Phalloplasty: Sensation & the Nerve Hook-Up

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Reader advisory: this week’s post talks frankly about the medical and physical aspects of sex, and the video contains diagrams illustrating these concepts. Discretion is advised.

A few weeks ago, we introduced you to free flap phalloplasty, which is one type of genital reconstruction (or “bottom surgery”) for transgender men and transmasculine folks. This week, we address one of the primary concerns raised by people considering this surgery: sensation and the ability to orgasm.

One of the most common misconceptions about trans male bottom surgery is that it results in a partial or total loss in sexual sensation. It’s not unusual to hear the sentiment, “I’d consider bottom surgery, but I don’t want to lose my ability to orgasm,” in trans male circles. In reality, free flap phalloplasty can include a nerve hook-up, a microsurgical technique in which nerves taken from another part of the body are attached to the clitoral nerve or other pelvic nerves and embedded into the new penis. This allows the patient to retain sexual sensation and function in the vast majority of cases. “In my experience, about 85% of free flap phalloplasty patients get erotic sensation, and 98% get tactile sensation,” says Dr. Curtis Crane. “And I’ve never had a patient lose the ability to orgasm.”

Although these numbers are promising, and certainly better than common bottom surgery lore, it’s important to remember that nerve regrowth is a slow, gradual process. Nerves must regrow through the axon sheath, and the rate at which this growth occurs is about 1 millimeter per day. At this rate, full sensation can take up to 2 years to reappear after surgery.

This video is captioned in English. To access the captions, click the CC button on the bottom right of the video.

Phalloplasty: Choosing Your Donor Site

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For trans men, transmasculine folks, and others who were assigned female at birth, there are two major types of genital reconstruction or “bottom surgery”: metoidioplasty and phalloplasty. Metoidioplasty is a procedure that relies on the clitoral enlargement resulting from testosterone, in which the surgeon releases the ligaments around the clitoris, freeing it and bringing it forward to create a small phallus. In later blog posts, we’ll cover metoidioplasty, but today, we’re focusing on the second option: phalloplasty.

Phalloplasty comes in many different varieties, and can utilize different surgical techniques depending on the surgeon’s expertise and the patient’s preference. Today, Dr. Curtis Crane will introduce us to free flap phalloplasty. The term free flap means that the surgeon harvests tissue — skin, fat, arteries, veins, and nerves — from another part of the body, and creates a penis using that tissue.

The first decision a free flap phalloplasty patient must make is which donor site to use. “The most common donor sites are the forearm, the back, and the thigh,” explains Dr. Crane. “There are positives and negatives to each of these.”

Indeed, choosing the right donor site for you can be challenging. There are many factors to consider, including the number of individual surgeries (referred to as stages in the video), the location of the donor site scar, the aesthetics of the resulting penis, and the amount of sensation typically expected from a donor site. In this video, Dr. Crane gives a detailed description of each of the three major donor sites, and discusses the pros and cons of each. “Really take some time and think about this,” he says. “This is the phallus you’re going to have for the rest of your life.”

Keep an eye out for more great information on phalloplasty from Informing Consent with Dr. Curtis Crane in the near future.

Note: this video is captioned in English. To access the captions, click the CC button on the bottom right of the video.