Graft Sites

There are four main graft types with different pros, cons, and recoveries. There are also a handful of less common graft sites that I will mention, but due to their obscurity it can be harder to find information on them. Not everyone is a candidate for each type of phallo. It’s largely dependent on body fat content and where you store your fat. And each doctor may have different requirements, so it never hurts to get a second or third opinion.

In general, phalloplasty is often done in about three stages, give or take. What happens in each stage is largely dependent on surgeon and their preference, though some surgeons do offer single stage phalloplasty. Even then, implants are pretty much always done in a later stage. One example of staging could be as follows: stage one- phallus creation; stage 2- urethral lengthening, glansplasty, scrotoplasty; and stage 3- testicular implants and placement of an erectile device.

If a patient desires a hysterectomy, it is usually performed prior to phalloplasty. Hysterectomy, oophorectomy, and vectomy are optional. Though hysterectomy must be done before vectomy. And even then people can keep one or both ovaries. Scrotoplasty and burial are also all optional. It’s important to note however that some surgeons require a vectomy if a patient is getting urethral lengthening. Urethro-vaginal fistulas are common otherwise, and vectomy strengthens the wall outside of the urethra.

*Also want to note that pros and cons can be subjective and everyone has different priorities. This is just an introduction to each donor site.

RFF or RFFF stands for radial forearm free flap. A free flap means the donor material is completely severed from the body. This is the most common graft site and is often considered the gold standard. A plastic surgeon takes the skin graft from the forearm, usually the non-dominant arm, to create the penis. The graft includes skin, fat, hair, nerves, and the radial artery. The medial and lateral cutaneous nerves are taken to provide sensory innervation to the flap. It is a full thickness graft, which means it needs to be covered in another skin graft. In the US, the donor arm is almost always covered in a split thickness graft taken from the thigh, though in the UK a full thickness graft is taken from under the butt cheeks and closed in a line.

Pros: Best chance at sensation, urethral lengthening is reliable, almost all phallo surgeons offer it, robust blood supply

Cons: visible and large arm scar, risk of mobility issues, risk of flap failure

ALT stands for anterior lateral thigh flap. This is probably the second most common graft site. A plastic surgeon takes the skin graft from the thigh, often times they’ll take from the non-dominant leg, to create the penis. The graft includes skin, fat, hair, nerves, and veins. It can be either a pedicle or free flap. Almost always the donor thigh is covered in a split thickness graft taken from the other thigh. Opting out of UL can reduce the girth, as the neourethra is often times created using the tube-within-a-tube method. Some surgeons offer an RFF graft for urethral lengthening to reduce girth. It would be smaller than the RFF graft to create the full penis.

Pros: Good sensation, comparable to RFF, urethral lengthening is possible but not all surgeons offer it, concealed scar, many phallo surgeons also offer it, robust blood supply

Cons: Often ends up very girthy and can need one or more rounds of debulking/degirthing, risk of flap failure

MLD stands for Musculocutaneous Latissimus Dorsi. This is probably the third most common graft site. A plastic surgeon takes the skin graft from the back, diagonal from the arm pit, to create the penis. The graft includes skin, fat, hair, a motor nerve, and veins. It is a free flap. It seems to be most common in Eastern Europe.

Pros: Sensation is not usually as good as RFF or ALT but is still possible, urethral lengthening is possible but not all surgeons offer it, concealed scar

Cons: Sensation is typically less developed than with RFF or ALT, nerve hookup is not possible because the genital nerve and the motor nerve are not compatible, can be hard to find a surgeon who offers it, risk of flap failure

There are a few different types of abdominal graft sites. It’s probably about as common as MLD. The skin is usually taken from just under the belly button and folded down to create the penis. US surgeons and UK surgeons take skin from the same area but close it differently, resulting in different scar patterns. The graft includes skin, fat, and hair. It does not have its own blood supply. Abdominal is also a pedicle graft, meaning the blood supply is never completely severed.

Pros: Concealed scarring, microsurgery usually not involved, some surgeons offer UL with an arm graft, in which a nerve may be harvested to increase the possibility of sensation, flap failure is less likely because the blood supply is never completely severed

Cons: Sensation is typically very minimal, ranging from half way up the shaft to no sensation at all, UL is not always possible and not offered by many surgeons, scar along the shaft ends up on the top

PIPE - This a new form of abdominal called PIPE, standing for phi innervated periumbilical eversion. It’s currently only offered by Dr O’Brian-Coon, and results in a large L shaped scar across the trunk of the body. A nerve can be harvested with this flap, increasing the chance of sensation. Only a few people have had this surgery yet, so public information is limited.

Birdwing - Another form of abdominal, shaped like bird wings or the top half of a butterfly, also taken from the abdomen under the belly button.

Fibula Free Flap (FFF) - A very uncommon graft taken from the lower leg, often taken with a piece of bone to use as an erectile aid. The harvesting of the bone can lead to mobility issues. It’s an old method, and I’m not sure anyone still offers it.

Island Tensor Fasciae Latae Free Flap (ITFL) - This is another thigh flap and the donor material includes a muscle, the TFL muscle. It’s used as a free flap for different defects and is similar to ALT flaps in this regard. Source.

Pudendal Thigh Flap - Skin is taken from the inner thighs. I’ve heard it’s more common in China, but I don’t believe anyone in the US, Canada, or even the UK offers it.

Gracilis - The gracilis muscle is used. A split thickness thigh graft can be taken for the neourethra. Seems to also be a method available in China.

Kim - Or formally known as conjoined bilateral pedicled groin flap, is another type of phallo that takes skin from the abdominal area, on top of the hips. It’s named after the creator, Dr Kim, from Seoul, Korea. UL is possible and patients report sensation half way up the penis from the base.