Penis construction

Having a clear understanding of the penis construction options available will help you make an informed choice.

Surgical options to create a penis

A penis and scrotum (if desired) can be created through three different procedures, each with its own benefits, complications and risks. They are (in order of increasing complexity): erectile tissue release, metoidioplasty and phalloplasty.

Erectile tissue release

Erectile tissue release is also called “clitoral release” or “simple meta.”

Before surgery, people take testosterone to enlarge their erectile tissue (clitoris). Some people wait 2–3 years to achieve maximum growth before proceeding with surgery.

After this period of growth, erectile tissue release creates a penis that has a length of 2–4 cm but no additional girth. Erectile tissue release preserves sexual sensation and allows you to get erections without the assistance of an implant. However, you will not be able to pee while standing.

While some people may be able to have penetrative sex with an erectile tissue release penis, this is not an expected outcome of this surgery.

After surgery, some people seek to increase the size of their penis using techniques like a pump or topical testosterone directly on their penis. There is no evidence that these techniques are effective, and some could potentially be harmful, so we recommend that you speak with your surgical team before trying something new.

Procedure

Surgical techniques vary from surgeon to surgeon, but in general erectile tissue release includes the following steps.

The ligaments holding the erectile tissue (clitoris) in place under the pubic bone are cut, allowing the shaft to fall away from the body, giving it a more pronounced appearance.
Fat may be removed from the pubis and skin may be pulled upward to bring your erectile tissue forward (also called a monsplasty) to improve the visibility of the shaft.

Optional additional procedures

Additional procedures you can have in conjunction with an erectile tissue release include: construction of a scrotum (scrotoplasty) and removal of the vagina (vaginectomy). Testicular implants can be added at a later stage, if desired.

Scrotum construction (scrotoplasty) The external genitals (labia or outer labia) may be shaped into a scrotum. Creating a scrotum also allows for testicular implants to be placed inside the scrotum at a later stage, usually a minimum of six months after the initial surgery.

Vagina removal (vaginectomy) This procedure involves the removal of vaginal tissue and closure of the genital opening (vaginal canal). In order to have a vaginectomy as part of your procedure, you need to have youruterus at least six months before your penis construction surgery.

metoidioplasty

Before a metoidioplasty surgery, people take testosterone to enlarge their erectile tissue (clitoris). Some people wait 2–3 years to achieve maximum growth before proceeding with surgery.

After this period of growth, metoidioplasty creates a penis that has a length of 2–4 cm. The girth of a metoidioplasty penis is variable and depends on your anatomy. Metoidioplasty preserves sexual sensation and allows you to get erections without the assistance of an implant. If you choose to have urethral lengthening (optional additional procedure), you will be able to pee while standing.

While some people may be able to have penetrative sex with a metoidioplasty penis, this is not an expected outcome of this surgery.

After surgery, some people seek options to increase the size of their penis using techniques like a pump or topical testosterone directly on their penis. There is no evidence yet that these techniques are effective, and some could potentially be harmful, so we recommend that you speak with your surgical team before trying something new.

Procedure

Surgical techniques vary from surgeon to surgeon, but in general metoidioplasty includes the following steps.

The ligaments holding the erectile tissue (clitoris) in place under the pubic bone are cut, allowing the shaft to fall away from the body, giving it a more pronounced appearance.
Labial tissue may be wrapped around the shaft to create more girth.
Fat may be removed from the pubis and skin may be pulled upward to bring your erectile tissue forward (known as a monsplasty) to improve the visibility of the shaft.

Optional additional procedures

Some people choose to have metoidioplasty without any additional procedures, while others choose to have it in combination with urethral lengthening, scrotum construction (scrotoplasty) and/or vagina removal (vaginectomy).

Urethral lengthening

Urethral lengthening enables a person to pee while standing. It re-routes the urethra (tube that carries urine from the bladder out of the body) up through the tip of the penis. Lengthening may be done using tissue from the vagina, inner labia or inside of the mouth.

If you forgo urethral lengthening, your urethra will remain in the same position and you will pee from the area behind your penis (and scrotum if created).

Urethral lengthening can increase the risk of urologic complications, which are described under Risks & Complications below.

Scrotum construction (scrotoplasty)

The external genitals (labia or outer labia) may be shaped into a scrotum. Creating a scrotum also allows for testicular implants to be placed inside the scrotum at a later stage, usually a minimum of six months after the initial surgery.

Vagina removal (vaginectomy)

This procedure involves the removal of vaginal tissue and closure of the genital opening (vaginal canal). In order to have a vaginectomy as part of your procedure, you need to have your uterus removed at least six months before your penis construction surgery.

phalloplasty

The goal of phalloplasty is to create a penis that has:

A length of 12–15 cm and a thicker girth
A head (glans)
Sexual sensation and can get erections with the assistance of an implant (if desired)
Enough length and bulk to be used for penetrative sexual intercourse (with an implant or external stiffening device)
The ability to pee while standing (when urethral lengthening is chosen).

Surgical techniques vary from surgeon to surgeon, but in general phalloplasty includes the following steps.

Skin, nerves, veins and arteries from your forearm (radial forearm flap or RFF) or the thigh (anterolateral thigh flap or ALT) are removed. This is called a graft. Part of this skin is used to create a tube that becomes the penis shaft and head (also called glans). And if you choose to have urethra lengthening (see optional additional procedures below), a second tube will be constructed to extend your urethra.
Surgeons will place a device known as a wound VAC (vacuum-assisted closure of a wound) on the donor site where your skin graft comes from to help it heal.
Around 3–5 weeks after the first surgery, surgeons will remove the wound VAC from the penile donor site. At this time, a skin graft from another part of the body (such as the thigh) is used to cover the penile donor site.
At a later stage, surgeons will place a penile implant (if desired and medically feasible). Testicular implants may also happen at this stage if a person chooses to have scrotum construction. Placement of implants can happen a year or so after the initial surgery, but may also take longer if someone has experienced complications.

Donor tissue

There are two potential donor sites for phalloplasty surgery: your forearm (called the radial forearm flap or RFF) or your thigh (called the anterolateral thigh flap or ALT). The choice between donor sites will be something you discuss with your surgeon.

With RFF, your donor scar will be on your forearm. RFF usually results in a slimmer penis.

With ALT, your donor scar will be on your thigh. ALT usually results in a penis that is thicker and may require some debulking after surgery.

Optional additional procedures

Some people choose to have phalloplasty without any additional procedures, while others choose to have it in combination with urethral lengthening, scrotum construction (scrotoplasty), construction of the head of the penis (glansplasty), penile implants and/or vagina removal (vaginectomy).

Urethral lengthening

Urethral lengthening enables a person to pee while standing. It involves re-routing the urethra (tube that carries urine from the bladder out of the body) up through the tip of the penis. Lengthening may be done using nearby tissue from the same skin graft that made the penis.

If you forgo urethral lengthening, your urethra will remain in the same position and you will pee from the area behind your penis (and scrotum if created).

Urethral lengthening can increase the risk of urologic complications, which are described under Risks & Complications below.

Scrotum construction (scrotoplasty)

Vagina removal (vaginectomy)

This procedure involves the removal of vaginal tissue and closure of the genital opening (vaginal canal). This procedure involves the removal of vaginal tissue and the closing of genital opening (vaginal canal). In order to have a vaginectomy as part of your procedure, you need to have your uterus removed at least six months before your penis construction surgery.

Construction of the head of penis (glansplasty)

This procedure constructs the glans (head of the penis) and the result is a circumcised-looking penis. This usually happens following the initial surgery. The surgeon will use additional skin to create the glans ridge which gives shape and texture to the head of your penis.

Penile implant

A penile implant allows the penis to become erect. This procedure involves insertion of prosthesis, such as an inflatable device, and happens at a later stage. Implants have a lifespan and may need to be replaced over time.

Risks & complications

All medical interventions have potential risks and benefits. It’s important that you understand the risks of having surgery so you can decide whether the potential benefits outweigh the potential risk of surgical complications. This list is not intended to scare you or dissuade you from having surgery but rather to help you make an informed decision.

General risks associated with surgery

Anesthesia issues — Some people experience a negative reaction to anesthesia.

Cardiovascular issues — Such as blood loss, blood clots and artery blockages.

Hematoma — This is when blood collects in the surgical site, causing pain, swelling and redness. Drains and compression bandages are used to prevent hematomas. Smaller hematomas can be sucked out, but larger ones require removal through surgery.

Seroma — This is when clear fluid accumulates in the surgical site. Your surgeon will manage this complication. The ways in which it might be managed include monitoring, clinical exam, ultrasound or possibly drainage.

Infection — This is when microorganisms such as bacteria get inside the body. Infection can occur at different locations such as the surgical site or bladder and are generally treated with antibiotics.

Abscess formation — This is a collection of pus caused by a bacterial infection. It can be treated with antibiotics or drained by the surgeon.

Wound separation — This is when there is a partial or complete opening of incisions along the sutures.

Nerve damage and pain — There is a wide range of possible experiences related to how nerves heal after surgery. Some changes are short term and some are long term or permanent. Some changes are mild and inconvenient, while others are painful and distressing. Changes can include numbness, increased sensitivity, burning sensations and nerve displacement (sensation may feel like it’s occurring in one place but the stimulus is in another part of the body). Speak with your surgical team about any concerns you have about sensation or pain management.

Scarring — Scarring can be reduced by following your surgeon’s advice, which may include activity restrictions, avoiding sun, seeing a physiotherapist or massage therapist and doing massage exercises (if recommended). Severe scarring may require medical intervention or surgical revision.

Postoperative regret — Regret can happen for several reasons, such as experiencing significant complications or being dissatisfied with the outcome of surgery.

Risks specific to penis construction

Dissatisfaction with appearance or function — The size or shape of your penis or scrotum may not align with your expectations. Your penis may not function in the ways that you had hoped. Sometimes when this happens a surgical revision is possible.

Decreased sexual satisfaction or inability to orgasm — There is risk of decreased sensation or inability to achieve orgasm after surgery. Changes to sensation are also possible.

Catheter complications — Having a catheter can cause urinary tract infections. The catheter can also malfunction or become blocked.

Bladder spasms — These are common when a catheter is in place and can vary from mild to debilitating. They can feel like an abnormal cramp or that you need to pee but can’t. Your surgeon may prescribe a medication to try to help relax your bladder. Drinking lots of fluids can help with this.

Urethral lengthening complications — If you are considering urethral lengthening, it’s important to know that it’s a complex procedure and complications are to be expected including:

Fistulas: flow of urine to areas other than urethra opening
Stenosis: narrowing of the urethra causing difficulty urinating
Strictures: scarring inside the urethra, causing difficulty urinating
Hair growth inside the urethra

Sometimes urological complications will resolve on their own with time, and other times they will require additional surgery.

Scrotoplasty complications — The placement of the scrotum may cause discomfort if the testicles press upwards into the groin or make it uncomfortable to sit. Infection can also occur with the addition of testicular implants.

Vaginectomy complications — These include delayed wound healing, injury to surrounding tissues (bladder, rectum), abscess formation, partial regrowth of the tissue after surgical closure and infection.

Donor site complications (arm or leg) — This may include numbness, swelling (edema) and reduced strength and function. Numbness usually resolves in a few weeks. Permanent changes to sensation or function are rare but possible. Some people experience ongoing swelling, reduced strength, function and mobility near the donor site (for example, in the wrist and hand or leg) and may require prolonged physiotherapy to recover. Applies to phalloplasty only.

Tissue transfer complications — These are related to the transfer of skin from your penile donor site to your groin. There is a small risk of a partial or complete loss of the penis if the transfer is unsuccessful. Applies to phalloplasty only.