Phalloplasty

Phalloplasty is a gender-affirming, masculinizing, lower body surgery that creates a penis and scrotal sac (phase 1), then testicular implants in the scrotum and implants for erection (phases 2 and 3).
he penis is created using tissues from your genitals and forearm. The scrotum can be created from the external genitals (labia or outer labia). Testicular implants can be inserted in the scrotum in a separate surgery months later. An implant to get erections can also be inserted at this time. The goal is to create a penis that preserves sexual sensation that can get erections with the assistance of an implant (if desired) and with enough length and bulk to be used for penetrative sexual intercourse, and to enable the ability to pee while standing.
Referral & consult

Referral & consultation process

1

Complete surgical readiness assessment

To get started, you will need to complete two surgical readiness assessments by qualified assessors, and and meet the eligibility and criteria required for this surgery. After you have completed your assessment, your primary care provider will direct your referral to the surgeon of choice. Additional assessments may be requested at the discretion of the surgeon.

2Review referral options

Your primary care provider will direct your referral to the surgeon office at GRS Clinic in Montreal. Visit the surgery referral page for steps required in the referral options for phalloplasty. 

3Speak to your surgeon

You may want to speak to your surgeon about:

  • The gender-affirming surgery goal you have after surgery, specifically, sexual penetration
  • The hair removal requirement prior to surgery - at GRS Montreal, you are advised to get electrolysis (hair removal) on your forearm at least 12 months before phalloplasty. Check with your surgeon and follow their advice.
  • The list of medications you should avoid around the time of your surgery
  • The different surgical techniques available
  • The advantages and disadvantages of each technique
  • What your options are if you are not satisfied with the appearance of your surgical results
  • What your options are if you are having difficulty with sexual function
  • Whether they have before-and-after photographs of their own patients, including those of both successful and unsuccessful outcomes
  • The risks and possible complications of the various techniques
  • The surgeon's own complication rates for each procedure
Surgery

The procedure

Surgical techniques vary from surgeon to surgeon.

  1. Skin, nerves, veins and arteries from your forearm or another site such as the thigh are removed. This is called a graft.
  2. A small part of the graft is used to extend your urethra.
  3. A larger part of the graft is wrapped around the urethra to create the penis shaft and glans, the head of the penis.
  4. The labia are repositioned and reshaped to make a scrotum.
  5. The vagina may be removed or closed (if desired).
  6. If the forearm is the site used, skin from the thigh is used to cover the graft site.
  7. A second stage to reposition the urethra through the penis is sometimes done 6 months after the creation of the penis.
  8. Testicular implants and an erectile device may be put in at a later stage (if desired).

Preparing for surgery

Be sure to review the pre-operative surgical package provided by surgeon's office before surgery. For more information about preparing for this surgery and about your post-operative care, contact the GRS clinic directly, or your appointed surgeon office directly.

While you wait for your referral to be processed, you should keep your personal information updated with all of your health care providers, including any change of name or contact information. This will ensure your health care professionals can reach you to schedule consultation and surgery appointments.

You may also want to visit the Preparing Surgery page to help you create a plan for success after surgery.

Hair removal
For this  surgical technique, hair must be removed from the donor site before surgery. The surgeon will usually provide templates that illustrate the area of the donor sites that need to have hair removed. Before proceeding with surgery, the surgeon will confirm that the hair from the donor site has been sufficiently removed.

Complications can arise if hair growth is found within the neourethra (the surgically created urethra). Removing hair after surgery can be painful and is extremely difficult. For more information on hair removal, please visit the Hair Removal page.


Complications

All surgical procedures involve some risks. Risks include negative reactions to anesthesia, blood loss, blood clots and infection. These complications can, in extreme cases, result in death. It's important to discuss these risks in detail with your surgeon. Your surgical care team will take a wide variety of steps to prevent these problems, detect them if they arise and respond to them appropriately. They will also inform you about what you can do to minimize your risks.

Some complications are particularly associated with phalloplasty. Below are a list of some possible complications of this surgery. Please note - this list is not comprehensive and you should have a detailed discussion of risks with your surgeon.

An abscess is a collection of pus caused by a bacterial infection. It can be treated with antibiotics or drained by the surgeon.

There is risk of decreased sensation or inability to achieve orgasm after surgery. 

Some people may be dissatisfied with the size or shape of the erectile tissue (penis). You can check with your surgeon to see if surgical revision is possible.

Complications associated with penile implants include poor positioning, technical failure and infection. The implant can be either be repaired or surgically removed and replaced. Complications associated with testicular implants include poor positioning and infection.

Complications associated with penile implants include poor positioning, technical failure and infection. The implant can be either be repaired or surgically removed and replaced. Complications associated with testicular implants include poor positioning and infection.

Usually resolves in a few weeks. Permanent changes to sensation or function are very rare but possible. Some people require prolonged physiotherapy to recover

You can take steps to prevent severe scarring by following your surgeon's advice about avoiding sun and doing massage exercises. Severe scarring may require surgical revision.

When clear fluid accumulates in the surgical site. Small seromas may need to be aspirated, or sucked out, once or more by the surgeon. Big seromas may need to be removed through surgery.

Related to the transfer of skin from your forearm to your groin. There is a small risk of a partial or complete loss of the penis if the transfer is unsuccessful.

Very common, though they often resolve with time. Examples include fistulas (flow of urine to areas other than urethra opening), stenosis (narrowing of the urethra, causing difficulty urinating), strictures (scarring inside the urethra, causing difficulty urinating) and hair growth inside the urethra. If these problems don't resolve on their own, they may require additional surgery.



After surgery

Post-operative care

The length of your hospital stay depends on where your surgery takes place but is typically 5 to 7 days. You will stay in a post-operative recovery centre for 2 to 4 weeks depending on your surgeon.

You will likely receive painkillers and antibiotics to prevent infection as well as muscle relaxants, anti-spasm and -nausea medications and stool softeners. Your surgeon will provide you with a list of medications to avoid around the time of your surgery.

The forearm that was used as a donor site for a skin graft will be wrapped under air- and water-tight dressings for 5 days. The part of your thigh that was used for a skin graft will be dressed with a sheet of gauze. The gauze will be gradually trimmed away as it lifts up from its edges over the following 1 to 2 weeks. Graft sites will be covered with dressings.

During the healing process, you should expect:

  • Some bleeding during the first 48 hours
  • Swelling of the penis, scrotum, pubic region and other surgical sites for the first month (this can take 4 months to completely disappear)
  • Bruising that can extend from your navel to your thighs (this takes 3 to 4 weeks to settle down)
  • Itching and occasional small, shooting electrical sensations as your nerve endings heal
  • Difficulty urinating while standing for the first few weeks
  • Numbness in the penis and scrotum (this will resolve in the first 18 months)
  • Stiffness in the elbow, wrist and hand of the arm where the skin graft was taken
  • Pink or red scars on your forearm, thigh and penis, which will pale over time (this takes 12 to 18 months to heal; the scar on your forearm will be permanent)


Check-ups

The number of check-ups needed varies from person to person and between surgeons. If possible, see your primary care provider about a week after you return home and then every 2 to 4 weeks for the first few months.

When you visit your surgeon or primary care provider, they should check your surgical sites to make sure there are no infections or wound healing problems. They will ask questions about pain, bleeding, urination, bowel movements, fever and how you are feeling physically and emotionally.

Recovery time

Recovery time varies from person to person, so always follow the advice of your surgeon. You'll be able to return to many of your normal activities within 6 to 8 weeks but may vary from person to person and may be longer if complications arise. Some activities, such as driving, heavy lifting, exercise, sex, and soaking in hot tubs, may be restricted in the post-operative period. Your surgeon will give you advice about when it is okay to resume these activities. Complete recovery can take up to one year. Recovery time also may vary after each stage of surgery.

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