaluations to assess overall health and determine suitability for the surgical procedures involved. ### **Hormone Therapy Guidelines** Hormone replacement therapy (HRT) with testosterone is frequently a prerequisite for phalloplasty. Additionally, a hysterectomy (removal of the uterus) is typically performed before proceeding with phalloplasty. In many cases, this includes the removal of the cervix and is often required at least six months prior to the first stage of the phalloplasty surgery. ### **Smoking Cessation** Smoking poses significant risks for complications during and after phalloplasty, making it a critical factor in pre-operative preparation. Individuals who smoke are often not considered candidates for this surgery due to the increased risk of poor wound healing and other complications. Therefore, patients are typically required to completely stop using all tobacco and nicotine-containing products for a minimum of six months before and after surgery. The use of tobacco products in the period leading up to surgery can significantly increase the likelihood of complications, potentially by as much as fivefold. ### **Hair Removal** Permanent hair removal is crucial when preparing for phalloplasty, particularly for individuals who desire the ability to urinate through their newly constructed penis. Hair needs to be permanently removed from the skin that will be used to create the urethra (the tube through which urine passes). This removal process, achievable through electrolysis or laser treatments, can be lengthy, sometimes taking up to 18 months to complete. It is essential that hair removal in the designated area is fully completed before scheduling the surgical stage involving urethral lengthening. Often, surgeons require an in-person consultation to assess the specific area of the arm or thigh that will be used for phallus construction before beginning permanent hair removal. It is also important that no hair regrowth is observed in the treated area for at least three months prior to surgery. ### **Other Lifestyle Adjustments** Beyond these essential preparations, surgeons typically provide customized guidance on nutrition and exercise protocols to optimize pre-surgical health. Arranging adequate post-operative support from friends, family, or professional caregivers is crucial for a smooth recovery. Additionally, cultivating mental resilience and securing ongoing psychological support throughout the surgical journey significantly enhances outcomes and overall patient satisfaction. ## **The Phalloplasty Surgical Procedure** Phalloplasty is a complex process that typically involves multiple surgical stages performed over a period of time. ### **Staging of Phalloplasty** Phalloplasty requires multiple surgical procedures to achieve the final outcome. These surgeries are typically scheduled with intervals of 3 to 6 months between them. The entire process, from the initial stage to completion, can take approximately 12 to 18 months. The surgeon works closely with the patient to determine optimal timing and sequence based on individual needs and goals. ### **Detailed Explanation of Each Stage** The phalloplasty procedure is typically divided into several stages, each addressing specific aspects of the genital reconstruction. **Initial Stage:** This stage primarily focuses on constructing the penis. Tissue is harvested from the chosen donor site (forearm, thigh, or back), shaped into a phallus, and attached to the groin area. Blood vessels and nerves of the flap are meticulously connected to establish circulation and sensation in the new penis. The donor site is then closed, often requiring a skin graft. Depending on individual goals and the surgical technique, urethral lengthening may also be performed during this initial stage. For those who do not desire urethral lengthening, a vaginectomy (removal of the vagina) may be optional. Scrotoplasty, the creation of the scrotum, is often performed using the skin of the labia majora. Glansplasty, the shaping of the penile head, may also be part of this stage. Additionally, the clitoris is typically buried at the base of the newly constructed phallus. **Second Stage (typically 3-6 months later):** If urethral lengthening was not completed in the first stage, it is often addressed in this stage. This may also involve the insertion of testicular implants into the newly created scrotum. If glansplasty was not performed initially, it might be done during this stage to further refine the aesthetic appearance of the penis. **Final Stage (typically 6-12 months later):** The primary focus of this stage is usually the insertion of a penile implant to enable erections. This is typically done once sufficient healing has occurred and sensation has begun to return to the phallus. Additional aesthetic refinements, such as liposuction, fat grafting, or mons resection, may also be performed during this or subsequent stages to optimize the cosmetic outcome. ## **Anesthesia and Hospital Stay** Phalloplasty is performed under general anesthesia, ensuring patients remain completely unconscious and pain-free throughout the procedure. The surgery typically lasts between 8 to 10 hours but may take longer depending on complexity and the number of procedures performed simultaneously. Following surgery, patients generally stay in the hospital for approximately 5 days, though this varies based on surgical technique and individual recovery needs. Immediately after surgery, patients can expect to feel groggy as the anesthesia wears off. ## **Post-operative Care and Recovery** Proper post-operative care is crucial for healing and achieving the best possible outcomes after phalloplasty. ### **Immediate Post-operative Care** In the immediate period following surgery, meticulous wound care is essential. This involves keeping the incisions clean and dry and regularly reapplying dressings as instructed by the surgical team. Pain will be managed with prescribed medications, and it is important to take these as directed. To facilitate urination during the initial healing phase, a Foley catheter or a suprapubic catheter will be placed. It is crucial to follow instructions on how to manage the catheter to prevent complications. Activity restrictions are also a key part of the immediate post-operative care. Patients will need to limit physical activity, including strenuous exercise and even household chores, to allow the surgical sites to heal properly. Throughout this period, it is important to closely monitor for any signs of infection or other complications and to contact the surgical team if any concerns arise. ### **Long-Term Aftercare** Long-term aftercare involves continued attention to wound and scar management, which may include specific techniques or products recommended by the surgeon. Pelvic floor exercises are often recommended to help with urinary control and overall pelvic health. Depending on whether urethral lengthening was performed, there may be a need for periodic dilation of the urethra to prevent the formation of strictures (narrowing) that could impede urination. Psychological support and the development of coping strategies can also be an important part of the long-term recovery process, as individuals adjust to the changes and navigate any challenges that may arise. ### **Recovery Timeline** The initial recovery period after phalloplasty can extend up to 12 weeks, depending on the specific procedures that were performed. More advanced healing and nerve regeneration continue to occur over the following months. Between 6 and 12 months post-surgery, patients may begin to experience the return of sensation. Protective sensations, such as the ability to feel temperature and pressure, often return first, with erogenous sensation typically taking longer. Achieving full functionality of the penis, including the ability to urinate, experience sensation, and have erections (with the aid of an implant), can take a year or longer. Before attempting penetrative intercourse, patients should receive approval from their surgeon and may need to use a pump or a silicone erectile sleeve to make adjustments and ensure comfort. ## **Potential Risks and Complications of Phalloplasty** As with any major surgical procedure, phalloplasty carries potential risks and complications that patients should be aware of. ### **General Surgical Risks** General risks associated with any surgery include complications related to anesthesia, such as sore throat, nausea, vomiting, constipation, severe allergic reactions (anaphylaxis), and, in rare cases, stroke. There is also a risk of bleeding and infection at the surgical sites. ### **Specific Phalloplasty Complications** In addition to general surgical risks, phalloplasty has specific potential complications. These can include partial or total loss of the skin flap used to create the penis (necrosis). Infections can occur at any of the surgical sites, including the donor site and the newly constructed phallus. The formation of fistulas, which are abnormal connections between two body parts (such as between the urethra and the skin), is another potential complication. Urethral strictures, or the narrowing of the urethra, can also occur, potentially affecting the ability to urinate. Complications at the donor site can include pain, excessive scarring, decreased mobility or sensation, wound breakdown, and the formation of granulation tissue (overgrowth of tissue during healing). Nerve damage can lead to paresthesia (abnormal sensations) or decreased sensation in the phallus or the donor site. Other potential complications include pelvic bleeding or pain, and, in rare instances, injury to the bladder or rectum. Some patients may experience a prolonged need for surgical drains to remove excess fluid. In the case of ALT phalloplasty, rare but severe complications such as compartment syndrome and muscle necrosis have been reported. ### **Management and Treatment of Complications** The management and treatment of complications following phalloplasty often require additional medical or surgical interventions. For example, infections are typically treated with antibiotics, and surgical repair may be necessary to address fistulas or strictures. ## **Sensory Outcomes and Erectile Function After Phalloplasty** The return of sensation and the ability to achieve erections are important outcomes for many individuals undergoing phalloplasty. ### **Expected Sensory Return** The extent and timeline of sensory return in the neophallus varies depending on the surgical technique used. Generally, Radial Forearm Flap (RFF) phalloplasty offers a better chance of developing sensation compared to other methods. Nerve regeneration occurs gradually, with protective sensations like temperature and pressure typically returning before erogenous sensation. Forearm flaps tend to provide superior sensory outcomes. In RFF phalloplasty, incorporating the posterior antebrachial cutaneous nerve (PABC) as an additional nerve connection may help optimize sensation throughout the penis shaft. ### **Achieving Erectile Function** Since the skin flap used in phalloplasty lacks erectile tissue, achieving an erection for penetrative sex typically requires surgical implantation of a penile prosthesis. This procedure usually occurs as a separate stage, approximately 10 to 12 months after the initial phalloplasty, once tactile sensation has begun to return to the new penis. While implants specifically designed for transgender men are under development, surgeons currently use prosthetics originally designed for cisgender men with erectile dysfunction. Potential complications with penile implants include infection and erosion. ### **Realistic Expectations for Sensory and Functional Outcomes** It is important for individuals considering phalloplasty to maintain realistic expectations regarding sensory and functional outcomes. Achieving full functionality, including urination, sensation, and erections, can take a year or longer after the initial surgery. ## **Financial Considerations for Phalloplasty** The financial aspects of phalloplasty represent a significant consideration for many individuals seeking this procedure. ### **Cost of Phalloplasty** The cost of phalloplasty in the United States varies widely, typically ranging from approximately $43,000 to $75,000, though in some cases it may reach as high as $150,000. These figures often exclude additional expenses such as hospital fees, anesthesia costs, and medications, which can substantially increase the overall financial burden. By comparison, several countries including Thailand, Turkey, and Mexico offer all-inclusive phalloplasty packages at more affordable prices, with procedures in Thailand ranging from $12,000 to $25,000, making these international options significantly less expensive than those in the U.S. ### **Insurance Coverage** While most insurance companies in the United States offer coverage for phalloplasty, this coverage typically comes with strict eligibility requirements. Patients must often provide comprehensive mental health assessments, documentation of hormone therapy, evidence of living in their affirmed gender role, and secure pre-authorization from their insurance provider. Even with insurance coverage, certain costs such as hospital stays, anesthesia, and post-operative care may not be fully covered. In countries with public healthcare systems like the UK, Australia, and New Zealand, the costs of phalloplasty may be subsidized, but patients often face lengthy waiting times ranging from 5 to 30 years. ### **Resources for Financial Assistance** For individuals facing financial barriers to accessing phalloplasty, various resources may provide assistance. These include organizations and programs that offer grants, loans, or other forms of financial aid specifically for transgender individuals seeking gender-affirming surgeries. Researching and exploring these options constitutes an important step in the pre-operative planning process. ## **Follow-up Care and Potential Revision Surgeries** Ongoing follow-up care and the possibility of revision surgeries are integral parts of the phalloplasty journey. ### **Typical Follow-up Schedule** After undergoing phalloplasty, regular follow-up appointments with the surgical team are essential for monitoring the healing process and addressing any potential issues that may arise. The specific schedule of these appointments will vary depending on the individual's progress and the surgeon's protocols. ### **Reasons for Revision Surgeries** Revision surgeries may be necessary for a variety of reasons. These can include addressing complications such as fistulas or urethral strictures, making aesthetic refinements to the neophallus appearance (including glans or scrotum revisions), and functional improvements like adjustments to penile implants. ### **What to Expect During Revision Procedures** Similar to the initial phalloplasty surgeries, revision procedures typically require anesthesia and a period of recovery time. The extent and duration of these will depend on the nature and complexity of the revision being performed. ## **Conclusion** Phalloplasty is a complex yet profoundly beneficial gender-affirming surgical procedure for transgender men. It employs various techniques, typically occurs in multiple stages, and requires thorough pre-operative preparation and diligent post-operative care. Despite potential risks and complications, advancements in surgical methods have significantly improved both aesthetic and functional outcomes. Key aspects of this journey include the return of sensation and the ability to achieve erectile function through penile implants. Planning for phalloplasty involves navigating financial considerations, including costs and insurance coverage. Regular follow-up care and potential revision surgeries help optimize results and provide ongoing support. Making an informed decision about phalloplasty requires comprehensive research, detailed consultations with experienced surgeons, and a strong support network. Various resources are available to provide information and support for individuals considering this life-affirming surgery. | | | | | | | | |---|---|---|---|---|---|---| |**Technique**|**Typical Donor Site**|**Primary Advantages**|**Primary Disadvantages**|**Typical Sensation Outcome**|**Need for Penile Implant for Erection**|**Common Staging**| |Radial Forearm Flap (RFF)|Forearm|Good sensation, relatively hairless for urethral reconstruction, often single-stage urethral lengthening|Visible forearm scar, potential hand function impact|Good to Excellent|Usually Required|1-stage (phallus & urethra), 2nd stage (implants)| |Anterolateral Thigh Flap (ALT)|Thigh|Concealable donor site, good potential for urethroplasty, larger girth than RFF, some natural rigidity|Can be bulky, potentially less sensation than RFF, may require multiple flaps for urethra|Good|Usually Required|Varies, often multi-stage involving phallus, urethra, glans, and implants| |MLD|Back|Concealable scar, donor site often doesn't require skin graft|Less sensation than RFF|Fair|Usually Required|Multi-stage| |Abdominal|Lower Abdomen|Can be used for shaft creation|Limited sensation, typically no standing urination|Limited|Usually Required|Often shaft-only, multi-stage for other components| |Groin|Groin|-|-|-|Usually Required|-| |Fibular|Lower Leg|Can include bone for rigidity|More complex surgery, potential donor site morbidity|Variable|Usually Required|Multi-stage| |Combined Forearm/Thigh|Forearm & Thigh|Smaller forearm scar than RFF alone|Higher complication rate than RFF, less penile girth than thigh flap alone|Good (forearm)|Usually Required|Multi-stage| | | | | |---|---|---| |**Feature**|**Phalloplasty**|**Metoidioplasty**| |Neophallus Source|Tissue flap from arm, thigh, or back|Hormonally enlarged clitoris| |Size|Average to large, depending on flap choice|Small (4-6 cm)| |Number of Procedures|Typically 3 or more stages|Usually 1 stage| |Sensation|Variable, can be good with nerve connection|Often retains full sensation| |Ability for Penetrative Sex|Possible with penile implant|Unlikely| |Typical Scarring|More visible scarring at donor and recipient sites|Low-visibility scarring in the genital region| |Recovery Time|Longer, up to a year or more for full functionality|Shorter, initial recovery around 4 weeks| |Need for Erectile Implant|Typically required for penetrative sex|May be able to achieve erection without an implant| | | | | |---|---|---| |**Complication**|**Description**|**Potential Management**| |Flap Loss|Partial or complete death of the transferred tissue|Surgical revision, wound care| |Infection|Bacterial, fungal, or other microbial invasion of surgical sites|Antibiotics, antifungals, wound care, potential surgical drainage| |Fistula Formation|Abnormal connection between two internal structures or an internal structure and the skin|Surgical repair| |Urethral Stricture|Narrowing of the urethra|Dilation, surgical repair| |Donor Site Complications|Pain, scarring, decreased mobility/sensation, wound breakdown, granulation tissue|Pain management, scar treatment, physical therapy, topical treatments, silver nitrate| |Nerve Damage|Paresthesia, decreased sensation|Observation, nerve regeneration may occur over time, potential nerve surgery| |Anesthesia Complications|Nausea, vomiting, sore throat, allergic reaction, etc.|Supportive care, medication| |Penile Implant Complications|Infection, erosion, mechanical failure|Antibiotics, surgical removal or replacement| - References 1. 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