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Gender-affirming surgery, the long road to it, and the account I went looking for and couldn't find.

Gender-affirming surgery, a first-hand and respectful account.

Phalloplasty: Staged Surgery, Flap Options and the Honest Complication Picture

Key takeaways

  • Phalloplasty builds a phallus from a skin flap, commonly the radial forearm or anterolateral thigh, as a masculinising gender-affirming surgery.
  • It is staged over multiple operations, with the total process commonly taking 12 to 18 months.
  • It carries the highest complication rate of common gender-affirming surgeries; urethral complications are the most frequent.
  • Urethral strictures and fistulae often need further surgery, so the honest picture includes the prospect of revision.
  • Satisfaction is still high overall, and regret across gender-affirming surgery is about 1 in 100.

By Jessica Tran  |  Medically reviewed by Mr Tobias Lindgren, FRCS(Plast)

Published · Last revised · Last reviewed · 3 min read

Phalloplasty is a masculinising gender-affirming surgery that builds a phallus from a skin flap, commonly the radial forearm or anterolateral thigh. It is staged over multiple operations, with the total process commonly taking 12 to 18 months, and it carries the highest complication rate of the common gender-affirming surgeries1. We say that plainly because an honest picture is the kindest one. It is one option on the masculinising pathway, chosen individually with a clinical team.

When I researched the masculinising procedures, phalloplasty was the one where the gap between glossy summaries and lived reality felt widest, especially around revision surgery. So here it is, checked by a consultant gender-affirmation surgeon: how the staged surgery works, the flap options, and the honest complication picture. This article sits within our guide to gender-affirming surgery and the masculinising procedures overview.

What is phalloplasty?

Phalloplasty builds a phallus from a skin flap, most commonly taken from the radial forearm or the anterolateral thigh2. Unlike metoidioplasty, which works with existing tissue, phalloplasty constructs a larger phallus from a flap, which is why it is more complex.

Surgery is one option among many, not an endpoint or a requirement of being trans. The decision is individual and made with a clinical team, and many trans men choose other procedures or none.

The flap options

The two most common donor sites are the radial forearm and the anterolateral thigh1. Each carries trade-offs in sensation, in the scar left at the donor site, and in bulk. Your surgeon recommends a flap based on your anatomy, your priorities, and their experience.

There is no single best flap; the right choice is the one that matches what matters most to you, discussed honestly in your consultation. For how metoidioplasty compares, see metoidioplasty.

The staged process

Phalloplasty is staged over multiple operations, with the total process commonly taking 12 to 18 months across stages1. It is the longest and most complex recovery of the common gender-affirming surgeries. The number of stages and their timing depend on the technique and on how each stage heals.

The staged nature is not a footnote: it shapes a year or more of your life. Talking with people who had been through it, the steadiness to live alongside a long, multi-stage process was the quality that seemed to matter most. To prepare, see preparing for gender-affirming surgery.

The honest complication picture

Phalloplasty carries the highest complication rate of the common gender-affirming surgeries, and urethral complications (strictures and fistulae) are the most frequent1. These often need further surgery, so the honest picture includes the real prospect of revision.

This is not said to frighten anyone. It is said because choosing well means choosing with open eyes. Where urethral lengthening is included to allow standing urination, that is also the part most associated with complications, so some people choose a version without it. These are decisions weighed carefully with your surgeon.

Satisfaction and regret, honestly

Despite carrying the highest complication rate of the common procedures, satisfaction with gender-affirming surgery is high overall, and regret across procedures is low: a 2021 systematic review and meta-analysis of around 7,900 patients found regret in about 1 in 1003. That figure is low but not zero, and it never trivialises the people it affects.

The honest approach is to weigh the staged process and the revision risk against what the surgery means to you, with your clinical team. For the pathway, see the pathway to gender-affirming surgery; under WPATH SOC-8 (2022), genital surgery asks for one referral from a qualified health professional2. Nothing here is personal medical advice.

Frequently asked questions

How long does phalloplasty take from start to finish?

Phalloplasty is staged over multiple operations, with the total process commonly taking 12 to 18 months across stages. It is the longest and most complex recovery of the common gender-affirming surgeries. The number of stages and their timing depend on the technique chosen and on how each stage heals.

What are the flap options for phalloplasty?

The phallus is built from a skin flap, most commonly the radial forearm or the anterolateral thigh. Each flap has trade-offs in sensation, scarring at the donor site, and bulk. Your surgeon recommends a flap based on your anatomy, your priorities, and their experience.

Does phalloplasty have a high complication rate?

Yes, relative to other gender-affirming surgeries. Phalloplasty carries the highest complication rate of the common procedures, and urethral complications (strictures and fistulae) are the most frequent. These often need further surgery, so the honest picture includes the prospect of revision operations.

Can you urinate standing after phalloplasty?

Many phalloplasty techniques include urethral lengthening to allow standing urination, but this is also the part most associated with complications such as strictures and fistulae. Some people choose a version without urethral lengthening to reduce that risk. It is a decision weighed carefully with your surgeon.

Is phalloplasty worth the complication risk?

That is an individual judgement, not one we make for you. Despite the highest complication rate of the common procedures, satisfaction with gender-affirming surgery is high overall, and regret across procedures is about 1 in 100. The honest approach is to weigh the staged process and revision risk against what the surgery means to you, with your clinical team.

How many referrals do I need for phalloplasty?

Under the WPATH Standards of Care, Version 8 (2022), genital gender-affirming surgery asks for one referral from a qualified health professional, after SOC-8 simplified the older two-referral norm. Continuous hormone therapy of about 12 months is usually expected where hormones are not contraindicated.

References

  1. An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient: A Review of the Literature, Plastic and Reconstructive Surgery (Frey et al., 2017). ↩
  2. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, World Professional Association for Transgender Health (WPATH). ↩
  3. Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis, Plastic and Reconstructive Surgery Global Open (Bustos et al., 2021). ↩
  4. Gender dysphoria: treatment, NHS.

Written by Jessica Tran. Medically reviewed by Mr Tobias Lindgren, FRCS(Plast).

Our guides are written from personal experience and reviewed by a qualified clinician for accuracy. Read our editorial policy.

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