Plastic Surgery Phalloplasty Female to Male
The “MLD Flap” plastic surgery phalloplasty of Professor SV Perovic “The Phalloplasty Dr.” is an excellent solution for both adult and child patients that need male genital modification, including congenital anomalies, iatrogenic, accidental and intentional penile trauma, the medical condition known as micropenis syndrome, as well as female to male (FtM) gender reassignment surgery. Phalloplasty to enlarge or lengthen a man's penis is a different procedure: Tissue Engineering with Biodegradable Scaffolds. (Iatrogenic comes from the Greek words “iatros” meaning “physician” and “gennan” meaning “as a product of” — in other words disease caused by a doctor.)
The major phalloplasty advances developed by Professor Perovic (a member of the American Academy of Phalloplasty Surgeons) with his close colleague Dr Rados Djinovic and others enable the creation of a large penis that is natural looking, hairless or relatively so, has normal color skin as well as tactile and erogenous sensation that enables the patient to have successful sexual intercourse and an orgasm.
Patients can choose the penis size they want up to 7 inches (18 cm) long with a circumference up to 5.9 inches (15 cm). It allows easy urethroplasty and enables safe, effective penile prosthesis implantation whether they choose a big penis or average penis size. A longer then normal penis for the particular age of a child is created because a neophallus does not follow normal genital growth in the child, only somatic growth, so must be adult-size from the start.
For more than 20 years, surgeons have been using a radial muscle from the forearm of patients to create a rather ineffective neophallus. This old technique still so widely used by doctors has many serious drawbacks, including a signficant rate of flap failure, the unsightly and obvious donor-site scar on the person's arm, very frequent urethral complications, and a small penis that doesn't allow the safe insertion of penile implants in many patients.
The goal of modern “Perovic Total Phalloplasty” is optimizing long-term sexual, cosmetic and voiding outcomes. For example, patients are able to urinate standing up. This penile reconstruction has THREE stages with three to six months between the first and second stage and again between the second and third stages to allow healing. All aspects of this complex and pioneering procedure were first approved by the ethics committee of the University of Belgrade's School of Medicine and informed consent for the surgical treatment has been obtained from all patients.
As of April 2008, Dr Perovic has performed this procedure on more than 80 patients, more than than 60 of the patients were FtM transsexuals but the professor emphasizes: “ Perovic Total Phalloplasty is indicated in men without a penis or with a micropenis insufficient for sexual intercourse, as well as for transsexual patients.” Dr Perovic only performs this procedure twice per week maximum so book your surgery as far in advance as possible to get the schedule you prefer.
“Perovic Total Phalloplasty” is one of the most demanding tasks in genital reconstructive surgery but the benefits for patients are great. The use of a musculocutaneous latissimus dorsi flap, called the MLD flap, for the creation of the new penis has achieved results superior to those of most of the past century. The latissimus dorsi used in this phalloplasty is the broadest muscle of the back comprised of a pair of flat, triangular-shaped muscles across the middle & lower back.
Dr Perovic says: “The patients should not be obese in order to be able to create a normal size penis — not too thick — and they should prepare the donor area skin by intensive massage in order to increase skin elasticity and to enable us to close the donor site defect directly. The massage is best done by a professional. All skin should be treated in directions shown by the arrows on the full-screen version of the photo on the right.” This is a key part of the process so read our article: "Massage Tips to Prepare for Total Phalloplasty" and study the training video. The MLD flap massage should be done at least one month before surgery. It should be superficial and involve only skin and subcutaneous tissue.
Dr Perovic says: “If the subcutaneous fat is thicker then 3 cm it is very hard to tabularize it and create the penis. Also that penis would be too thick for sexual intercourse. In these cases we advise patients to lose weight or if it is difficult for them, then we advise liposuction of a donor region 1-2 months before surgery in order to decrease its thickness.”
In the ‘Free Flap Reconstruction of Head and Neck Defects’ report of The University of Texas Medical Branch Department of Otolaryngology, doctors Muller, Newlands & Pou report: “Decreased flap perfusion, hypercoagulation, and impaired wound healing have been associated with smoking. Thus, smoking should be discontinued for at least one week prior to surgery and forbidden in the postoperative period. Obesity may also decrease the success of free tissue transfer as the increased adipose tissue makes dissection of the vascular pedicle more difficult and interferes with the microvascular anastomosis, insetting, and flap tailoring after transfer.”
Patients older then 50 with hypertension must get a color doppler of the blood vessels in the legs (femoral vessels) before surgery. The patient should be admitted to the medical facility one day before surgery for standard pre-operative analyses as well as bowel preparation.
Since 1999, Dr Perovic has performed this plastic surgery phalloplasty successfully on patients ranging in age from 10-years-old to middle-age with a remarkable level of success. All patients have been satisfied with the function of the penile implants. None of the patients have reported any muscular weakness after surgery. Scarring at the donor-site has been moderate and more than 80% of patients have been satisfied with the appearance of the area from which the MLD flap was taken. Hospital stay after the first stage is usually seven days.
Only about 7% of patients have experienced any complications, all of which have been successfully treated with minor surgery. This procedure has a 100% success rate except for the case of one patient who suffered partial flap necrosis in mid-2008 due to a unique vascular drainage problem. Dr Perovic explains: “In the moment of flap elevation it appeared OK, but the problem started later after surgery — it was struggling for several weeks to survive which was very unusual. When a flap fails it becomes necrotic very soon after surgery, not like in his case.” The patient will need corrective surgery by the professor who does such corrections for free.
The professor is usually able to identify insufficient vascularization immediately upon removing the MLD flap. If this is encountered:
- 1) the blood circulatory system of the flap will be enhanced;
- 2) the flap will be returned to it's location at the donor site for six weeks or longer for improvement of its vascularity (flap autonomization);
- 3) and the surgery will be postponed to a later date when the patient's body has improved the blood supply within the donor tissue.
Insufficient blood circulation in donor tissue makes it inappropriate for a neophallus.
The solution is to enhance circulation in the flap and return it to it's original location so the patient's body can improve and make permanent the increased vascularity.
Because the characteristics of the flap make it inappropriate for the intended purpose, it is not made into a neophallus. The flap blood supply is engineered to make it suitable and the tissue returned to the donor site to heal in preparation for future use.
In line with Dr Perovic's primary goal of giving patients the very best surgical results with minimal risks and complications, less than ever will the doctors try to overcome physical insufficiencies of a donor flap using exemplary medical skills.
Virtually all reasons for delaying surgery are totally preventable by the patient (except insufficient vascularity):
- improper donor site preparation;
- insufficient skin elasticity (a characteristic for which proper donor site preparation can compensate);
- low BMI (a characteristic for which proper donor site preparation can compensate);
- high BMI (a characteristic for which prior weight loss and/or liposuction of the donor site can compensate);
- insufficient blood circulation in the donor flap preventing engineering into a viable neophallus.
A patient could choose to stay in a hotel for 42 days at a cost of about Euros 2100 or return to Belgrade at a mutually agreed later date. Six weeks is the minimum period surgery would be delayed, not the ideal.
Dr Perovic's high rate of success and low incidence of complications is unique and not standard for flap transfers. Other surgeons experience a higher rate and greater variety of of complications including, hematoma, vascular thrombosis, partial necrosis, excessive swelling of the neophallus and skin graft loss at the donor site. A treatable infection after penile prosthesis occurs in a small percentage of patients. In cases of penile reconstructive surgery done in Belgrade, Dr Perovic and Dr Djinovic work with a team of associates in allied specialties. This is an important factor in determining where Professor Perovic can perform your surgery.
In cases of penis injury, treatment should be immediate to prevent complications caused by delay such as infection, curvature, erectile dysfunction, missed urethral injury and chronic pain. However, severe penis injuries can be associated with injury of adjacent organs and the scrotum, pelvis and buttock so staged treatment may be recommended.
In addition to the fact that “Perovic Total Phalloplasty” can be used successfully in children, it also satisfies the aesthetic and functional goals of modern penile reconstruction — a penis that:
- is large, long, of large volume, and enables safe insertion of a prosthesis;
- is hairless, or relatively so;
- has satisfactory aesthetic appearance;
- has normally colored skin;
- has penile tactile and erogenous sensation;
- has a competent neo-urethra with a meatus at the top of the glans;
- can have sexual intercourse; and
- leaves no conspicuous, disfiguring scars at the MLD flap donor site as well as very low occurrence of disease or other complication.
Suitable candidates for this surgery include:
- patients with congenital anomalies such as micropenis; epispadias, hypospadias, intersex;
- FtM transsexual patients; and
- male victims of minor to serious iatrogenic, accidental or intentional penile trauma injuries (or total emasculation) caused by motor vehicle accidents, child abuse, animal bites, gun shots, burns, electrocution or self-mutilation.
Important note to FtM transsexuals from Dr Perovic: “Most of the surgeons/gynecologists who perform oophorectomy and hysterectomy do NOT perform vaginectomy because it is a risky procedure with possible bleeding and many other complications. All they do is close the vagina leaving only a small opening for drainage of its secretion. But the problem is that when persons with this are sexually aroused, they have abundant secretion and a lot of wetting. We perform vaginectomy routinely and advise it for all patients before Perovic Total Phalloplasty.”
The surgical stages of “Perovic Total Phalloplasty” are:
- Stage One Part A — Neophallus creation using the MLD free flap is a microsurgical procedure and involves mobilization of the flap from the back, creation of the penis and its transfer to the pubic region with creation of microsurgical anastomoses with the blood vessels and the ilioinguinal nerves of the legs. General anesthesia is combined with epidural anesthesia during the 10 hours of surgery. (Anastomoses [plural noun]: surgical connection of hollow tubular parts or structures, such as blood vessels.)
- Stage One Part B — In the past, this was done in separate stage but is now done at the same time as Part A. It prepares for a long urethra so patients can void from the tip of the penis. This first-step urethroplasty uses a buccal mucosa inlay from the mouth. If the patient has leukoplakia or other mouth disorders, the Dr Perovic and Dr Djinovic use split-thickness skin grafts, harvesting 2-3 strips of bucal mucosa and closing the defect directly. Grafts are transferred and quilted to the ventral side of the new penis in order to allow graft acceptance and development of its own blood vessels.
At the same time, the penile remnants are incorporated into the neophlallus.
The patient must lay in bed for about 48 hours to protect the microsurgical anastomoses. After that, the patient starts standing up and walking. The buccal mucosa graft must be wetted post-operatively for 5-7 days. The patient wears a trans-urethral catheter for approximately 5-7 days. Total hospital stay is 7-10 days. The surgery is followed by a 3-6 months healing period before the next stage.
After Total Phalloplasty Stage One (preceded by organ removal or not), it takes 2-3 days until the patient can walk unaided, 14 days until he will be able to drive and work and at least 28 days before he can resume playing sports.
Possible complications are flap failure, partial flap necrosis, injury of the femoral artery or unsightly donor site scar [5% in early years, approaching 0% in 24 most recent patients]. (Read our article about “Complications of Surgery”) - Stage Two — This is the second-step of urethroplasty during which the neourethral plate is tubularized and joined with the native urethra. The patient must mainten the buccal mucosa urethral plate by application of antiscar and moisturizing ointments or gels every day prior surgery.
The surgery takes about three hours and is usually performed using epidural or spinal anesthesia but general anesthesia can also be used if the patient prefers.
During recovery the patient wears a suprapubic urinary drainage catheter for about three weeks, as well as trans-neo-urethral splint (short catheter) and after that starts to void.
Possible complications include stenosis (constriction or narrowing of the opening and passageway) in about 3-5% of patients. Most of those cases can be solved by temporary catheterization. Occasionally, a small surgical procedure using local anesthesia is required. Approximately 5% of patients develop fistula, an unintentional passageway from the neophallus which enables leakage of bodily fluids to somewhere other than intended. Less than 3% of the 20 most recent patients experienced this. If small, it heals by itself by prolonged suprapubic drainage. If larger, additional surgery is required. (Read our article about “Complications of Surgery”)
- 3) Stage Three — During this surgery 3-6 months after the second stage, the penile prosthesis is implanted. In some cases, implantation of a semi-rigid prosthesis is recommended for three months after the phalloplasty to prevent phallic retraction. It can be removed and replaced later with an inflatable prosthesis. Patients receive treatment with a combination of several wide-spectrum antibiotics starting one day before surgery.
Surgery takes 3-4 hours and is usually performed using epidural or spinal anesthesia although general anesthesia can be used if the patient prefers.
Prosthetic rods/cylinders are enveloped in a vascular graft to decrease the chance of prosthesis protrusion. Since a semi-rigid prosthesis has a higher risk of protrusion due to permanent pressure of prosthetic tips, Dr Perovic and Dr Djinovic highly recommend an inflatable prosthesis and also enveloped in a vascular graft. Envelopment of the prostheses in a vascular graft greatly decreases risk of prosthesis protrusion.
After surgery, the patient wears a transurethral catheter for 5-7 days. Strong combined antibiotic treatment is continued for 7-10 days postoperatively.
There are three primary possible complications, including prosthesis infection in 4-5% of patients. The rate of infection significantly decreased after introduction of antibiotic-coated inflatable penile implants by American Medical Systems. About 7% of patients with a semi-rigid prostheses experience protrusion but those with an inflatable prosthesis less then 3%. In rare instances, inflatable devices fail. In these cases, as well as in all cases of infection, the producer provides a new prosthesis without additional charge.
The MLD flap gets an excellent blood supply because of a large and reliable subscapular artery and its two branches, the circumflex scapulae and thoracodorsal artery, as well as two concomitant veins which join to form a single large thoracodorsal vein. The glans is designed over the distal 5 cm of the flap. A one centimeter wide skin strip between the future glans and penile shaft is de-epithelialized to imitate the coronal sulcus. Only a small strip of muscle around the blood vessels is isolated, to decrease flap bulkiness and allow its safe tubularization.
First stage is micro-surgical procedure and involves mobilization of the flap from the back, creation of the penis and its transfer to the pubic region with creation of microsurgical anastomoses with the blood vessels and nerves of the legs. (Anastomoses [plural noun]: surgical connection of hollow tubular parts structures, such as blood vessels).
While one surgical team is constructing the neophallus, a second surgical team must prepare the recipient site simultaneously. After surgery, the new penis is elevated off the abdominal wall for 7–10 days using a specially-constructed dressing, which is important to prevent pedicle kinking. Urethroplasty is performed in the second stage 3-6 months after the first surgery and includes a buccal mucosa graft inlay. Urethroplasty is usually an operation for the repair of an injury or a defect in the walls of the urethra, the tube that drains urine from the bladder through the prostate and out through the penis. In this procedure the urethra is created.
Dr Perovic adds: “We can do this procedure in Bangkok but it is better to peform it in Belgrade in order to have longer and better follow-up. Medical facilities in Belgrade are not as good as in Bangkok in terms of hospital size and maybe patient rooms but the operating theaters are usually much better than the ones at Piyavate Hospital. Also, we have excellent anesthesiologists in Belgrade.” In the past, Dr Perovic performed surgery at Piyavate Hospital in Bangkok. A larger Bangkok hospital specializing in plastic surgery has invited the professor to perform surgery there. When he has experienced their operating theater his opinion may change.
This news report for non-medical persons is a review of total phalloplasty studies by Sava Perovic (SV Perovic) and others published in the "British Journal of Urology International", Volume 100, Issue 4, pp 899-905, under it's Reconstructive Urology section and titled: “Total phalloplasty using a musculocutaneous latissimus dorsi flap” and his report in Urologia Polska (The Polish Journal of Urology) 2005/58/3, ISSN 0500-7208: "Severe Penile Injuries: Etiology, Management and Outcomes".
