The basic procedures have similarities (except in extreme cases of micro/macropenis), although surgery on cisgendered men can be simpler, since the urethra still ends in the front of the genital area, whereas the urethras of transmen end near the vaginal opening and have to be lengthened considerably. The lengthening of the urethra is a difficult part of total phalloplasty, and also the one where complications often occur.
An erectile prosthesis can be inserted into the neophallus to replace the erectile tissue and enable sexual penetration. A separate surgery is done for this to enable healing. Several types of erectile prostheses are there ranging from malleable rod-like medical devices so the neo-penis can either stand up or hang down, to elaborate pumping systems. In order for this to be a safe option, Penile implants require a neophallus of appropriate length and volume. The long term success rates of implants in a reconstructed penis have been poor. Good sensation of the reconstruction can help reduce the risk for the implant eventually eroding through the skin. It is for this reason that living bone was first used inside the reconstruction. Long-term follow-up studies from Germany and Turkey of more than 10 years now prove that these reconstructions maintain their stiffness without late complications.
There are three different techniques for phalloplasty using graft from the arm, leg, abdomen or musculocutaneous latissimus dorsi.
This technique involves using a free graft of tissue that is removed from its original place, rolled up, with a part of it forming the new urethra and grafted to its new place between the thighs. In the past, the donor site was usually the inner side of the forearm but sometimes the upper arm, leg or abdomen can be used. The arm flap operation is easier to perform but requires an implant and has a cosmetically undesirable scar on the exposed area of the arm. The lower leg operation takes along with the skin a piece of the small bone of the leg. Like the appendix, humans can live fine without it. The scar in the leg is easily covered with a sock and hidden from view. These are the two operations which are used most commonly today in the world. They have normal skin on them and can have good cosmetic results. Skin grafted muscle flaps have fallen from popularity. The grafts have a less natural appearance and are less likely to maintain an implant long term.
The four total phalloplasty method of penile reconstruction takes a period of 9-18 months
It is able to achieve the 12 major aesthetic and functional goals of modern penile reconstruction— a penis that:
- is large, with substantial volume
- enables safe insertion of a prosthesis
- is hairless
- has satisfactory aesthetic appearance
- has normally colored skin
- has both penile tactile and erogenous sensation
- has a competent neo-urethra with a meatus at the top of the glans
- can have sexual intercourse
- leaves no conspicuous, disfiguring scars at the donor site
- has very low occurrence of disease or other complication
- achieves patient satisfaction
- improves quality of life
Sensation is retained through the clitoris which is at the base of the neo-phallus. Often a large nerve in the graft is connected to nerves either from the clitoris or other nearby nerves. In addition, nerves from the graft and the tissue it has been attached to usually connect after a while, thereby allowing additional sensation.
The forearm and leg flaps are the most common surgical techniques for total phalloplasty today. They remain the state of the day for both function and aesthetics. Muscle Flap procedures need long term publications of their function and aesthetics before making extreme claims of their popularity and superiority.