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Carter et al. Plast Aesthet Res 2020;7:33 I http://dx.doi.org/10.20517/2347-9264.2020.81 Page 3 of 15
[10]
divide the procedure into multiple stages . There is no consensus or “gold standard” among gGAS surgeons
regarding the optimal number of stages or sequencing of reconstructive steps. Of note, our high-volume
center generally does not stage phalloplasties except in unusual situations.

Centers like ours that usually perform phalloplasty, vaginectomy, scrotoplasty and urethral lengthening in
[10]
a single stage have shown decreased rates of flap-related complications and increased patient satisfaction .
A major advantage to the single-stage approach is that most patients (up to 60% at our center) will require
no further surgery until the time of penile prosthesis placement. We use a team approach to efficiently use
operating room time such that a single-stage phalloplasty routinely takes about 6 h, and seldom as much as 8 h.
Other centers favor a staged approach, citing the potential for fewer neourethral complications and more
straightforward management of complications, even at the cost of more operations for these patients [4,9,10] .
[4]
However, not all researchers have found that staging phalloplasties will result in fewer complications .
Even if staging ultimately proves to not be effective at decreasing complications, multiple staged procedures
allow for sophisticated surgical planning. For example, hysterectomy may be consolidated into one of the
phalloplasty stages. Regardless of staging choice, it is agreed that any prosthetic placement, including penile
prosthesis and testicular prostheses should be performed in a later stage after complete healing has occurred
and some sensation restored [6,8,11] .

FLAP SELECTION, PREPARATION AND DONOR SITE HEALING
When selecting a donor site for creation of the penile shaft and penile neourethra, it is important to consider
the benefits and drawbacks of each potential site, as well as patient goals. All flaps must have sufficient
innervation and vascularity to allow for microsurgical creation of the neophallus. The radial forearm flaps
(RFF) are the most commonly used and most widely studied option [6,12] , followed by pedicled anterolateral
thigh flaps (ALT) [3,11] . RFF provides a robust, well vascularized and appropriately-sized neophallus in most
cases, at the cost of requiring a microvascular anastomosis that may clot suddenly (< 1% of cases). The RFF
tends to be thinner (particularly important in patients with increased adiposity) and more pliable, and
may be more similar to natal genital tissue [3,11] . The major downside of the RFF is removal of skin from an
[13]
exposed and functionally important location on the body . Some patients may have concerns about the
visibility and potential recognizability of the resultant scar, and thus may want to avoid using a RFF flap [1,5,6] .

The ALT has the noted benefit of not usually requiring a microvascular anastomosis, and may have less risk
of significant vascular occlusion emergencies as a result. However, the microcirculation of ALT flaps is less
robust than RFF flaps, and a moderately higher chance of partial flap loss is well described with ALT flap
use [9,12] . It is said that in some cases, the inherent rigidity of the ALT flap may allow for sufficient rigidity for
penetrative intercourse without the need for an additional prosthetic device, although most of our patients
[3,6]
still require the addition of a penile prosthesis for penetrative intercourse . The resultant scarring at the
donor site may be less distressing and easier to hide for ALT flaps.

Less common flap donor sites include abdominal flaps, modified latissimus dorsi flaps (MLD), tibial free
[3]
flaps, and superficial circumflex artery perforator flaps . Of these, only the MLD is frequently chosen today.

Preoperative hair removal
The consensus is that donor flaps should be hairless, either innately or following removal methods such
as laser hair removal or electrolysis. However, the efficacy and long-term permanence of these methods
is poorly studied. While preoperative hair removal likely decreases the number and thickness of hairs, it
is unlikely that the results of even the most thorough hair removal protocol are ever truly permanent [3,14] .
Many phalloplasty patients have some hair regrowth in the neourethra [9,14,15] . Most patients are unaffected by
urethral hair, but complications including infection, calculi, and trichobezoars/hairballs can occur, although
uncommon [15,16] . Urinary obstruction from neourethral hair [Figure 2] can happen despite thorough