About 1.4 million adults in the USA identify themselves as transgender. As society grows more accepting of these individuals, more transgender people elect to physically alter their sex.  Currently, most elect to receive hormone therapy or non-genital surgery.  For example, they may undergo a breast augmentation or a mastectomy.  Only a small number of these individuals choose to undergo genital surgery such as creation of a penis or neo-phallus[1].

The terminology regarding this subject can be confusing.  Let’s define a few terms.

Definition of Gender Dysphoria

Gender dysphoria refers to the distress caused by the discrepancy between a person’s gender identity and the gender assigned at birth.  Gender dysphoria should no longer be considered a disease and it should not have a negative connotation.

Definition of Gender Incongruence

Gender incongruence represents the conflict between those who wish to alter their sex and the prevailing culture of intolerance towards these individuals.  If cultural norms conflict with those who wish to alter their sex, these individuals may develop anxiety, depression, and mental illness.

Female to Male – Medical and Surgical Steps

The transformation of an individual from female to male is a multi-step procedure that typically occurs over the space of one year. Complete transformation involves the following:

  1. Testosterone therapy
  2. Removal of breast tissue
  3. Removal of uterus, vagina, and ovaries
  4. Creation of penis
  5. Creation of scrotum and Insertion of testicular prosthesis
  6. Insertion of penile implant into the new penis

Creation of the Penis or Neo-phallus

The creation of the neo-phallus is a complicated plastic surgical procedure. The ideal neo-phallus has several characteristics that enable the recipient to do the following:

  1. Stand when urinating
  2. Have penetrative intercourse
  3. Have penile sensation
  4. Experience an orgasm.

Creation of a Small Penis – Metoidioplasty

A metoidioplasty creates a small penis from the clitoris.  The penis that results from a metoidioplasty is about 2.5 to 3 inches long.

Before surgery, you will receive hormone therapy to the clitoris. This increases the length of the clitoris.  During surgery, all the attachments are cut in order to make the clitoris longer. Plastic surgical grafts are then used to further lengthen the clitoris.

This procedure has a high success rate and a low complication rate. This new penis permits standing urination. The penis has excellent sensation and allows the individual to have an orgasm.  The penis, however, is usually too short for penetrative intercourse[2].

Creation of a Full Length Penis

A full length penis or neo-phallus is created from tissue flaps.  A flap refers to tissue that is transferred from a donor site located on your body to a recipient site that is also located on your body.  There are two basic types of flaps – a pedicle flap and a free flap.

A free flap is completely separated from the body at the donor site.  The flap is transferred to the recipient site.  Using the microscopy, the surgeon connects the arteries, the veins, and the nerves of the flap to those located at the recipient site.

A pedicle flap is never separated from the body.  The tissue from a nearby donor site is rotated into the donor site.  The arteries, veins, and nerves remain connected to the pedicle flap at all times.

The most popular flap used to create the neo-phallus is the radial forearm free flap which is harvested from the patient’s non-dominant forearm.  This free flap is considered the gold standard because it has the best results.

The second most popular flap used to create the neo-phallus is the anterior lateral thigh flap. This is a pedicle flap that is harvested from the thigh and rotated into position.

Sometimes, both the radial forearm free flap and the anterior lateral thigh flap are both used to create a single neo-phallus[3].

Insertion of Penile Implant into the Neo-phallus

The final step of the transformation of female to male involves the placement of a penile implant into the neo-phallus.  This implant will enable the individual to have penetrative intercourse.

Surgical Principles

Placing a penile implant into a patient with a neo – phallus is a challenging procedure.  The implant surgeon must appreciate how the particular neo-phallus was constructed in order not to damage the neo-phallus. In other words, your surgeon must consider the “flap anatomy”.

Placing an implant into a transsexual male is also challenging because there are no corpora cavernosa to anchor the implant. The corpora run the full length of the penis.  In a non-transgender male, the implant is placed inside the corpora cavernosa.

Instead of placing the implant inside the corpora cavernosa, the implant is placed inside a sleeve made of a synthetic material called Dacron.  The Dacron is then sutured to the pubic bone. This effectively anchors the implant.

Finally, most patients with a neo-phallus receive an implant containing only one cylinder instead of the customary two cylinders.  Placing a single cylinder implant into the neo-phallus leads to a superior cosmetic result. In addition, there is less chance of cylinder migration[4].

When is the Penile Implant Performed?

After you receive your neo–phallus, your surgeon will wait about one year before inserting the penile implant.  This allows the neo–phallus to heal and the nerves to regain their function.

Complications of Penile Implant Placement into Neo-Phallus

The complication rate of this procedure is high.  About 40% of implant patients will require a revision surgery within 5 years.  Complications include implant infection, implant erosion, and implant malfunction.  Most of the complications occur because the implant is not contained within the protective corpora cavernosa of the penis[5].

Satisfaction with Neo-Phallus Penile Implant

Despite the high number of patients who require revision surgery, overall satisfaction with the penile implant is high.  Generally, 80 to 90% of patients with a neo-phallus are satisfied with the penile implant[6].

New Penile Implant Specifically Designed for the Neo-Phallus

There is a new penile implant specifically designed for the neo-phallus.  The device is called ZSI 475 FtM and it is manufactured by a Swiss company called Zephyr Surgical Implants. Initial reports concerning this implant are promising[7].

The new implant is inflatable and consists of a single cylinder. The device has a metallic plate at the base of the cylinder that contains holes. This metal plate allows the implant to be directly sewn to the pubic bone. This effectively anchors the implant and makes the Dacron sleeve unnecessary.

References

[1] Lane, M, Ives, G, Sluiter, E, Waljee, J, Yao, T, Hu, H, Kuzon, W, Trends In Gender Affirming Surgery In Insured Patients In The United States, Plastic And Reconstructive Surgery Global Open, 2018, 6, e1738, 1 – 7

[2] Stojanovic, B, Bizic, M, Bencic, M, Kojovic, V, Majstorovic, M, Jeftovic, M, Stanojevic, D, Djordjevic, M, One-Stage Gender – Confimation Surgery as a Viable Surgical Procedure for Female – to – Male Transsexuals, The Journal of Sexual Medicine, 2017, 14, 741 – 746

[3] Namba, Y, Watanabe, T, Kimata, Y,  Flap Combination Phalloplasty in Female – to – Male Transsexuals, The Journal of Sexual Medicine, 2019, 16, 934 – 941

[4] Neuville, P, Morel – Journel, N, Maucourt – Boulch, D, Ruffion, A, Paparel, P, Terrier, J, Surgical Outcomes Of Erectile Implants After Phalloplasty: Retrospective Analysis of 95 Procedures, The Journal of Sexual Medicine, 2016l 13, 1758 – 1764

[5] Falcone, M, Garaffa, G, Gillo, A, Dente, D, Christopher, A, Ralph, D, Outcomes of Inflatable Penile Prosthesis Insertion In 247 Patients Completing Female to Male Gender Reassignment Surgery, British Journal of Urology, 2018, 121, 139 – 144

[6] Ibid 5

[7] Neuville, P, Morel – Journel, N, Cabelguenne, D, Ruffion, A, Paparel, P, Terrier, J, First Outcomes of the ZSI 475 FtM, A Specific Prosthesis Designed for Phalloplasty, The Journal of Sexual Medicine, 2019, 16, 316 – 322