Phalloplasty

Phalloplasty involves the construction of a neophallus using tissue from a donor site, most commonly the forearm (RFF) or thigh (ALT). Additional procedures may include urethral lengthening, scrotoplasty, and erectile prosthesis placement. Phalloplasty is one of the most complex gender-affirming procedures and requires multiple stages for optimal outcomes.

• Construction of the Phallus – The phallus is created using a free or pedicled flap from a donor site (e.g., forearm, thigh, back, or abdomen). The goal is to achieve a natural-looking and functional penis with adequate length and girth.
• Urethral Lengthening (Standing to Pee) – If patients want to urinate while standing, a new urethra is constructed using tissue from the donor site or local tissue. This involves connecting the existing urethra to the neophallus, which requires multiple surgical stages.
• Scrotoplasty – Scrotoplasty creates a scrotum using existing genital tissue. Testicular implants can be placed in a later stage to provide a natural look and feel.
• Perineoplasty – Perineoplasty reshapes the perineal area for better anatomical alignment, often in conjunction with urethral lengthening.
• Native Tissue (Clitoral) Burial – This is performed to internalize the native tissue at the base of the phallus so it is no longer externally visible, but still maintains erogenous sensation.
• Glansplasty – Glansplasty sculpts the tip of the phallus to resemble a natural glans (head of the penis), adding a more realistic appearance.
• Erectile Prosthesis – A penile implant can be placed in a later stage to allow for penetrative intercourse. Options include inflatable and semi-rigid implants.
• Donor Site Coverage – After tissue is removed from the donor site, coverage techniques are used to promote healing and minimize scarring. These include:
• Integra – A synthetic skin substitute that supports skin regeneration.
• Skin Graft – A layer of skin taken from another part of the body to cover the donor site.

Donor Sites

The donor site determines the size, shape, and sensation potential of the neophallus. Options include:

• Radial Forearm Flap (RFF) – Most commonly used; provides good nerve connections for sensation.
• Anterolateral Thigh Flap (ALT) – Requires less scarring but may result in a bulkier phallus.
• Musculocutaneous Latissimus Dorsi Flap (MLD) – Taken from the back; least reliable sensory outcomes
• Abdominal Phalloplasty – A newer option that avoids arm or leg scars but may have less sensation.

Urethral Lengthening vs. Shaft-Only

• Urethral Lengthening – Allows standing urination but presents the risk of strictures and fistulas (the most common complications of phalloplasty).
• Shaft-Only Phalloplasty – Does not include urethral extension; recommended for those prioritizing reduced complication risks who do not prioritize standing-to-pee

To undergo phalloplasty, you will need to be over 18 and have 2 referrals from qualified mental health professionals attesting to your gender dysphoria and desire to get bottom surgery. The letters will need to correspond to the WPATH Standards of Care guidelines. You will also need to be on HRT for a full year (or detail in writing why you don’t want to be on HRT) and will need to have a BMI (body mass index) of 35 or below. (Higher BMIs can lead to high risks of surgical complications.)

Dr. Keith and Dr. Marano, who you will meet during your consultation in New York City/New Jersey, devote significant time to the consultation process. They will answer all of your questions and concerns in depth and ensure you have realistic expectations for your results. They will assess the donor regions, review your medical and surgical history, and create a customized treatment plan that achieves your bottom surgery goals.

In addition to undergoing a detailed consultation with Dr. Keith or Dr. Marano in NYC, there are a few important steps you will need to take in order to ready yourself for phalloplasty, outlined below:

• Mental Health Provider Letters – Many insurance providers and surgical guidelines require two letters from a qualified mental health professional confirming a diagnosis of gender dysphoria and the patient’s readiness for surgery. These letters should follow WPATH (World Professional Association for Transgender Health) standards and address the patient’s understanding of the procedure and its implications. Our team will assist in ensuring the proper language is used and the provider is appropriately credentialed
• Well-Controlled Medical or Mental Health Issues / Medical Clearance – Patients with underlying medical conditions (e.g., diabetes, high blood pressure) must have them well-managed before surgery. Medical clearance will be required.
• BMI Requirement – BMI is an imperfect assessment of weight-related risk factors. Each patient will be evaluated on an individual basis to assess surgical readiness. Generally, patients should have a BMI of 35 or below to reduce surgical risks and optimize healing.
• Nicotine Cessation – Nicotine must be stopped at least four weeks before and after surgery to prevent serious complications such as wound healing issues and tissue necrosis.
• Hair Removal – Hair removal is necessary for areas used to construct the urethra or shaft. Patients must undergo laser hair removal or electrolysis based on a provided hair removal template.
• Hysterectomy / Vaginectomy (If Getting Urethral Lengthening) – A hysterectomy and vaginectomy are required if the patient opts for urethral lengthening. Direct referrals for these procedures can be provided.
• Insurance That Will Cover Surgery – GAMMA works with multiple insurance providers and will assist with pre-authorization and documentation. Patients should verify specific phalloplasty coverage with their insurance carrier

Phalloplasty is typically performed in multiple stages over 1 to 2 years, allowing for optimal healing and reducing the risk of complications. While the exact number of surgeries varies depending on the patient’s surgical goals and anatomy, most individuals undergo at least three stages:

• Stage 1: Phallus Creation (First Surgery) – The phallus is constructed using a flap of tissue from a donor site (e.g., forearm, thigh, back, or abdomen). If desired, urethral lengthening may be initiated, but full connection to the native urethra occurs in a later stage. The donor site is covered using skin grafts or Integra. A scrotum and perineal reconstruction may be performed during this stage, depending on the discussion with your surgeon during consultation. This stage typically requires a 5–7 day hospital stay and a 6-week recovery period in town for close monitoring.

• Stage 2: Urethral Hookup (Second Surgery, Typically 3-6 Months Later) – The new urethra is connected to the native urethra, allowing the patient to urinate through the phallus while standing. Additional refinements may be performed, such as glansplasty (creating a more defined head of the penis), scrotoplasty, and native tissue burial if not completed in Stage 1. This stage typically requires a 3–5 day hospital stay, and the patient must stay in town for at least 4 weeks to monitor for complications like strictures or fistulas. This stage involves a partnering reconstructive urologist for urethroplasty and placement of a suprapubic tube.
• Stage 3: Prosthesis Placement (Optional, Typically 6–12 Months After Stage 2) – If the patient desires, an erectile device (implant) and/or testicular implants can be placed to allow for penetrative intercourse and a more natural scrotal appearance. If necessary, additional minor revisions to the phallus, urethra, or scrotum may be performed. This stage typically requires a 1–2 day hospital stay and a 4-week recovery period before resuming normal activities.
• Additional Stages (If Needed) – Some patients may require additional revision surgeries to refine the aesthetic or functional aspects of their phalloplasty. If complications arise (such as strictures, fistulas, or wound healing issues), additional corrective procedures may be necessary.

*Each stage is tailored to the patient’s individual needs and surgical goals. During consultations, we develop a personalized surgical plan to optimize both function and appearance while ensuring the safest possible outcome.

Hospital Stay (5–7 Days)

Patients should prepare for an extended hospital stay:

• Day of Surgery – Arrival, check-in, anesthesia, and surgery (6–10 hours).
• Days 1–3 – Close monitoring, pain management, and bed rest.
• Days 4–5 – Gradual movement, catheter checks, and wound care.
• Day 6–7 – Potential discharge if healing is stable.

How to Prepare for the Hospital Stay

• Pack comfortable clothing, toiletries, and personal items.
• Arrange for post-op care and transportation home or to a recovery location.
• Expect limited mobility in the first few weeks post-surgery.

Recovery from phalloplasty is a gradual process that requires patience, adherence to post-operative instructions, and regular follow-ups. The timeline varies depending on the surgical approach, the number of stages completed, and individual healing.

• Positioning Restrictions – No sitting directly upright for 6 weeks. Sleeping on the back or reclining is recommended.
• Pain Management – Pain will be managed with medications and gradually improve over weeks.
• Dressings & Showering – The donor site (e.g., forearm, thigh) will have either Integra or a skin graft, which requires special care. Showering is allowed after discharge from the hospital, with precautions.
• Drains & Catheters – Patients will have surgical drains to remove excess fluid and prevent complications. These are typically removed within 1–2 weeks. After urethral hook-up (second stage), a suprapubic catheter (a tube placed directly into the bladder) is used for urination while the urethra heals. It remains in place for 3-4 weeks, depending on healing progress. A foley catheter will also be placed through the new penile urethra for additional support.
• Swelling and Healing – Swelling is most pronounced in the first 2–3 weeks and gradually subsides over the next 3–6 months.
• Activity Restrictions – No heavy lifting, strenuous exercise, or sexual activity for at least 6–8 weeks. Light walking is encouraged to promote circulation and prevent blood clots. Patients should avoid bending, squatting, or straining during the first several weeks. Gradual stretching and mobility exercises may be recommended to prevent stiffness at the donor site.

Timelines

• Time off work: Desk jobs require 6–8 weeks off work. Physically demanding jobs can require 10–12 weeks or longer
• Time to sexual activity – If no erectile device is placed: At least 3 months to allow for proper healing. If an erectile prosthesis is placed in a later stage, activity restrictions will be determined based on that procedure.
• Full healing and final results occurs approximately 12–18 months after the final surgery

Dr. Keith and Dr. Marano will go over these risks in greater detail during the consultation process so you are fully aware and informed. Possible risks include:

• Urethral Fistula – An abnormal connection between the urethra and skin, leading to leakage.
• Urethral Stricture – Narrowing of the urethra, which may require revision surgery.
• Pain – Most commonly in the donor site, scrotum, and surgical areas.
• Tissue Necrosis – Partial or complete loss of tissue due to poor blood supply.
• Wound Separation – Incisions may take time to heal properly.
• Discharge – Temporary discharge from healing surgical sites.
• Bleeding – Post-surgical bleeding that may require intervention.
• Infection – Can occur at the donor site, urethra, or phallus.
• Sensation Loss – Varies based on nerve connections and healing
• Donor site specific complications – of the forearm, thigh, back, or abdomen

Insurance carriers will typically cover gender affirmation surgery, including phalloplasty, when it is performed to treat gender dysphoria, a condition in which the patient’s outer traits do not reflect their authentic gender identity. You’ll need letters from mental health providers detailing your decision to undergo phalloplasty. Our team can go over the insurance requirements in greater detail during your consultation.

• Resources – For patients traveling to NYC for surgery, GAMMA provides recommendations for LGBTQ+ friendly accommodations, post-op caregivers, and recovery services. Our team can also assist with logistics such as medical transport and aftercare arrangements.
• Requirements – Out-of-town patients must plan to stay in NYC for at least two weeks after surgery to ensure proper healing and attend necessary post-operative appointments. We encourage having a trusted friend, family member, or professional caregiver for the first few days post-surgery.

You will be recuperating for about six weeks, during which time you should avoid strenuous activities and attend all follow-up visits. Dr. Keith and Dr. Marano will customize a timeline for when you can return to normal activities, including traveling.

Our team at Gender Affirming Medical and Microsurgical Associates (GAMMA) in New York City and New Jersey is known for providing the highest-level care in an affirming environment. We utilize today’s most progressive and cutting-edge techniques to provide the highest level of service possible. Our goal is to help transgender, nonbinary, and gender nonconforming individuals achieve their unique appearance goals and thrive with confidence, security, and peace of mind.

Dr. Drew Marano

Dr. Drew Marano is an accomplished, board- certified, and fellowship-trained plastic and reconstructive surgeon who has devoted his career to the art of gender affirmation surgery. He graduated from Rutgers New Jersey Medical School at the top of his class, receiving AOA honors before embarking on a competitive six-year Integrated Plastic and Reconstructive Surgery Residency at Columbia University/Cornell University in New York City. Following his residency, Dr. Marano was selected as the first-ever Harvard University Complex Gender and Microsurgery Fellow, during which time he underwent advanced training in groundbreaking and innovative surgical techniques. He is a prolific author, researcher, and lecturer who has contributed to over 40 publications and presentations at regional and national meetings. Dr. Marano offers ongoing support for transgender patients as they navigate their unique and rewarding journey of transitioning.

Dr. Jonathan Keith

Dr. Jonathan Keith is a renowned, fellowship-trained, board-certified plastic surgeon known for his progressive approach to microvascular surgery. He is an active member of the World Professional Association for Transgender Health and the founder of the Rutgers Center for Transgender Health. In 2018, Dr. Keith created the first multidisciplinary clinical program for transgender patients in New Jersey and was the first surgeon in the state to perform a female-to-male phalloplasty for gender affirmation. Regarding his extensive educational background, Dr. Keith completed a demanding seven-year residency at the University of Pittsburgh, one of the nation’s most elite and well-regarded plastic surgery training programs. As a testament to his skill and artistry, in 2012, he received the Stephen S. Kroll Fellowship in microsurgery at the University Hospital of Gent, Belgium. Today, Dr. Ketih performs a range of complex and delicate procedures to assist transgender and nonbinary individuals in achieving their ideal appearance, including DIEP flaps for breast reconstruction, vaginoplasty, and phalloplasty.