What are the steps of masculinizing genital surgery?

Medications are administered for your comfort during the surgical procedure. You will be completely asleep during the procedure.

You might have a separate surgery before your phalloplasty to remove the uterus (hysterectomy) and the ovaries (oophorectomy). The blood vessels and nerves in the pelvis, which will receive the attachments to the newly constructed neophallus, are identified and preserved.

Phalloplasty

Phalloplasty is a multistage operation. It may include different procedures, depending on your goals. Your surgeon will discuss your personalized surgical plan and the recovery time between each stage. A general plan might look like:

Stage 1

Your surgeon will construct a neophallus from tissue taken from another part of your body. They may take skin, fat, nerves, arteries and veins from your:

• Forearm: Called a radial forearm free (RFF) flap. You will need a skin graft to cover the place where the tissue is removed from your wrist to about halfway up your forearm. Forearm flaps have good sensation and usually a good aesthetic result.
• Thigh: Called an anterolateral thigh (ALT) flap. You will need a skin graft to cover the place where the tissue is removed from the front/side of your thigh. Using this flap may give you more options for neophallus length.
• Back: Called a musculocutaneous latissimus dorsi skin (MLD) flap. Usually, you will not need a skin graft to cover the place where the tissue was removed from the side of your back.

Stage 2 (about five months later)

Your plan might include procedures such as creating the neoscrotum and lengthening the urethra (the tube that drains urine from the body), so you can urinate from the tip of the neophallus while standing.

Stage 3 (about six months later, if desired)

Your plan may include putting artificial testicle implants and an erectile device into your body. Right now, there is no FDA-approved erectile device for phalloplasty during transgender surgery, but your surgeon can use a device that was originally approved for erectile dysfunction. This is called off-label use of the device.

Metoidioplasty

Metoidioplasty is an alternative option to phalloplasty. This surgery has fewer steps and a shorter recovery than phalloplasty. It creates a small neophallus of usually around one to three inches using the clitoris. Penetrative sex may not be possible after a metoidioplasty.

Stage 1

The clitoris is enlarged using testosterone hormone therapy. This may take 12 months or longer.

Stage 2

After the clitoris has enlarged, you will have surgery to release some of the ligaments that surround the clitoris. The released clitoris is used to create a neophallus. You will not need an erectile device implanted in your body. If you choose urethral lengthening, the urethra (the tube that drains urine from the body) will be extended, so you can urinate from the tip of the neophallus while standing. A neoscrotum can be constructed from the skin of the outer labia.

Stage 3

After about three to six months of healing, you may choose to have additional procedures. These can include surgery to add testicle implants or to improve the cosmetic appearance of the neophallus or neoscotum to make it appear more masculine.