Phalloplasty is the creation of a penis via skin graft.
Background
The origins of phalloplasty date back to the early 20th century. The first known modern attempts at penile reconstruction were performed in the 1930s by the Russian surgeon Nikolaj Bogoraz, who used a rib cartilage graft covered with a skin flap from the abdomen to create a neophallus. This pioneering work laid the foundation for subsequent developments in reconstructive genital surgery.
In the 1940s and 1950s, further advancements came from surgeons such as Harold Gillies and R. J. Harrison in the United Kingdom, who refined flap-based techniques for reconstructing the penis in men injured during World War II. Their work introduced the use of tubed pedicle flaps, a method that improved both vascular supply and tissue survival. By the 1970s, microsurgical advances allowed the use of free flap transfers, marking a major milestone in phalloplasty.
The 1980s and 1990s saw the introduction of the radial forearm free flap (RFF) technique, which became the gold standard for many years. Developed by Chang and Hwang in 1984, this method used skin, fat, nerves, and blood vessels from the forearm to construct a sensate and aesthetically proportionate penis. Subsequent innovations focused on improving sensation, urethral construction, and erectile function through the integration of nerve coaptation and prosthetic implants.
In the 21st century, new donor sites and refinements in microsurgery have expanded the options for phalloplasty. Modern surgeons aim to achieve a balance between functionality (urination while standing, sexual sensation, and penetrative ability) and reduced donor site morbidity.
Types of Procedures
There are several main types of phalloplasty procedures, each using different donor tissue and surgical techniques:
- Radial Forearm Free Flap (RFF) Phalloplasty
The RFF technique remains one of the most widely performed methods. It uses skin and soft tissue from the forearm to create the shaft and, when desired, the urethra. It offers good tactile and erogenous sensation potential due to the possibility of connecting donor nerves to local genital nerves. - Anterolateral Thigh (ALT) Phalloplasty
The ALT flap uses tissue from the thigh and avoids the visible scarring of the forearm. It can provide sufficient bulk for a natural appearance, though achieving full sensation may be more challenging. This option is preferred for patients seeking less conspicuous donor sites. - Abdominal (Suprapubic) Phalloplasty
This older method constructs the neophallus using abdominal skin. It is less technically demanding and does not require microsurgery but offers limited sensation and aesthetic refinement. - Musculocutaneous Flap Phalloplasty
Variants such as the latissimus dorsi flap use muscle and skin from the back to form the penis. These techniques can create a larger neophallus but typically require a prosthetic device for rigidity. - Composite and Hybrid Approaches
Contemporary surgeons may combine elements of multiple flaps or integrate nerve grafting and urethral lengthening techniques to enhance outcomes.
Current research in phalloplasty emphasizes improved nerve regeneration, reduction of complications such as urethral strictures, and the development of bioengineered tissue. Advances in surgical robotics and regenerative medicine hold promise for future refinements. Phalloplasty today represents a complex blend of reconstructive and aesthetic surgery, reflecting decades of innovation in microsurgery and gender-affirming care.
Resources
Healthline (healthline.com)
UCSF Transgender Care (transcare.ucsf.edu)
Phalloplasty (phallo.net)