Thinking outside the box: Alternative techniques for gender affirming phalloplasty

Aims: The benefits of gender affirmation surgery have long been established, and with improved access to care, these operations are being performed with increased frequency. As these surgeries continue to be performed, the surgical techniques continue to evolve. Phalloplasty, or the creation of a phallus, remains one of the most complex surgical endeavors in which a variety of factors influence surgical decision making. This article aims to present the lesser known and less frequently performed means of phalloplasty in gender affirming genitourinary reconstruction.

Methods: A literature review of relevant articles, whether case series or more comprehensive, was performed to describe some of the more obscure and less frequently utilized flaps for phalloplasty.

Results: The most performed or widely accepted technique is that of the radial forearm free flap, but numerous other options decorate the surgical landscape. With limited and unreliable outcomes data, a standard of care is difficult to establish.

Conclusions: Ultimately, phalloplasty reconstruction should aim to achieve standing micturition and penetrative intercourse, resolute tactile and erogenous sensation, desirable aesthetics of the phallus, and acceptable donor site morbidity. Although some procedures are more commonly performed, the standard for phalloplasty has not been established. Ultimately, approaching this reconstructive puzzle with persistent creativity will unearth more reliable options in the future.