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Lane et al. Plast Aesthet Res 2020;7:51 I http://dx.doi.org/10.20517/2347-9264.2020.106 Page 11 of 15

Table 2. Phalloplasty: common staging strategies for construction of pars fixa and pendulans urethra
Staging Procedural sequence
Single stage reconstruction [28] Phallus and pars pendulans created from a single, “tube-in-a-tube” flap (usually RFFF),
simultaneous vaginectomy and pars fixa construction (specific methods vary), simultaneous
scrotal construction
Two stages: pars pendulans first [73] Stage one: phallic flap with pars pendulans created via “tube-in-a-tube” strategy; no disturbance
of female urethra or labia (i.e., a discontinuous urethra without pars fixa is created)
Stage two: pars fixa construction (multiple specific techniques), anastomosis to previously
created pars pendulans, simultaneous scrotal construction
Two stages: pars fixa first [73] Stage one: pars fixa construction, often combined with vaginectomy, sometimes as a formal
metoidioplasty
Stage two: phallic flap with pars pendulans created via “tube-in-a-tube” strategy; anastomosis
to previously created pars fixa urethra, simultaneous scrotal construction
Three stages: pars pendulans first, but Stage one: phallic construction without pars pendulans (often ALT flap), no disturbance of
requiring two stages [73] female urethra or labia
Stage two: incise ventral surface of the phallus, skin graft to the ventral portion of the phallus
Stage three: tubularization of the grafted, ventral surface of the phallus to create pars pendulans,
simultaneous pars fixa construction (specific methods vary), anastomosis of pars fixa and
pendulans, simultaneous scrotal construction
Like all aspects of phalloplasty, there are countless variations in the construction and staging of the pars pendula and pars fixa. The
most common permutations are presented. RFFF: radial forearm free flap; ALT: anterolateral thigh

Mitek anchors and/or encasing the prosthesis within a sleeve of acellularized dermal matrix, or other
[77]
[76]
biocompatible material .
SUMMARY AND CONCLUSION
The wide variation in both overall strategies and in surgical specifics between surgeons and centers
underscore the complexity and difficulty of masculinizing GCS. The multiple options discussed above,
along with the paucity of multicenter, prospective data to guide surgical practice, has created phalloplasty
chaos, which is confusing to both surgeons and patients. When guiding a patient desiring masculinizing
GCS, it is paramount that surgeons are knowledgeable of all available options and the associated
advantages, disadvantages, and risks. Because constructing an algorithm encompassing the multiple
variations in virtually every aspect of phalloplasty discussed above would include a dozen or more specific
decision points and many dozens of specific surgical pathways, each center performing masculinizing GCS
should ideally employ a consistent, local algorithm tailored to the available expertise of the participating
surgeons while also allowing for appropriate patient preference. All algorithms for masculinizing GCS,
however, should determine first if the patient desires standing urination and if their own profile of
comorbidities would make this possible. If a patient does not desire standing urination, a shaft only-
phalloplasty is a reasonable option. If a patient does desire standing urination, institutional preferences
for staging and surgical specifics come into play and should be explained to the patient to provide for
appropriately informed consent. The most commonly employed combinations of the multiple options are
presented in Table 2.

All that said, from our interpretation of available, data we draw the following conclusions and make the
following recommendations:
(1) Data strongly support the maintenance of an innervated clitoris to preserve erogenous and orgasmic
potential. We strongly advise against the division of both clitoral nerves to neurotize the neophallus.
(2) From available data and from the advantages and disadvantages of each choice discussed above, the
RFFF should be considered the best current flap for phallic construction. There should be compelling
reasons to use other flaps in individual patients.
(3) The most frequent and most difficult complications from masculinizing GCS arise from reconstruction
of the pars fixa and pars pendulans urethra. We strongly advocate close collaboration between a
reconstructive microsurgeon and a reconstructive urologist to achieve the best patient outcomes.