Phalloplasty - Indications, Techniques, Procedure, and Complications

Introduction:

Phalloplasty does not involve the creation of the penis alone; there are several stages in the procedure. The other procedures that form a part of phalloplasty are increasing the length of the urethra so that the patient can stand and urinate, creating the tip of the penis, creating the scrotum, and removing the vagina. Not all these procedures need to be carried out in every patient, it depends on the requirement of the patient, and the surgery is planned accordingly.

What Is Phalloplasty?

Phalloplasty aims to create a penis by lifting the tissue from the donor site within the body of the person and moving it to the recipient site (the site where the penis and urethra are to be created). The penis is an important organ of the male reproductive system that helps the person pass urine outside the body and ejaculates sperms into the female vagina at the time of sex. Phalloplasty is a gender confirmation surgery for transgender people and those who were assigned females at birth. The doctor gave them this gender because they were born with the organ characteristic of females: a vagina.

However, as life progresses, they might have felt some discomfort or a desire to acquire the features of the opposite sex, known as gender dysphoria, that led them to opt for this surgery. So phalloplasty allows those suffering from gender dysphoria to undergo gender transition and acquire the bodily features of males, especially the penis.

What Are the Indications of Phalloplasty?

Phalloplasty, or the creation of the penis, is usually done under the following conditions:

• Gender Dysphoria: It is a feeling of uneasiness that people suffer from throughout their lives when the gender assigned at birth does not match their gender identity. These people have a constant desire to acquire the bodily features of the opposite sex, due to which they suffer from anxiety and depression. Phalloplasty is a ray of hope for them because it allows them to change their birth-assigned gender and surgically incorporate all the required features to become a male.

• Ambiguous Genitalia: It is a condition in which the reproductive organs of the baby have not developed clearly, or the baby has features of both genders. The penis is usually small, which can be reconstructed by phalloplasty.

• Aphallia: The absence of a penis by birth is known as aphallia. A new penis can be surgically created for the child by phalloplasty.

• Epispadias: In this condition, the urethra opens at the top of the penis rather than the tip. As a result, the urine leaves through the top of the penis rather than the tip. Phalloplasty can help fix this problem by making the penis look normal so that it works effectively.

• Micropenis: The penis appears normal structurally and functionally but is small, so-called micropenis. Phalloplasty can help increase the length of the penis to make it look normal.

Apart from the conditions mentioned above, phalloplasty is a treatment of choice when the penis gets damaged due to injuries, burns, accidents, and other forms of trauma.

What Are the Eligibility Criteria for Phalloplasty?

The doctor will recommend phalloplasty only if the patient is eligible for it, and they are listed below:

1. The patient should be 18 years or above to undergo this procedure.

2. The patient must live his birth-assigned gender for one year or more.

3. The patient must undergo testosterone therapy for at least a year to be eligible for this surgery.

4. Body mass index (BMI) should be less than 35 because above that, the patient is considered overweight. Body mass index indicates body fat, which is calculated based on the height and weight of the person.

5. The patient must undergo a hysterectomy (surgery that involves the removal of the uterus) two months before phalloplasty.

6. It is required that the patient stops smoking and tobacco consumption at least seven to eight weeks before the surgery because it can interfere with the healing process after the surgery and cause complications.

7. The patient must get a recommendation letter from the doctor who diagnosed the disease or started the hormone (testosterone) therapy. The letter should mention the health status of the patient and if he is medically fit for the surgery or not.

8. A recommendation letter from a psychologist is also needed because that gives the surgeon an idea about the mental health of the patient. It also confirms that the patient has opted for surgery and is not under peer pressure.

What Tests Are Done Before the Surgery?

Following tests must be done before the surgery:

• Blood Tests: The patient needs to undergo a blood test so that the doctor can analyze the blood report thoroughly and check for the presence of infection.

• Type and Screen Blood Test: This test aims to identify the blood group of the person and detect the presence of any antibodies that can cause problems during blood transfusion (transfer of blood from the donor to the recipient).

• Physical Examination: It is done to get more ideas about the health of the patient. It is also recommended that the hairs present near the penis should be removed before the surgery.

What Are Some of the Lifestyle Changes to Be Done Before the Surgery?

• Before the surgery, it is important to introduce changes in the lifestyle like having a diet rich in proteins, multivitamin capsules to be taken daily, and proper nutrition to keep the body healthy. The patient must avoid eating solid foods a day before the surgery and restrict himself to a liquid diet.

• The doctor might prescribe certain medications, mainly Laxatives (drugs used to treat constipation), like magnesium citrate solution and Bisacodyl, to improve the bowel habits before the surgery.

• The patient needs to inform the doctor about the drugs he is taking because medications like Aspirin and Ibuprofen need to be stopped a week before the surgery only if the doctor recommends it.

What Are the Different Techniques of Phalloplasty?

Phalloplasty techniques have been classified based on the sites from where the tissue is taken (donor site). They are listed in the table below:

What Happens During the Surgery?

Phalloplasty is a complex procedure carried out in multiple stages, and each step requires six to eight hours for completion. The stages of phalloplasty are listed in the table below:

It is not necessary that the patient undergoes all the above-listed procedures in the same order. However, proper planning needs to be done before the surgery. There should be clarity between the patient and the doctor regarding the stages of the surgery to be included first and the ones to be included later.

1. The procedure is performed under general anesthesia (solution injected into the body to fall asleep for some time).

2. The doctor first removes a tissue of skin from the area of the body that acts as the donor site (thigh, forearm, abdomen, or back are the donor sites mainly).

3. The tissue can be removed completely, or a part of it is left attached to the site. If the tissue is large, it is made in the form of a tube.

4. The bigger tube encircles the smaller one.

5. Next, a patch of skin (skin graft) is taken from the area of the body that is not visible externally and stitched to the donor site.

6. The other procedure that the doctor can do is lengthen the urethra. It is because the female urethra is smaller than that of the male, allowing the urine to flow from the tip of the penis.

7. The procedure gets completed in seven to eight hours, and the patient stays in the hospital for four to five days.

How Should One Take Care After the Surgery?

The following things need to be kept in mind after the surgery:

1. The patient must avoid strenuous activities, household chores, exercises, lifting heavy objects or weights, and office-related work. However, the patient can go for walks four to six weeks after the surgery.

2. A catheter (the tube that drains the urine from the bladder) will be inserted and left in place.

3. It is important to keep the area dry and clean to avoid infection, and the dressings should be changed at regular intervals.

4. Avoid bathing for two weeks.

5. The bag attached to the catheter in which the urine is drained should be emptied timely; otherwise, it can become a potential source of infection.

6. The penis is elevated with the help of dressing to ensure that the blood supply to the area is proper.

7. Itching, uneasiness, blood in the urine, and constipation will present for a few days after the procedure, but they will subside.

8. It takes about 10 to 12 months for the site to heal completely.

What Are the Complications of Surgery?

The complications associated with phalloplasty are listed below:

• In addition, skin infection near the urethra is commonly seen for one month, which subsides on taking appropriate antibiotics.

• Wound breakdown is frequently seen when the incision is made and can be managed by changing the dressings regularly or removing the infected tissue (debridement).

• A catheter (the tube that drains the urine) is inserted at the time of surgery. However, complications can arise if the catheter gets twisted during placement and causes problems like urinary leakage, infection, and cloudy urine.

• The most common complication usually presents within three days of surgery is flap loss or flap failure (loss of blood supply of the transferred tissue).

• During vaginectomy, injury to the rectum (the organ that holds the stools) can occur. This happens rarely but presents severe problems.

• The narrowing of the tubes that carry urine outside the body (urethra) occurs six months after the surgery and leads to urine retention.

• Scarring and wound contraction are a part of the healing process of the body. Scars usually appear as lines but can become thick (hypertrophic scar) as an abnormal response to wound healing.

Conclusion:

Phalloplasty aims to create a new penis surgically. It is a boon for people suffering from gender dysphoria in which the person is uncomfortable with the birth-assigned gender and feels depressed throughout his life. This surgery allows them to come out of the mental trauma and change their gender. The surgery comprises several stages, so the patient needs to understand them clearly. Also, consultation with the doctor helps identify the risks and benefits of the surgery so that it can be carried out successfully.