What is phalloplasty?

Phalloplasty is the correction and/or reconstruction of the male penis through surgery. The need for this plastic surgery may arise for various reasons.

Indications for the procedure

Indications for undergoing phalloplasty in men include:

• damage and trauma to the penis, including its crushing and complete loss (traumatic amputation), burns, impingement with subsequent tissue necrosis, etc.;
• medical penectomy (particularly for malignant neoplasms of the urethra or penis);
• Penile skin defects that do not respond to conservative therapy;
• abnormal location of the external urethral opening - epispadias or hypospadias;
• congenital deviation (curvature of the penis) or deformity caused by the formation of fibrous plaques within the white membrane of the spongy and cavernous bodies (Peyronie's disease);
• Congenital anatomical anomalies: penile agenesis, micropenis, hidden penis;
• penoscrotal lymphedema - elephantiasis or elephantiasis of the penis.

In addition, some men who doubt their sexual abilities or are simply dissatisfied with the appearance of their genitals - most likely due to dysmorphophobia - decide to take drastic measures: using plastic surgery to increase the "size" of the penis. However, most men do not have medical indications for such surgery, and in such cases phalloplasty is aesthetic and its purpose is to improve self-esteem. [1]

How surgeons make the penis longer, in detail in the material - Operation ligamentotomy. And the technique of penis enlargement in volume is devoted to the publication - Penis thickening surgery.

Sex reassignment phalloplasty, which the experts of the American Society of Plastic Surgeons (ASPS) call gender confirmation surgery, also involves plastic surgery, but in this case - as in traumatic amputation and after penectomy - it is total phalloplasty. In such a comprehensive surgical procedure, a transgender man (that is, a woman who feels like a man) is given an artificial penis by transplanting tissue from his own body (autograft), which is similar in appearance and function to the natural penis. The essential difference of such operation at sex change from female to male (female to male or FtM) is that there is not restoration of the original male anatomy, but phalloplasty in women with creation of neophallus - non-existing external sexual organ. It should be borne in mind that artificial modification of the penis through surgery is not the only masculinizing surgical procedure used in the sexual transformation of women with diagnosed and confirmed by a consilium of psychiatrists gender dysphoria - gender identity disorder.

Preparation

Regardless of the indications for phalloplasty in men and the chosen technique, preparation is necessary, in particular, preoperative examination: ECG, ultrasound of the penis, Dopplerography of its vessels, and before surgery for hypospadias - echography of the urethra.

In addition to a general blood test and coagulogram, blood tests for STDs, HIV, hepatitis C, as well as a comprehensive metabolic panel, including more than a dozen blood tests, including sugar, electrolytes, albumin, urea nitrogen, creatinine, alkaline phosphatase, C-reactive protein, etc., are required.

Hair is removed from the skin graft area and in the genital area using laser hair removal.

Also requires preparation of the intestine: two days before the operation from the diet exclude fried and spicy, red meat, legumes, coarse vegetable fiber, alcohol, the day before the operation inside take a solution of magnesium citrate or laxative tablets Bisacodyl (up to 20 mg), and in the afternoon stop eating solid food and make a cleansing enema.

Penile plasty is a long operation performed under general anesthesia, and an anesthesiologist is involved in the preparation for it. He finds out the condition of the cardiovascular and respiratory system of the patient, his allergic status and determines the drugs for premedication and anesthesia itself.

Mandatory conditions for FtM sex reassignment phalloplasty: taking male sex hormone medications (for 12 months), having a hysterectomy (removal of the uterus), vaginectomy (removal of the vagina) and ovariectomy (removal of the ovaries), and a subcutaneous mastectomy (removal of the mammary glands) - at least three to five months before the surgical creation of the neophallus.

Technique What is phalloplasty?

After a scalp injury to the penis, a burn with significant skin loss (necrosis), abscess removal or tissue excision in penile elephantiasis, phalloplasty with skin replacement is required, for which the classic technique of autodermoplasty is used. Both skin flaps on a pedicle (from the scrotum, lower abdomen or inner surface of the thigh) and free skin grafts are used: in the form of split-thickness flaps from the inner surface of the thigh and full-thickness flaps taken from the inguinal region. The flap is attached with interrupted absorbable sutures and covered with a supporting dressing; the area where the skin was taken is closed with an occlusive or vacuum dressing.

In phalloplasty performed in cases of hypospadias, the penile shaft is straightened; the lumen of the urethra passing through the penis is corrected; the external opening of the urethra (urinary meatus) is moved to the apical point of the glans; the skin defects are closed with autograft.

In case of penile curvature due to fibrotic changes in the tunica albuginea, the technique of flap plasty of the penile body (corpus penis) is used - corporoplasty, plasty with transverse plication, shortening of the t. Albuginea on the contralateral side. Albuginea on the contralateral side. All details - in the publication Peyronie's disease.

The material for the new penis in total phalloplasty is:

• free radial flap of the forearm skin (with thin dermis, optimal subcutaneous fat layer and sufficient innervation); blood vessels and nerves are sutured using microsurgery; the urethra for standing urination is formed simultaneously - tube within tube method;
• skin flap (with legs) of the anterolateral part of the thigh - without blood vessels and nerves (urethra for standing urination can be formed and penile implant can be placed);
• rectangular skin flap from the suprapubic part of the abdomen (without the urethra passing in the neophallus, i.e. Urination is performed in a sitting position);
• A free flap of the musculocutaneous latissimus dorsi with thoracic vessels and thoracodorsal nerve.

Total phalloplasty is carried out in several stages; first, a skin graft is taken with appropriate treatment and a new penis is formed, which is transferred to the pubis and sewn into the incision. In the female to male operation, the urethra can be either left in its native position, taken outward (as a perineal urostomy) or lengthened to the base of the penis with tissue from the labia minora.

Dermoplasty with a split skin flap is performed on the donor site (the site where the flap was taken). A Foley urethral catheter is placed for urine outflow, the sewn graft is raised a few centimeters from the abdominal wall with a special dressing.

The next stages include shaping the head of the penis, repairing or creating the scrotum (scrotoplasty), connecting the newly created urethra to the bladder; the last stage is the placement of the prosthetic penis and testicles. Of course, this is not all done in one operation: there are at least three months between stages, and a complete phalloplasty can take up to two years.

Phalloplasty with prosthetics

For additional density and axial stability of the neophallus trunk formed from a skin autograft, phalloplasty with prosthesis, which is the implantation of a penile endoprosthesis in a separate surgical procedure, is performed. [2]

Two types of penile prostheses can be used: rod-based semi-rigid devices and inflatable devices. The first type is a silicone rod with a flexible but rigid core; the rigidity does not allow to "translate" the neopenis into a relaxed state and, in addition, constant pressure on the skin, leading to erosion.

The basis of hydraulic inflatable phalloprostheses are inflatable cylindrical chambers (placed in the reconstructed penis), a pump (implanted in the scrotum and actuated by hand compression) and a fluid-filled reservoir (which is sewn into the abdominal cavity). [3]

Contraindications to the procedure

Penile reconstructive or penile corrective surgery is contraindicated in:

• acute inflammation or exacerbation of chronic inflammatory process (any localization);
• STDs, AIDS or hepatitis C;
• fever;
• poor blood clotting;
• diabetes;
• Overweight (body mass index ˃30);
• systemic autoimmune and skin diseases;
• of mental illness and disease.

Phalloplasty for men has age restrictions: it is not performed after the age of 60. And sex reassignment phalloplasty is not performed on patients under the age of 18.

Consequences after the procedure

Immediately after phalloplasty surgery, patients feel pain, including in the area from which the skin flap was taken. There are such consequences of surgical intervention as nausea field of prolonged general anesthesia, soft tissue reporting and hematomas in the area of the surgical wound, bleeding, burning and hematuria during urination.

But the list including complications after phalloplasty is longer, and surgeons and other specialists have included in it:

• bleeding;
• A bacterial infection requiring antibiotics;
• problems with the blood supply to the neophallus, which can lead to partial or complete necrosis of the graft;
• pelvic pain;
• damage to the bladder or rectum;
• the formation of painful subcutaneous granulomas;
• venous thrombosis;
• loss of sensation when urinating (with the need for a permanent urethral catheter);
• recurrent urinary tract infections;
• formation of urethral fistulas (fistulas) requiring urethrostomy;
• urine leakage after catheter removal and stress urinary incontinence;
• Impaired urination due to urethral stricture of the new penile urethra;
• Lack of sensation of the transplanted penis and erection;
• large scars where the skin flap was taken from.

Care after the procedure

Care after the procedure requires hygiene and maximum limitation of physical activity.

For the first 24 hours after surgery, patients do not receive food, then a fiber-free diet is prescribed (for a couple of weeks) to avoid overloading the intestines. Postoperative pain is controlled with analgesics, compression stockings are used to prevent thrombosis in the leg veins, and acetylsalicylic acid (Aspirin) is prescribed to prevent groin vein thrombosis.

During the first three days, the body temperature is constantly monitored, as well as the level of blood flow and the state of blood vessels supplying the penis (vascular Dopplerography). The condition of the donor skin area is checked, and the dressing is changed if necessary.

After five days, you can walk around a little, wearing supportive underwear. For the first time after the operation, urination takes place through the suprapubic catheter and the area around it should be cleaned with a sponge for the first week after leaving the hospital. Showering is only allowed after two weeks: both the penis and the donor site on the forearm, thigh, etc. Need to be kept dry, so they should be covered from water. Taking a bath or swimming in a pool is prohibited. [4]

When corporoplasty corrects the shape of the penis, surgeons recommend applying Bacitracin, Baneocin or Argosulfan ointment (twice a day) to the incisions and sutures.

The penis should be kept in an elevated position (including lying in bed) and avoid pressure on it, so you should not bend the body in the waist at an angle of more than 90°. Lifting heavy weights is also contraindicated.

And only the doctor, after examination and consultation, can allow the operated patient to try to have sexual intercourse - always with the use of a condom. When can this happen? The recovery period - rehabilitation after the procedure, especially when sex reassignment phalloplasty has been performed - can last about two years.

Analyzing the feedback from their patients regarding the actual results of phalloplasty - functional and aesthetic - and problems arising from its complications, experts remind that urogenital plastic surgery has not yet managed to restore physiology of sexual function, despite the continuous improvement of techniques of this surgical intervention and accumulated clinical experience.