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Page 10 of 15 Hontscharuk et al. Plast Aesthet Res 2020;7:65 I http://dx.doi.org/10.20517/2347-9264.2020.124

Figure 8. The clitoris de-epithelialized during the phalloplasty procedure

[23]
erogenous stimulation during intercourse. In their series, Ascha et al. described outcomes of 64 transgender
men undergoing an ALT flap with coaptation of the lateral femoral cutaneous nerve to the dorsal clitoral
nerve, and 149 transgender men undergoing RFF with coaptation of the dorsal clitoral nerve to branches
of the antebrachial cutaneous nerves. At 6 months follow up, 1 patient (1.6%) in the ALT group and 2
(1.3%) patients in the RFF group had not gained any sensation. Papadopulos et al. reported on the
[42]
outcomes of 32 osteocutaneous fibula flap phalloplasties involving the coaptation of sural nerve branches or
subcutaneous nerve branches to the dorsal clitoral nerves. They report “acceptable” tactile and erogenous
[28]
sensation in all patients at 6 months following the procedure. In one study of 56 RFF phalloplasties ,
nerve coaptations were performed to the ilioinguinal and iliohypogastric nerves. The authors report the
return of only tactile sensation, with minimal erogenous sensation noted.

Many surgeons postulate that preservation of the clitoris allows and preserves erogenous sensibility and
[15]
hence, orgasmic function following phalloplasty . As such, one branch of the dorsal clitoral nerve is typically
left intact to maintain clitoral sensation [10,15] . The denuded or de-epithelialized clitoris is buried at the base
of the neophallus to provide an additional source of erogenous sensation [Figures 8 and 9] [7,8,10,15,28,29,42,70] .
[24]
Monstrey et al. describe burying the de-epithelialized clitoris above the pubic symphysis. With this
technique, it is thought that manipulation of the base of the neophallus during penetrative intercourse or
masturbation allows for the stimulation of the buried clitoris. Other authors describe incorporating the
clitoral hood into the neoscrotum to preserve as much original erogenous sensitivity as possible [29,30] .

Other authors describe placement of the clitoris on the shaft of the neophallus [22,71] or at the junction of the
[72]
[25]
neoscrotum and the inner thigh so as to increase stimulation during penetrative intercourse . Garaffa et al.
report offering two options for clitoral management during phalloplasty procedures. One option was to
leave the clitoris exteriorized so as facilitate manipulation, and the second option entails burying the de-
epithelialized clitoris beneath the skin. Patients may select the first option due to a concern that clitoral