Phalloplasty

What is phalloplasty?

In most cases, phalloplasty (FAL-oh-plas-tee) is a type of gender affirmation surgery that uses large sections (flaps) of skin to create a neophallus (neopenis). “Neo” means “new,” and “phallus” means “penis.” But phalloplasty can also be a type of genital reconstructive surgery to create a neophallus to treat a congenital (present at birth) anomaly, severe penile injury (trauma) or disease.

Phalloplasty surgery goals may include creating a natural-looking penis that allows you to:

• Pee while standing up.
• Feel sensation and sexual pleasure.
• Get an erection with the use of a penile implant.
• Have penetrative sexual intercourse.

When is a phalloplasty done?

People assigned female at birth (AFAB) sometimes request a phalloplasty to align their physical bodies with their gender identities. It helps treat gender dysphoria.

Phalloplasty is also for people who have congenital conditions or experienced trauma to their penises.

Congenital conditions include:

• Genitals that don’t look typically male or female (atypical genitalia).
• The penis doesn’t develop during embryo development (aphallia).
• The opening at the end of the urethra (meatus) forms at the top of the penis instead of the tip (epispadias).
• The meatus forms below the tip of the penis (hypospadias).
• An atypically small penis (micropenis).

Penile trauma may include:

• Car accidents.
• Complications after removing the foreskin (circumcision).
• Penile cancer.

How should I prepare for phalloplasty?

If you’re having gender-affirming phalloplasty, you’ll work with healthcare providers for at least a year to help prepare you for the procedure. This may include:

• A physical exam to assess your overall health and learn more about your medical history.
• Patient education, including conversations with a provider and literature so you fully understand the risks, benefits and postsurgical care requirements.
• A mental status exam from a qualified mental health provider (therapist, psychiatrist or social worker) to ensure your understanding of the procedure. They’ll ask why you want a phalloplasty, explain how the procedure will affect your life and ask about your expectations. You’ll need surgery referral letters from two mental health providers.
• Hair removal (electrolysis or laser hair removal) in an area your provider will take tissue from to create your neophallus.
• Taking masculinizing hormone therapy for at least one year.
• Living for at least one year in a manner consistent with your gender identity.
• Health recommendations to help reduce your risk of complications, such as quitting smoking or having a body mass index (BMI) of less than 32.

Where will the tissue for the neopenis come from?

A healthcare provider may take tissue flaps from your:

• Forearm (radial forearm free flap).
• Thigh (anterolateral thigh free flap).

The donor tissue area will also require a skin graft. You may have the donor area skin graft at the same time as the phalloplasty or a few weeks later.

What happens before phalloplasty?

In general, before phalloplasty, you’ll need to:

• List all of your allergies.
• List all of your prescription or over-the-counter (OTC) medications, including herbal supplements.
• Temporarily stop all blood-thinning medications, if you take them.
• Not eat or drink eight to 12 hours before your surgery.

If you must take some medications before surgery, you may take them with a small sip of water.

What healthcare providers make up a phalloplasty team?

The following healthcare providers may make up your phalloplasty team:

• Reconstructive urologist.
• Plastic surgeon.
• Anesthesiologist.

What happens during phalloplasty?

An anesthesiologist first gives you general anesthesia before surgery. General anesthesia puts you to sleep. You won’t feel pain or experience any other sensations during surgery.

Then, surgeons take a large flap of skin from your forearm or thigh. The flap contains all the parts that make up biological penile tissue, except for erectile tissue. This includes:

• Nerves.
• Arteries.
• Veins.

They’ll roll the flap to form a shaft and attach it to your groin. You’ll just have a shaft — you won’t have a head (glans).

You may also get additional changes or gender-affirming surgeries at the same time as your phalloplasty, or your surgeons may break them up into different stages so you have time to heal between procedures. These extra procedures may include:

• Making your urethra longer (urethroplasty or urethral lengthening) so you can pee while standing.
• Constructing a head for your penis (glansplasty).
• Inserting a penile implant to enable erections.
• Creating a scrotum (scrotoplasty) to add testicular prostheses.
• Closing your vagina (vaginectomy), which may also include removing your uterus (hysterectomy) and/or ovaries (oophorectomy).

How long does phalloplasty take?

It depends on many factors, including whether your phalloplasty care team performs other procedures. But in general, phalloplasty may take eight to 10 hours or longer to complete. If you choose to have other procedures in different stages, it may take between 12 and 18 months to complete.

What happens after phalloplasty?

After phalloplasty, you’ll stop receiving anesthesia. You’ll wake up after a few minutes but likely feel groggy. Healthcare providers will monitor your overall health and manage your pain once you fully wake up.

Phalloplasty is an inpatient procedure. You’ll be in the hospital for at least a week after phalloplasty to monitor the blood supply to your neophallus.

You need time to heal after the procedure. If your phalloplasty team performs the surgery in several stages, you need to schedule the other procedures several months after your first procedure.

What are the benefits of phalloplasty?

One of the main benefits of phalloplasty is relief from physical or emotional challenges. Results include a natural-looking penis that’s capable of functioning sexually. As part of gender-affirming surgery, it helps you achieve your gender identity.

Other benefits depend on which options you choose:

• Flaps from your forearm provide excellent cosmetic results and better sensation.
• Flaps from your thigh give you more penis length options. Scars on your thigh from removing the flap are also easier to hide with pants or shorts.
• Making your urethra longer enables you to pee while standing.

Does a penis get erect after phalloplasty?

You may get a penile implant to get an erection whenever you choose. A healthcare provider will talk to you about and review penile implant options with you.

Can I feel anything after phalloplasty?

Yes, you can feel sensation after phalloplasty. But you may have less feeling in your neophallus than the donor area of your skin before the procedure. The sensation may increase on its own over time. A healthcare provider may also recommend a special rehabilitation training to improve feeling over time.

How realistic will my penis look after phalloplasty?

In the hands of a qualified surgeon with a lot of experience, you’ll have a typical-looking penis after phalloplasty.

The skin that healthcare providers use to make your neophallus is different than typical penis skin, so there may be differences in color and thickness — you may not be able to see veins. You may have scarring on the bottom of your shaft and around the tip. Your penis will also be about the same size when it’s erect as it is flaccid (not erect).

How many inches will my penis be after phalloplasty?

Your penis length may vary according to the donor site. But on average, you should expect your penis to be 5 to 6 inches (12.7 to 15.2 centimeters).

Can I orgasm after phalloplasty?

Yes, it’s possible to orgasm. Regardless of your flap type, the nerves for orgasm connect to the flap. For most people, this preserves their ability to orgasm.

How successful is phalloplasty?

Studies show that phalloplasty has a very high satisfaction rate. Most people are happy with how their neophallus looks and its sexual function.

What are the risks or complications of phalloplasty?

Phalloplasty is a complex penis surgery. Many people experience complications. It’s very important to go to an experienced surgeon to lower your risk. Complications are less likely to affect your long-term results if a healthcare provider catches them early.

Potential complications of phalloplasty may include:

• Anesthesia complications. These may include sore throat, nausea and vomiting, constipation, severe allergic reaction (anaphylaxis) and stroke.
• Bacterial infection. Harmful bacteria can enter your body through your open wounds and cause sepsis.
• Partial phallic loss. Your neophallus must have adequate blood flow. If it doesn’t, the neophallus tissue can die (necrosis).
• Urethral stricture. Inadequate blood flow can cause scar tissue to form. Scar tissue can slow or completely block pee from leaving your body.
• Urinary fistula. An abnormal connection or opening may form between your urinary system and a nearby organ, like your intestines (bowel). A urinary fistula may also open to the outside of your body.
• Dribbling pee. You may dribble pee, especially after using the bathroom (postvoid dribbling).

What is the recovery time from phalloplasty like?

After phalloplasty, you must rest. Many people don’t resume their usual activities until at least six weeks after surgery. Recovery includes:

• Limiting physical activity. This includes exercising and household chores.
• Using a Foley catheter or suprapubic catheter to pee.
• Keeping your incisions clean and dry.
• Reapplying dressings over your surgical wounds during the early stages of your recovery.
• Taking medications as prescribed by your healthcare provider to ease pain, prevent infection and relieve constipation.

When can I go back to work/school?

Most people can return to work or school about two to three months after a phalloplasty. But if you have a more physically demanding job, it’s a good idea to take more time off — you may need to take up to three to four months off work to recover.

How long will it take to achieve a functioning penis?

Achieving the full function of your penis takes time — in most cases, a year or longer. It will require multiple surgeries. The time it takes depends on whether your treatment involves:

• Repairing or constructing a penis.
• Closing the vagina and removing the uterus or ovaries.
• Taking a flap from your arm or leg.
• Constructing a scrotum or glans.
• Implanting a device to allow erections.

When should I call a healthcare provider?

Schedule regular follow-up appointments with your healthcare team after a phalloplasty to see how your body is healing. It’s also a good idea to continue seeing a mental health professional with experience in transgender care if you get a phalloplasty to help transition to your gender. They can offer support as you work through your recovery and adjust to life after surgery.

Call a healthcare provider or seek emergency care if you have:

• Signs of infection, including a fever, chills, headache, discoloration, swelling or pus.
• Vomiting and not being able to keep fluids down.
• Excessive bleeding or blood-soaked dressings.
• Difficulty or pain while peeing.
• Pain that lasts longer than expected or doesn’t respond to medications.
• Signs of blood clots, such as abnormal swelling in your groin or lower leg.
• Discoloration or other skin changes in your neophallus.

How do people pee after phalloplasty?

It depends on if you get urethral lengthening.

If you don’t get urethral lengthening, you’ll pee out of your original urethra, which will be in the layer of skin between your genitals and anus (perineum).

If you get urethral lengthening, you’ll pee out of your new urethra in your neophallus. This may feel strange at first — it may feel like you’re going to pee out of your old urethra in your perineum. But as you adjust to your new penis, you’ll acclimate to this new way of peeing.

Does phalloplasty grow hair?

If your phalloplasty includes urethral lengthening, surgeons will use donor skin from areas of your body that may have a lot of hair to extend your urethra. Without electrolysis or laser hair removal, the hair will continue to grow when the surgeons use the donor skin to make your urethra. If hair grows inside your urethra, it can increase your chances of developing urinary tract infections (UTIs) or urethral stones (kidney stones in your urethra). Before phalloplasty, your surgeon will help you identify where you must undergo permanent hair removal on your donor area.

What are other names for phalloplasty?

Other names for phalloplasty include:

• Female to male (FTM) phalloplasty.
• Bottom surgery.
• FTM bottom surgery.

A note from Cleveland Clinic

You may wish to pursue phalloplasty for many reasons. It may be a step in your gender affirmation process, or it may be treatment for trauma or a congenital condition. Whatever the reason, it’s a big decision, and it’s natural to be nervous and have questions. How will my penis look? How big will it be? What will it be like to pee? Will I be able to get an erection? Will I be able to feel sensations and orgasm?

When it comes to choosing what’s right for you and your body, the input of healthcare providers with extensive experience in phalloplasty is invaluable. Make sure they answer all of your questions and consider all of your concerns. It’s your body. Your comfort and satisfaction matter most.