Phalloplasty

Phalloplasty is the construction or reconstruction of a penis, or the artificial modification of the penis by surgery. A phalloplasty creates a full-size penis like that of a cisgender man for patients who had a clitoris (such as transgender men and nonbinary people who were assigned female at birth), or a natural but different shape of penis (such as micropenis, epispadias, and hypospadias, which can be intersex conditions), or a damaged or lost penis. With all types of phalloplasty in trans men and transmasculine nonbinary people, scrotoplasty can be performed using the labia majora (vulva) to form a scrotum where prosthetic testicles can be inserted. If the patient has not had a removal of their vagina (vaginectomy), uterus (hysterectomy), and/or ovaries/gonads (oophorectomy), then these can be done at the same time. However, it is not necessary to have had these other surgeries done in order to have a phalloplasty. There are people who have had a penis created by phalloplasty while still keeping their vagina, uterus, and/or ovaries/gonads.

History
The Russian surgeon Nikolaj Bogoraz performed the first reconstruction of a total penis using rib cartilage in a reconstructed phallus made from a tubed abdominal flap in 1936. The first phalloplasty done for the purposes of sexual reassignment was performed in 1946 by Sir Harold Gillies on fellow physician Michael Dillon, a trans man. His technique remained the standard one for decades. This is documented in Pagan Kennedy's book The First Man-Made Man. Later improvements in microsurgery made more techniques available.

Techniques and related procedures
There are different techniques for phalloplasty. Construction of a new penis (sometimes called a neophallus) typically involves taking a tissue flap from a donor site (such as the forearm). Extending the urethra through the length of the neophallus is another goal of phalloplasty. .

Temporary lengthening can also be gained by a procedure that releases the suspensory ligament where it is attached to the pubic bone, thereby allowing the penis to be advanced toward the outside of the body. The procedure is performed through a discreet horizontal incision located in the pubic region where the pubic hair will help conceal the incision site. However, scar formation can cause the penis to retract. Therefore, the American Urological Association "considers the division of the suspensory ligament of the penis for increasing penile length in adults to be a procedure which has not been shown to be safe or efficacious."

As of November 2009, there is research in progress to synthesize corpora cavernosa (erectile tissue) in the lab on rabbits for eventual use in patients requiring penile construction surgery. Of the rabbits used in the preliminary studies, 8 of 12 had biological responses to sexual stimuli that were similar to the control, and four caused impregnation.

Penile implants
Phalloplasty requires an implanted penile prosthesis to achieve an erection. Penile prostheses are implanted devices intended to restore the erectile rigidity in biological amen and to build a neophallus (new penis) in trans men. Penile implants were used in phalloplasty surgeries both in cis and trans men since 1970s. There are two main types of penile implants – malleable and inflatable implants. Both types have a pair of cylinders implanted into the penis and replace the non-erectile tissue in biological men and serve as the core for the neophallus in trans men. The cylinder of the inflatable implant is filled with sterile saline solution. Pumping saline into the chambers of this cylinder produces an erection. The glans of the penis, however, remains unaffected. In sex-reassignment surgeries, a new penis is formed with the use of penile implant surrounded with a tissue flap. The pump unit of inflatable penile implants resembles a human testicle and can serve as an artificial testicle for concomitant scrotoplasty. Initially, standard penile implants were used in phalloplasty procedures. However, since there is no corpus cavernosum in the penis undergoing phalloplasty, and the fact that standard penile implants were designed to be implanted in corpus cavernosum, there were many adverse outcomes. Since 2015, Zephyr Surgical Implants proposes malleable and inflatable penile implants particularly designed for phalloplasty surgeries. Implantation procedures are usually done in a separate surgery to allow time for proper healing.

Flap from the arm
An operation using the forearm as a donor site is the easiest to perform but results in a cosmetically undesirable scar on the exposed area of the arm. Arm function may be hampered if the donor site does not heal properly. Electrolysis and/or laser hair reduction is required for a relatively hairless neophallus.

Sometimes a full-scale metoidioplasty is done a few months before the actual phalloplasty to reduce the possibility of complications after phalloplasty. Sensation is retained through the tissue of the clitoris at the base of the neophallus, and surgeons will often attempt to connect nerves together from the clitoris or nearby. Nerves from the flap and the tissue it has been attached to may eventually connect. This does not necessarily guarantee the ability to achieve genital orgasm after healing, as the most important task of nerve reconnection is to ensure the penis is able to sense injury, but it is rare to lose the ability to orgasm.

The following explanation of this technique has many similarities to other approaches, but the construction of the glans differs.
 * The surgery starts (after the patient is prepped) with the forearm marked for graft size. After the graft is taken, another graft will be used to cover the arm (resulting in a secondary scar).
 * The graft is dissected to expose the veins and antebrachial cutaneous nerves. (the latter done carefully for later reattachment)
 * If the urethra is being constructed at the same time as the phallus, it is joined at this step. If not, the glans is shaped. Sometimes glansplasty is done in a separate surgical stage after urethral extension.
 * A segment of vein going to the patient's groin is "borrowed" to allow easier joining of the graft with the preexisting tissues.
 * The vein is carefully attached to the femoral artery.
 * The blood supplies from the graft and the vein leading to the femoral artery are joined.
 * The clitoral hood and ligament are cut away, and the nerve bundle is isolated for the time being. While this assumes the clitoral tissue is assimilated (buried) into the penis base, some surgeons give the option of leaving it as-is in a post metoidioplasty like state.
 * The flap is partially attached physically while the surgeon attempts to join the nerve bundles.
 * If the urethra was extended, it is now joined with a catheter that will remain in place for healing purposes for two to four weeks. Otherwise, the skin is sutured up and/or the scrotum is created (scrotoplasty).

If the patient chooses to have the urethra extended to the glans of the neophallus, it is formed by the following steps:
 * The labia minora is injected with a mixture of saline and epinephrine.
 * It is then split open and layers separated using sharp and blunt dissection.
 * The layers are wrapped around a catheter and stitched.
 * A mucosal flap from the vagina may be used to bridge the urethra with the extension. This is often done in a separate procedure. Alternative graft locations include the mouth/cheeks or experimentally, the intestines. If the labia minora is not used during construction of the urethral extension, (or in the chance there is enough material remaining) it can be used during glansplasty to provide for better results compared with a full thickness skin graft.

Flap from the side of the chest
A relatively new technique involving a flap from the side of the chest under the armpit (known as a musculocutaneous latissimus dorsi free transfer flap) is a step forward in phalloplasty. The advantages of this technique over the older forearm flap technique include:
 * Hairlessness (little to no electrolysis needed)
 * Aesthetic appearance of normally colored skin (the glans may be tattooed to proper color)
 * Capable of tactile sensation (as with any form of phalloplasty, this does not necessarily mean the ability to have a genital orgasm after healing, as the erogenous zone is limited to the base of the penis)
 * Leaves an inconspicuous scar
 * Has a lower occurrence of complications from both the initial surgery and the erectile prosthesis insertion

The disadvantages include: This is a three-part surgery that takes place over a period of six to nine months. The steps consist of:
 * Uses a motor nerve so erogenous sensation cannot be achieved, only tactile sensation.
 * It can pull the nipple to the side causing it to be off the usual location.

Neophallus creation using MLD free flap
 * The surgery starts (after the patient is prepped) with the side of the chest marked for flap size.
 * The flap is dissected to expose the veins and the thoracodorsal nerves.
 * The flap, while still attached to the blood supply, is formed to a rough phallus shape by rolling the edges together.
 * A segment of vein going to the patient's groin is "borrowed" to allow easier joining of the flap with the preexisting tissues.
 * The vein is carefully attached to the femoral artery.
 * The blood supplies from the flap and the vein leading to the femoral artery are joined.
 * The clitoral hood and ligament are cut away and the nerve bundle is isolated.
 * The flap is partially attached physically while the surgeon attempts to join the nerve bundles.

During initial recovery, the neophallus is protected from contact with other tissues with a specially constructed dressing as to avoid blood supply complications.

After three months, urethroplasty (urethral extension) is performed.
 * The neophallus is dissected and a buccal (oral) mucosa graft inlaid into the created cavity and extended to the native urethra and joined to permanently allow urination while standing
 * A catheter is placed for several weeks to allow for proper healing

After another three to six months, a device that allows an erection can be inserted.

Flap from the leg
The lower leg operation is similar to a forearm flap with the exception that the donor scar is easily covered with a sock and/or pants and hidden from view. Other details are the same as forearm flap, especially the need for permanent hair removal before the operation. A flap from the leg or another area where the scar is less noticeable may be combined with free forearm flap to create the urethral lengthening or to sculpt the glans penis.

Pubic area flap
The flap location is around the pelvic bone, usually running across the abdomen under the belly button. As such, there is a large horizontal scar that may not be aesthetically acceptable. The flap has a less natural appearance and may not maintain an erectile implant long term. Electrolysis is required before surgery with the alternative being clearing of hair via shaving or chemical depilatory.

Gillies technique
This technique was pioneered by Sir Harold Delf Gillies as one of the first competent phalloplasty techniques. It was simply a flap of abdominal skin rolled into a tube to simulate a penis, with urethral extension being another section of skin to create a "tube within a tube." Early erectile implants consisted of a flexible rod. A later improvement involved the inclusion of a blood supply pedicle which was left in place to prevent tissue death before it was transplanted to the groin. Most latter techniques involve tissues with attached pedicle.

Abdominal muscle
Skin grafted muscle flaps have fallen from popularity. This procedure is a minimum of 3 steps and involves implantation of an expansion balloon to facilitate the amount of skin needed for grafting. The grafts have a less natural appearance and are less likely to maintain an erectile implant long term.

Subcutaneous soft silicone implant
This phalloplasty procedure involves the insertion of a subcutaneous soft silicone implant under the penile skin.

No-touch surgical technique
This technique for penile prosthesis implantation is a surgical procedure developed by J. Francois Eid for the implantation of a penile implant. Implantation through the use of the "No-Touch" Technique minimizes the risk of infection.

As advancements in the design and manufacturing process of the IPP improved its mechanical survival infection has emerged as the leading cause of implant failure. Although relatively infrequent (varying from .06% to 8.9%) infection of a penile prosthesis results in serious medical consequences for the bearer, requiring complete removal of the device and permanent loss of penile size and anatomy. Bacterial contamination of the device occurs during the surgery, and is caused by allowing direct or indirect contact of the prosthesis with the patient's skin. Over 70% of infections form from skin organisms including Staphylococcus epidermis, aureus, streptococcus and Candida albicans.

Traditional strategies to combat infections aim at decreasing skin colony count such as scrubbing skin preparation with alcohol and chlorhexidine or kill bacteria once the implant is contaminated by skin flora such as intravenous antibiotics, antibiotic irrigation and antibiotic-coated implants. The "No-Touch" technique is unique in that it aims at preventing bacterial contamination of the prosthesis by completely eliminating contact of the device with the skin.

Paired with the antibiotic-coated implant, the "No Touch" Technique decreases infection to a rate of 0.46%, opposing the traditional method which has an infection rate of 5%. The use of an antibiotic-coated implant and a no-touch surgical technique with skin preparation measures and peri-operative antibiotic use has been found to be of high importance in the prevention of infection among penile implants. J. Francois Eid developed his no-touch technique in 2006 on the hypothesis that eliminating any contact between the prosthesis and the skin, either directly or indirectly via surgical instruments or gloves, should reduce the incidence of contamination of the device with skin flora responsible for infection.

Procedure
Three days prior to the procedure, a patient is placed on oral fluoroquinolone, an antibacterial drug. During this time, the patient scrubs their lower abdomen and genitals daily with chlorhexidine soap. On the day of the surgery, Vancomycin and Gentamicin are administered intravenously one to two hours prior to the procedure. The lower abdomen and genitals are shaved, scrubbed for five minutes with a Chlorhexidine sponge and prepped with Chorhexidine/Alcohol applicator. The area is then draped with a surgical drape and a Vi Drape over the genitalia. Before the incision is made, a Foley catheter is inserted in the bladder through the urethra.

A 3-cm scrotal incision is made on the penoscrotal raphe and carried down through the subcutaneous tissue to the Buck's fascia. A Scott retractor, a flexible device that holds open the skin of the surgical site, is applied to the area.

Up until this stage of the surgery, the process has been consistent with the sanitary practices associated with standard surgical sterility. At this stage of the "No-Touch" Technique, after the incision has been made, all instruments, including surgical gloves that have touched skin are discarded. A loose drape is then deployed over the entire surgical field and secured at the periphery with adhesive strips. A small opening in the drape is then made overlying the incision and yellow hooks utilized to secure the edges of the opening to the edges of the incision, completely covering and isolating the patient's skin. At this point, new instruments and equipment are replaced and the entire prosthesis is inserted through the small opening of the loose drape. The loose drape allows for manipulation of the penis and scrotum required for this procedure without touching the skin.

Implantation of the device continues with an incision and dilation of corpora, sizing and placing the penile cylinders, and placement of the pump in the scrotum and the reservoir in the retropubic space. Saline is used throughout the implantation for irrigation. Once the corporotomies are closed and all of the tubing and components of the prosthesis covered with a layer of Buck's fascia, subcutaneous tissues are closed and the "No-Touch" drape is removed and the skin closed.

Future
In the future, bioengineering may be used to create fully functional penises.

Common complications
As phalloplasty has improved over the decades, the risks and complications from surgery have been reduced. However, there is still a possibility of a need for revision surgery to repair incorrect healing.

A study of postoperative men showed that on average, 25% had one or more serious complications of the neopenis. The ones reported consisted of:
 * Loss of the phallus from either disease or blood supply issues
 * Cephalic vein thrombosis (blood clot)
 * Arterial ischemia (shortage of blood supply)
 * Infection
 * Distal limited necrosis (death of parts of the penis)
 * Hematoma (bruise)

In the same study, chances of complications of the extended urethra were higher, averaging 55%. The most common complications reported were:
 * Urinary fistula (hole) requiring perineal urethrostomy
 * Urinary fistula (hole) with conservative treatment
 * Urinary retention (from stenosis or narrowing of the new urethra)
 * (Erectile) prosthesis change (from complications)
 * (Erectile) prosthesis explantation (removal of the prosthesis without replacement)

There is also a possibility of fat embolism "associated with liposuction and autologous fat transfer, a procedure where fat from liposuction is injected back into the same patient’s face, breast, buttocks or penis".