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Page 2 of 15 Carter et al. Plast Aesthet Res 2020;7:33 I http://dx.doi.org/10.20517/2347-9264.2020.81

Figure 1. Excellent aesthetic results following phalloplasty and placement of erectile and testicular prostheses

[1-5]
relieve gender dysphoria and decrease suicidality . Masculinizing gGAS usually involves some combination
of removing natal female genital structures and creating functional natal male-type genitourinary structures.
Phalloplasty (with or without simultaneous vaginectomy, urethral lengthening and scrotoplasty) is one such
procedure that seeks to create an aesthetic and functional neophallus.

Phalloplasty uses existing analogous structures that share a common embryologic origin, as well as carefully
harvested fasciocutaneous allograft(s), to create a neophallus. The goals are to create an aesthetic neophallus
that has both tactile and erogenous sensation that can be directed for standing micturition, and has sufficient
[6-9]
girth to accommodate penile prosthesis . Erection and penetrative intercourse may be achieved, usually
following penile prosthetic placement .
[6,7]
Phalloplasty is an exceptionally complex reconstructive surgery. For instance, a single-stage phalloplasty
(including vaginectomy, urethral lengthening and scrotoplasty) represents 200 relative value units (RVUs)
of surgery (RVUs are a measure of value used in the United States which rank on a common scale the
resources used to provide physician services). As a comparison, a craniotomy for removal of a glioblastoma
multiforme brain tumor is 85 RVUs. Though this ultracomplex surgery may be daunting, excellent aesthetic
and functional results with high patient satisfaction are achievable [Figure 1].

[4]
Surgical techniques used by gGAS surgeons for each component varies widely and are largely nonstandardized .
This article seeks to describe the components of phalloplasty as well as common complications and potential
technical improvements that may be used to lower complications. Some targets for improvement in outcomes
concern neourethral fistula/stricture, efficacy of reinnervation of the phalloplasty flap, postoperative flap
monitoring, and donor site morbidity. Although several improvements in technique have occurred in recent
years, ongoing innovation in surgical technique is necessary to further improve patient outcomes.

THE QUESTION OF STAGING
The components of phalloplasty include the creation of a penile shaft, penile urethroplasty, urethral lengthening
(perineal urethroplasty), scrotoplasty, glansplasty, vaginectomy, hysterectomy, salpingoophorectomy (if
desired), testicular implants, and erectile device implant . The inclusion, staging, and order of these
[6,9]
procedures may be altered to align with each patient’s treatment goals as well as the surgeon’s assessment of
best practices. Each individual component, especially penile shaft creation and penile urethroplasty, have
multiple surgical approaches.

The ideal phalloplasty would be a single-stage and reproducible surgery with minimal complications.
However, because of the range, severity, and prevalence of complications of the surgery, some have elected to