There are many different techniques for FTM phalloplasty. Major transgender surgery centers around the world, including all that Dr. Crane performed his transgender surgery fellowship with, believe the standard of care in phalloplasty utilizes donor sites from either the forearm (RF), the back (MLD) or the outside of the thigh (ALT). These flaps heal well due to robust blood supply and offer sensation that’s superior to others, such as abdominal and groin flaps.
About nine months after phalloplasty, a penile implant may be inserted into the phallus so as to cause rigidity for penetration. The nine month wait time allows the nerves to grow down the phallus giving sensation, which will reduce the risk of implant erosion through the phallus. It is risky to place a penile implant in a phallus with no sensation. As with metoidioplasty, scrotoplasty, and vaginectomy can also be performed.
Phalloplasty does result in a phallus long enough for penetration (approximately 15 cm, on average), however, when compared to metoidioplasty, it is a more complex surgery with a greater possibility of complications. Dr. Crane learned his phalloplasty techniques while in Ghent, Belgium in a transgender surgery fellowship.
Dr. Crane is trained as 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 the surgeon to dissect out the arteries serving the donor tissue, transfer the flap to where the phallus should reside, and use an operating microscope 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.
The donor site choice is a complex one and depends on many factors.
Radial Forearm Flap: Patients with a larger body habitus get the best result with the radial forearm flap because the forearm has smaller amounts of fat under the skin than other parts of the body. A complete urethra can be made and the entire phallus constructed in one stage in conjunction with vaginectomy, scrotoplasty, and glansplasty. About 9 months to a year after the phallus is made, testicular implants and a penile implant can be placed. Most patients do achieve erogenous sensation.
ALT Phalloplasty: Patients that are near their ideal body weight or have a body mass index (BMI) in the low twenties can also have a one stage phalloplasty from the lateral thigh. Some patients prefer this as the donor scar is less visible. Erogenous sensation can still be achieved as the sensory nerve from the thigh is connected to the clitoral nerve, however, some surgeons performing phalloplasty speculate that sensation is a little better with the radial forearm flap. This is controversial.
If a patient is heavier, the lateral thigh is still an option, however one stage is added to the phalloplasty. If there is too much subcutaneous fat in the thigh, it can be difficult to construct a urethra within the phallus. In this case, the first stage consists of creation of the phallus, extension of the urethra to the base of the neophallus so that many patients can stand to urinate, vaginectomy, and scrotoplasty. About four months later the phallus is opened on the underside and a graft is placed for the future urethra. The patient can still stand to urinate. Four to six months later the urethra is turned into a tube, the penile and testicular implants are placed and glansplasty is performed.
MLD Phalloplasty: See ALT Phalloplasty above. This same series of surgeries is followed for all MLD flaps.
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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.