If you identify as a trans man and are reviewing your surgical options, then you have probably already thought about what a phalloplasty would be like. This procedure involves the construction of a penis through the installation of a prosthetic along with the use of a skin graft.
The first successful reconstruction of an entire penis took place in 1936 by Russian surgeon Nikolaj Bogoraz, who used rib cartilage and a tubed flap of abdominal tissue to create a new phallus. The first phalloplasty performed as part of FTM sexual reassignment took place a decade later, when Dr. Harold Gillies performed the procedure on Michael Dillon in 1946.
Some patients undergo a metoidioplasty several months before the phalloplasty. In some cases it is possible to graft nerves from remaining clitoral tissue to the new phallus so that the patient may experience sexual pleasure, although doctors cannot yet guarantee genital orgasm even after a successful procedure.
For the patient to achieve erection, phalloplasty requires the use of some sort of prosthesis which is usually inserted in a separate procedure (to give the body time to heal after the penile formation). Several different types of prostheses are used in phalloplasty, including a device that resembles a rod but can also change its shape under some pressure, allowing the penis either to hang down or to stand up from the pelvis.
Historically, surgeons used bone grafts as a part of reconstructing the penis, and long-term studies in Turkey and Germany have shown that bone graft prostheses keep their stiffness without causing complications over time. The downside of this is that patients who receive a bone graft as part of their phalloplasty also lack the ability to return to a flaccid state unless they break that bone graft.
Patients who want to maximize the length of their neopenis can undergo a procedure that releases the ligament connecting the penis to the public bone, letting the penis move toward the edge of the body. The surgeon makes one incision in the pubic region, in a place where the public hair will help to hide the scar. There is no incision made on the penis. There is some research underway to determine whether synthetic erectile tissue will actually work in the body. In rabbit studies, the synthetic tissue had promising results, but more study is needed at this time to see if this will be a workable solution.
In addition to the prosthesis, a phalloplasty also takes a graft from the skin — most commonly the arm, even though the procedure leaves an unsightly scar on the arm afterward. Other possible sites for the skin graft include the chest, leg and the pubic area. When the leg is the source of the graft, it is easier to hide the scar by wearing pants and/or a sock over the affected area. When the graft comes from the pubic area, there is a risk that the graft will not look as natural and may not hold the implant over time. There is research under way to see whether stem cells or other materials in bioengineering can be used to manufacture a synthetic penis.
To determine whether a phalloplasty is right for you, we encourage you to contact a qualified surgeon.