The phalloplasty procedures are differentiated from the donor organ from which the graft is taken.
Graft 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 clitoral tissue at the base of the neophallus, and surgeons will often attempt to graft nerves together from the clitoris or nearby. Nerves from the graft 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.
Graft from the side of the chest
A relatively new technique involving a graft 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
This is a three part surgery that takes place over a period of six to nine months.
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.
Graft from the leg
The lower leg operation is similar to forearm graft with the exception that the donor scar is easily covered with a sock and/or pants and hidden from view. Other details are same as forearm graft, especially the need for permanent hair removal before the operation. A graft from the leg or another area where the scar is less noticeable may be combined with free forearm graft to sculpt the glans penis.
Pubic area flap
The graft 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 grafts have 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.
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.
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 implant erectile long term.