There are many different techniques for FTM phalloplasty. Major transgender surgery centers around the world, including those Dr. Crane trained in, believe the standard of care in phalloplasty utilizes donor sites from either the radial forearm (RF), the back (musculocutaneous latissimus dorsi – MLD), or the outside of the thigh (anterolateral thigh – ALT). These flaps heal well with good sensation due to robust blood supply and innervation. Dr. Crane is also a microsurgeon, so he mainly performs “free flap” phalloplasty. Free flaps, such as the radial forearm, MLD (musculocutaneous latissimus dorsi flap from the back), and ALT (anterior lateral thigh flap, free or pedicled) require meticulous dissection of arteries, veins, and nerves. Subsequently, after transferring the flap to where the phallus should reside, an operating microscope is used to sew the small blood vessels together from the patient’s body to the transferred flap. The sensory nerves are also sewn together to maximize sensation.
About 9 months after phalloplasty, a penile implant may be inserted into the phallus to provide axial rigidity for penetrative intercourse. The 9 month wait time allows the nerves to heal and grow along the phallus, thereby reducing the risk of implant erosion. Like metoidioplasty, urethral lengthening, scrotoplasty and vaginectomy can be performed at the same time.
The donor site choice is a complex one and depends on many factors.
RF Flap: This is the ideal flap for phalloplasty given the thin skin and lower fat content, the large amount of blood vessels, the large sensory nerves, and the end result of a physiologic appearing phallus. The only downside to this flap is the donor site wound, which can be obvious. Some patients strongly oppose the RF flap for this reason. That being said, many patients prefer the forearm for reasons depicted earlier and improve their forearm scar appearance by getting a forearm tatoo once the site has healed or wearing a sports sleeve over it. Other benefits include being able to create a skin tube urethra from the RF flap at the first stage as well as glansplasty given the rich arterial network. Furthermore, RF phalloplasties have lower urinary stricture and fistula rates with overall denser sensation development than the other flaps.
ALT Flap: Patients that are near their ideal body weight or have a body mass index (BMI) in the low twenties can have a one stage phalloplasty from the lateral thigh. Some patients prefer this over the RF flap because they want a very large phallus and because the donor site scar is less visible. Urethral lengthening (UL) to the tip of the phallus is achievable most of the time in one stage, but patients with a thick layer of underlying fat in their thigh may require 2 stages for the UL. In this case, the first stage consists of creation of the phallus, extension of the urethra to the base of the neophallus, vaginectomy, and scrotoplasty. About 4 months later the phallus is opened on the underside and a flap or graft is used to create a urethra. About 6 months after UL, the penile and testicular implants are placed and glansplasty is performed. Glansplasty is not performed at the first stage phalloplasty because of a lense dense arterial network with compared to the RF flap
MLD Flap: Many patients choose this donor site because of the less obvious scar, but the nerve for this flap is a motor nerve and not a sensory nerve. Because of this anatomical difference, patients with a forearm or thigh flap typically have much better sensation. This flap is performed in 3 stages and requires oral mucosa graft for urethral reconstruction.
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The prices may vary somewhat between flaps with the radial forearm being the least costly. Patients stay in town for 3-4 weeks, including a 4-5 day hospital stay.
For more information about phalloplasty costs, and more phalloplasty photos, please contact us.