SURGICAL PROCESSES

Who performs my hysterectomy?

A gynecologic surgeon who works with us usually performs the hysterectomy at the time of phalloplasty.   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 oncologist 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.  Most men in the United States are circumcised, most men in Europe and Asia are not.   This is why most American trans men prefer to have a glansplasty. 

Which method of phalloplasty do you perform?

My 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 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 anastemosis of arteries, veins, and nerves.  If the procedure is successful, it can create a neo-phallus which is sensitive because it is 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 anastemosis 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 anastemosis 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 are able to develop better techniques with fewer complications, I do not recommend urethroplasty.   When there is no urethral extension, the patient must continue to sit to urinate.   Many natal/biologic men sit to urinate so that they don't void on the floor, shoes, pants or toilet seat.  When an individual enters a men's room and enters a stall, no one really cares whether you are moving your bowels , urinating, reading the paper or sleeping.  So, many men don't find it a problem to continue to sit to void.

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.  We sometimes do the hysterectomy and mastectomy at the same time. 

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

Scars are permanent.  Incisions heal with scars and the scars remain as permanent marks on the skin to any patient who has surgery at any location on the body.  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.  There are several types of implants but I prefer not to use any type of implant as there is a very high rate of extrusion of the implant (it simply gets pushed out through the end of the penis or can extrude through a pressure ulcer in the side of the penis).  I usually recommend some type of external support to the penis.  This can consist of placing one or two condoms over the penis which can give sufficient rigidity to allow intercourse.    Many of our patients use either Coban or some other self-adhesive wrap once or twice around the penis and then cover this with a condum.  Other patients purchase a penile "extender" or "enhancer" which can be found on the Internet and this can give not only a larger or wider penis, but one that will maintain rigidity when utilized. 

 

RECOVERY

How long does it take me to recover from phalloplasty?

Following one or two days in the hospital you will need to  remain in the Philadelphia area for about 2 weeks after gender reassignment surgery   You can stay in a local hotel or, when available, most patients prefer to stay in one of the studio apartments above our office which rent for $50/night.  You can bring a companion at no additional charge, and Dr. Leis can see you daily.   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 6-8 weeks.

When can I go back to work after metoidioplasty (clitoral release)?

In most cases trans men can return to work 3-4 weeks following surgery.

 

EXPENSES

 
What do the fees cover?
 
The fees as listed on our fee schedule include the surgeon's fee, operating room fee, anesthesia fee, and overnight fee in hospital.  The total fee can range anywhere from approximately $15,000 to $23,000 depending on which options (most described above) are chosen. 

 

What other costs are involved for surgery?

The only other costs a patient incurs will be for transportation to and from Philadelphia and for food and lodging during your recuperation. 

Patients who come from out of town should remain in the Philadelphia area for about 2 weeks after surgery.  Most patients prefer to stay in one of the studio apartments above our office which rent for $50/night (check for availability) and Dr. Leis can see you daily.  You may bring a companion at no additional charge. You can also stay in a local hotel.  Ask us for referrals.