FtM reassignment surgery

LPhalloplasty is surgery to create a penis as part of the gender reassignment of a woman to the male gender. Although it is considered to be a "cosmetic" surgery, it has nothing to do with aesthetics but with the functionality of the male body. This classification suits well the health care of the state and the surgeons who can therefore ask for the amount they want as remuneration.

The first penile reconstruction was performed in 1936 by a Russian surgeon. The first phalloplasty was performed ten years later by an English surgeon from New Zealand. His technique remained in use for several decades.

Penile reconstruction is performed on men with either penile abnormalities such as micropenis or epispadias or hypospadias or who have lost their penis.

Phalloplasty is performed on transgender men as part of an operation of gender resignation from woman to man.

The different techniques and procedures

There are four different techniques for performing a phalloplasty but they all involve taking a tissue graft from the person's body and stretching the urethra.

Penile reconstruction is simpler than gender reassignment phalloplasty because the urethra requires less lengthening. A trans man's urethra stops near the vaginal opening and therefore needs to be lengthened considerably.

For the trans man, at the same time as the phalloplasty, a scrotoplasty can be performed using the labia majora to build the scrotum where the testicular prostheses can be inserted.

During this same operation, a vaginectomy, a hysterectomy and an oophorectomy can be carried out if they have not been done previously.

Phalloplasty requires the implantation of an erectile prosthesis so that the person can obtain an erection of the penis. This implantation is generally carried out after this operation to allow perfect healing after the phalloplasty.

There are several types of malleable erectile prostheses that allow the neo-penis to rise and stop.

These penile implants require a phallus of appropriate length and volume to be fully functional.

Another technique called "metaidoplasty" which consists of using the clitoris, which has been lengthened and enlarged thanks to hormonal treatment, to make the neo-penis. This technique is not sufficient if the person wishes to have intercourse with penetration.

These two techniques are therefore not comparable and do not have the same purpose either.

Other prior techniques used a bone graft. This caused a continuous rigid hold of the penis. Although this situation did not cause postoperative complications, it has the disadvantage of not allowing the penis to become soft without having to break the bone graft.

Lengthening of the penis can also be achieved by releasing the suspensory ligament from its attachment to the pubic bone. This allows the penis to be advanced outward from the body. But this elongation is still insufficient to allow the person to have intercourse with penetration.

Since 2009, research has been underway to synthesize corpora cavernosa (erectile tissue) for possible use in patients requiring penile reconstruction. Tests have been carried out on animals but so far the results have only been satisfactory in 66% of the cases analysed.

Possible complications

As the techniques of this operation have improved significantly over the past decades, the complications and risks associated with this surgery have been significantly reduced. There is, however, revision surgery that can repair improper healing.

A post-operative study carried out shows that approximately 25% of the people concerned presented one or more serious complications relating to the neo-penis. This ranges from loss of the phallus due to disease or lack of blood supply, through venous thrombosis, arterial ischemia, necrosis and hematoma.

In this same study, 55% of people presented risks of complications related to the urethra. The most common concerns reported are: urinary filter (hole) requiring perineal urethrostomy, urinary filcide (hole) with conservative treatment, urinary retention (from stenosis or narrowing of the new urethra).

Other concerns relating to the erectile specificity of the penis were noted: change of prosthesis following complications and also elimination of the prosthesis without replacement for health reasons.

In the future, bioengineering could be used to create fully functional penises.