MUJER/HOMBRE (MaH)

Gender Affirmation Surgery

Genital surgical procedures for female to male patients include:

  • Vaginectomy: resection and closure of the vaginal cavity
  • Metoidioplasty: release of the clitoris to create a micro penis
  • Scrotoplasty: construction of the scrotum from the upper lips
  • Uretroplasty: repositioning of the urethra
  • Placement of testicular prosthesis
  • Phalloplasty: construction of the penis

 

There are currently a variety of surgical techniques for phalloplasty. The choice of the technique may be limited by anatomical or surgical considerations. If the goals of phalloplasty are to create neofalo of good appearance, standing urination, sexual sensation, and / or coital ability, patients should be clearly informed that there are several separate stages of surgery and frequent technical difficulties that may require additional operations. Even metoidioplasty, which in theory is a single-stage procedure for building a microphalon, often requires more than one operation. The goal of standing urination with these techniques cannot always be guaranteed.

 

Complications of phalloplasty may include frequent stenosis and fistulae of the urinary tract and, occasionally, necrosis of the neofalo. Metodioplasty results in a micropenis without the ability to urinate standing up. Phalloplasty, using a pedicle or a free vascularized flap, is a long, multi-stage procedure with significant morbidity including frequent urinary complications and inevitable scarring in the donor part of the body.

 

Average time: 6 hours

Type of anesthesia: Epidural + sedation

 

Prerequisites:

Mandatory:

  • Adult age
  • A true transsexual with gender dysphoria
  • Surgery recommended by 2 mental health specialists trained in gender identity issues.
  • Emotionally stable
  • Medically healthy with any medical conditions being treated and under control.
  • Living as a male 24 hours a day at least for one year in a row.

 

Optional:

  • Support of spouse, family, significant other, friends
  • Economically stable

 

Frequently asked questions:

¿Who performs my hysterectomy?

A gynecologic should perform this surgery. If a hysterectomy is performed prior to the time of phalloplasty it is important not to have the procedure done utilizing a long horizontal incision across the lower part of the abdomen.  An incision at this location transects and eliminates the majority of blood vessels and nerves feeding the lower abdominal tissues which are the primary choice of tissues to be used for the phalloplasty construction.  

Hysterectomy ideally should be performed vaginally, laparoscopically, or as a laparoscopic assisted vaginal hysterectomy. If it is not possible to do the procedure utilizing one of these techniques and an open abdominal approach is required, then a lower abdominal vertical mid line incision should be requested. 

¿ Is it necessary to wait any specific length of time after a hysterectomy has been performed before a phalloplasty is done?

If a hysterectomy has already been performed, it would be wise to wait at least four months prior to phalloplasty so healing and reduction of swelling and inflammation can be sufficiently advanced in order to not interfere with the phalloplasty procedure. 

¿Is it necessary to have a vaginectomy before getting phalloplasty?

No, it is not necessary to have a vaginectomy either before or after phalloplasty.  The vaginectomy procedure is a major and complex procedure which should be done only by a gynecologic who is very familiar with the detailed and complex deep anatomy of the pelvis.   If a patient wishes to remove the vagina, we can safely remove 1/2 to 2/3 of the vagina in the form of a sub-total vaginectomy at the time of phalloplasty.  This leaves a very narrow vagina and small introitus (open) of the vagina, which permits drainage of mucous from the remaining vaginal mucosa. Total vaginectomy runs a high risk of complications because of the important arteries, veins, and nerves deep in the pelvis which can be easily injured when doing a total vaginectomy.  This is why we recommend a sub-total vaginectomy as a safer way to eliminate the majority of the vagina.  The remaining vaginal opening is inconspicuous where it is located below and behind the scrotum. 

¿ Is a scrotoplasty included as part of the same stage phalloplasty?

Yes, we give our patients several options when planning the phalloplasty procedure.  One option is to do a glansplasty if an individual wants to shape the end of the penis to appear circumcised.  We can create the appearance of a circumcised or non-circumcised penis. 

¿Cual técnica de faloplastia utiliza?

The first choice for phalloplasty is using the lower abdominal skin and soft tissues as a “turn-down” flap.  This maintains the arteries, veins and nerves to the lower abdominal tissues and maintains good blood supply and sensation to the penis.  The sensation is not erotic as these tissues are not connected to the pudendal nerve.  The phallus will have the same sensation as the tissues of the lower abdomen.  Sensation comes from the clitoris which is maintained in its original location or can be transposed upward to be buried under the skin between the scrotum and the base of the penis.   Because it is easily stimulated in this location, most trans men can experience orgasm either by direct stimulation to this area or during intercourse.   In addition to clitoral transposition, another option is scrotoplasty, the creation of a scrotum from the labial tissues along with insertion of testicular implants.

Other local flaps can be used, but they don’t have as good a blood supply as the lower abdominal “turn-down” flap and so we rarely use these types of flaps unless the abdominal flap is not available to us.

Some surgeons use a “free flap” from the forearm wherein tissues from the forearm are transplanted to the pubic area utilizing microvascular anastomosis of arteries, veins, and nerves.  If the procedure is successful, it can create a neo-phallus which is sensitive because its connected to the pudendal nerve which permits erotic sensation.  This procedure can also create a longer urethra which permits the individual to void while standing.   However, if the vascular anastomosis fails, the entire penis can be completely lost and another technique is then required. 

The abdominal “turn-down” phalloplasty technique does not include a urethral extension (urethral “hook-up”) because the urethroplasty procedure has a very high rate of complications associated with stenosis (i.e. scarring and closure of the new urethra where it attaches to the old one) and results in urinary tract obstruction.  This commonly causes diverticulae where the proximal urethra “balloons” out from the increased pressure of urine, or fistualae formation when the anastomosis breaks down and urine leaks out through and abnormal opening at the base of the penis.   These complications require additional surgery to correct and this means more hospitalization, more expense, and more downtime.   For these reasons, until we can develop better techniques with fewer complications, I usually don’t recommend urethroplasty.   When there is no urethral extension, the patient must continue to sit to urinate.  

 

¿ How do you incorporate the clitoral nerves to the neo-phallus during the phalloplasty procedure?
The clitoral nerves and clitoral sensation are maintained by preserving the entire clitoris.  The clitoris can be left in place or can be transposed and buried under the skin between the scrotum and the penis. 

¿ Is the phalloplasty done in one stage or more than one stage?

I prefer to do the entire phalloplasty in one stage and this includes the creation of the neo-phallus, clitoral transposition, glansplasty, and scrotoplasty with testicular implants. Sometimes we do the hysterectomy and mastectomy at the same time. 

¿ What kind of scars are left on the neo-phallus and will they eventually disappear?

With our technique, scars are located in the lower abdomen and in the medial line of the scrotum. They are permanent, but with time they improve their appearance. During the first several months, scars can be pink, raised and wide, but from around 6 – 12 months the scars become flat, soft and white and not very obvious.  

 

¿ What is the functional result of the neo-phallus?

There is no technique available in the world today which can create a penis which can have a natural erection.  We simply do not have the ability to create the thousands of small blood vessels required to achieve a natural erection and so we must choose another form of support if the patient desires the ability to have intercourse.  This support can be either internal or external.  Internal support means placing some type of penile implant into the center of the phalloplasty flap.  External support consists in placing one or two condoms over the penis which can give sufficient rigidity to allow intercourse.   

¿ How long does it take me to recover from phalloplasty?
You must stay for 1-2 days in the hospital after the procedure and at least 3 weeks in the city of Cali. During this time dressings are changed, incisions are checked, and after one week the catheter is removed from the bladder.  Sutures are removed approximately 7-9 days following surgery. 

¿ When can I go back to work after phalloplasty?
Generally, barring any unforeseen complications, phalloplasty patients can return to work after about 4-6 weeks depending on the patient’s recuperative progress and the type of work.   If the patient’s job requires strenuous activity, return to work should be after 6 weeks.