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Everything You Need to Know About Phalloplasty

Medically reviewed by Jennifer Richman on February 16, 2024.

What is a phalloplasty?

Phalloplasty is a gender affirming genital surgery which creates a penis using the existing genital tissue and tissue from another part of the body–often the forearm, thigh, groin, back, or abdomen. Some types of phalloplasty operations can use the nerve from another part of the body to allow for the possibility of heighted, erotic sensation in the new penis. Dr. Ley (she/her) is our board-certified gender affirming surgeon who performs phalloplasties for patients regardless of gender identity. Here we present information about the different phalloplasty options we offer, their results and why patients opt for them. Some of the topics we cover are phalloplasty scarring, urinating while standing, sensation, orgasms, penis size, penetrative sex (erections) and additional accompanying procedures that patients often solicit. Elsewhere on our website we have more information on how to prepare for and recover from a phalloplasty.

What kinds of phalloplasty operations does the GCC offer?

At the GCC, there are three donor zones we use to make a phallus for a patient:

• The groin tissue is used in a groin flap phalloplasty
• The sensitive inner forearm tissue is used in a radial forearm flap (RFF) phalloplasty 
• The sensitive outer thigh tissue is used in an anterolateral thigh flap (ATF) phalloplasty

During the initial phase, Dr. Ley and her team will construct the new penis. In a second phase, 4-6 months after the new penis has healed, our team can conduct a urethral lengthening (so you can urinate while standing) and a removal of the natal genital tissue: the uterus, ovaries, vaginal canal, vulva and/or a clitoral burying. Patients are also given the option of preserving their vaginal canal and/or natal penis, which means we could leave the clitoral tissue in-tact at the base of the new penis. If a patient wishes to undergo a urethral lengthening to be able to pee from the tip of their penis, they cannot preserve their vaginal canal due to the high risk of urethral complications.

In the third phase, we can add glands to the head of the penis, insert an erectile device, construct a scrotum and/or insert testicular implants. You can read more about these additional procedures, their timeline and recovery processes here.

What are the common deciding factors between the three phalloplasty types?

Patients who chose a groin flap phalloplasty often do so because:

• They are fine with their new penis having a normal level of tactile sensation as opposed to heightened, erotic sensation (exceptions are described below)
• They have a preference for the operation not leaving any sizable, visible scars (e.g., on the thigh or forearm)
• They do not want their new penis to be too large
• They do not mind undergoing three initial surgeries over the course of 3-4 months to construct the new penis

Patients who chose a forearm (FFF) or thigh (ATF) phalloplasty often do so because:

• They are fine with having visible scar tissue (on their inner forearm or outer thigh) from a large skin graft
• Having a heightened, erogenous sensation in the penis is a high priority
• Having a large penis size is important
• They prefer to only undergo one surgery, as opposed to three, to construct the new penis. That said, to complete urethral lengthening, add glands to the penis, create a scrotum and/or conduct liposuction around the genitals to make them more visible, later surgeries will still be required.

What are the expected results of a phalloplasty?

How visible are scars from the procedure?

Patients who get a groin flap phalloplasty will have the most easily concealable scars. On the other hand, patients who get a forearm (RFF) or thigh (ALT) phalloplasty will have a large rectangular swath of scar tissue visible on either their inner forearm or outer thigh. This swath of scar tissue will be depressed and discolored compared to the surrounding skin. It can be concealed with shorts or a long-sleeved shirt. Patients can have the area repigmented by an experienced medical tattoo artist a year after it has been healed.

Can a patient urinate from their penis (urinate standing up) with a phalloplasty?

During the initial construction of the phalloplasty, a urethra can be built inside of the penis to allow for a patient to eventually urinate while standing up. However, to let the phalloplasty heal, the natal urethra and the urethra in the penis are not connected until 4-6 months afterwards. This means a patient will not be able to urinate out of the tip of their penis until then. Catheters and tubing will be used during the initial recovery process of each of these procedures.

What determines phalloplasty size?

The size and girth of a patient’s phalloplasty result from the unique plan you make with your surgeon during a free, virtual consultation. Generally speaking, the size of the patient’s body (specifically the skin flap donor site) can limit how large and thick the penis will be. Patients who get a forearm (RFF) or thigh (ALT) phalloplasty tend to have more tissue to work with to maximize size.

When can a patient see the final size of their penis?

About six months after the penis is constructed through a phalloplasty, swelling will go down enough so that a patient should be able to see its final size.

What is the sensation like after a phalloplasty?

Nerve regeneration can start as early as three weeks after surgery, but is different for every patient. As nerves regenerate, patients may experience tingling sensations in the site until they heal after a few months. Some patients experience no nerve regeneration at all.

Whether sensation is tactile or erotic (heightened), it will generally be felt equally along the entire penis. The groin flap phalloplasty has regular tactile sensation as opposed to erotic sensation. That said, if a patient opts for a urethral lengthening using a small skin graft from the forearm, erotic sensation can be established. The radial forearm flap (RFF) and anterolateral thigh flap (ATF) phalloplasty can give patients a heightened, erotic sensation in their penis since the nerves used in the donor site (the inner forearm or the outer thigh) have heightened sensation. 

Some patients who undergo a clitoral burying can still stimulate the skin above where it has been buried to experience erotic sensation. Patients who preserve their clitoris or natal penis tissue will still be able to stimulate it.

Is orgasm possible after phalloplasty?

Especially if your phalloplasty involves preserving erotic sensation, orgasms are possible through stimulating the penis. Patients are recommended to wait 3-4 months before masturbating or engaging in other kinds of sexual activity with the new penis. With a completed urethral lengthening, some patients report being able to ejaculate clear fluid when they orgasm.

How soon can a patient have penetrative sex after a phalloplasty? Can a patient experience erections with a phalloplasty?

3-4 months after the phalloplasty is constructed, a patient can begin engaging in sexual activity, alone or with partners, with their new penis. For a groin flap phalloplasty, this is about 6 months after the first surgery. For the forearm (RFF) and thigh (ALT) phalloplasties, that is about 3 months after the first surgery. 

To have penetrative sex with a phalloplasty, a patient can use the assistance of a silicone erectile sleeve and/or a penis pump after this healing window is completed. 12 months after the phalloplasty is constructed, a patient can have an erectile device inserted: a malleable rod or a saline pump system. You can read more about these options here.

Will an erectile device increase the size of a phalloplasty?

Erectile devices––whether a saline pump or malleable rod––can be inserted into the penis 12 months after the phalloplasty operation(s) is/are concluded. Erectile devices increase the girth, but not the length of the penis created from a phalloplasty.

What can a phalloplasty operation involve?

The groin flap phalloplasty:

• Groin flap phalloplasty uses groin tissue to create the new penis. Using groin tissue allows the scars from this surgery to be more easily concealed, and allows a penis of adequate length and girth for most patients.
• The groin flap does not have erogenous sensation; most patients experience normal levels of tactile sensation in their new penis.
• If a patient wishes to urinate standing up, our surgeon can perform a urethral lengthening using a forearm or hip skin flap.
  • An advantage of a radial forearm flap is that nerve innervation microsurgery can be performed. This allows for the possibility of erogenous sensation to be felt in the new penis, as a sensory nerve is also taken from the forearm and connected to a clitoral nerve. Second, the skin graft that is taken from the forearm is relatively small (typically 2 inches by 7 inches) and can later be covered up by a full-thickness skin graft. This means that this small forearm scar would heal significantly better than the large scar of a radial forearm flap (RFF) phalloplasty.
  • A hip skin flap would be easily concealed since it is usually covered by clothing. That said, it does not allow for the possibility of heightened, erotic sensation to be felt in the penis. This procedure is called the superficial circumflex iliac artery perforator (SCIAP) flap.

• A groin flap phalloplasty procedure requires three initial surgeries over the course of 3-4 months to create the new penis.
  • The first stage involves the creation of the new penis in the form of a “bucket” handle, for about three weeks. Through the next two stages, the penis is slowly detached and left hanging. The bucket handle stage allows the penis to strengthen its blood flow to be dependent on the blood supply which goes through its base.
  • During the third and final stage, the bucket handle flap is fully released, allowing the penis to detach from the groin and remain connected only at its base. Additionally, the tip of the penis is rounded.
  • If a patient would like to urinate out of the tip of their penis, a urethral lengthening will be conducted during the third and final stage.

The radial forearm flap (RFF) phalloplasty and the anterolateral thigh flap (ATF) phalloplasty:

• The RFF phalloplasty takes a large skin graft from the sensitive inner forearm region to construct a phallus. The ATF phalloplasty takes a large skin graft from the sensitive outer thigh region to construct a phallus.
• Nerve innervation microsurgery allows the patient to experience erogenous sensation in their penis by hooking up one of the clitoral nerves to the sensory nerve of the forearm or thigh.
• A very noticeable scar is left on the inner forearm or outer thigh from the skin graft. Due to its size, a full thickness skin graft cannot be performed to cover up the area after. 
• The illustrations below demonstrate what steps are involved in a RFF phalloplasty, which is similar to the ATL. Specifically, we show how a penis is constructed, a urethra is lengthened and nerves are “hooked up” to allow for erotic sensation.

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Additional procedures patients get alongside, before or after a phalloplasty

• Vaginal and/or vulva preservation: Several patients request that the vaginal canal and/or parts of the vulva be kept in-tact with the creation of a penis. Vaginal preservations are only possible when the original urethra is kept intact; this means a patient could only urinate while sitting down or with the use of an assistive device, as opposed to being able to pee out of the tip of their penis. Likewise, the clitoris/natal penis and labia can be kept intact so long as the patient does not wish to bury them and/or have them used to create a scrotoplasty.
• Urethral lengthening: If a patient wishes to get a urethral lengthening to pee out of the tip of their penis, they must have a vaginectomy performed before or at the same time as this procedure. This is done to reduce the chance of urinary complications. Patients who wish to have a vaginal preserving phalloplasty are advised not to undergo a urethral lengthening.
• Elimination and/or burying of natal genital tissue: 4-6 months after the penis is constructed, a patient can have their clitoris buried or have any of the following natal genital tissues removed: the uterus (hysterectomy), the vaginal canal (vaginectomy) and/or one or both ovaries (oophorectomy).
• Scrotum and/or testicles: If a patient would like a scrotum, a scrotoplasty can be done 4-6 months after the construction of the penis. If a patient would like the appearance of testicles, after three months of healing, scrotal tissue expanders can be inserted. Three months after that, silicone testicular implants can be inserted.
• Erectile device: A year after the penis is constructed through a phalloplasty, an erectile device can be inserted to facilitate its use for penetrative sex. The insertion of the device would increase the girth of the penis. Even without an erectile device being surgically inserted, patients can still have penetrative sex with their phalloplasty results using a silicone erectile sleeve or other assistive device.
• You can read more about these additional procedures and their recovery protocols here.