By Richard A. Santucci MD, FACS, HON FC Urol(SA) Senior Surgeon, Crane Center for Transgender Surgery (Cranects.com)
When considering a phalloplasty for masculinizing genital confirmation surgery, you have some big decisions to make. One of the biggest is whether the new phallus will be built from tissue from your arm or leg. (It can also be built from the “back” latissimus dorsi muscle, but at Crane Center we avoid this surgery when we can, as it has several disadvantages over RFF (arm) or ALT (leg) donor sites).
A quick primer on RFF (arm) vs ALT (leg) donor sites:
The “Radial Forearm Flap” (RFF) is located in the arm. The incision generally starts right at your wrist and goes up about 5 inches. It is 8.5 X 5 inches in size total. The space left when this flap is used to make a phallus is then covered with a skin graft.
The “Anterio Lateral Thigh” (ALT) flap is located in the leg. The incision starts about two inches above the kneecap and is 8.5 X 6 inches in total size. The wound is then covered with a skin graft just like the arm (RFF).
WHY TO CHOOSE RFF (ARM) PHALLOPLASTY: The RFF (arm) phalloplasty gives the most “normal” size phallus without the need for further surgery. We can also build the corona (“make a glans”) at the time of surgery. Also, the arm tissue may have a better network of the tiny blood vessels that keep the flap healthy after surgery. This may mean that RFF (arm) phalloplasty could have a lower incidence of “partial flap loss”, where a bit of the edge of the flap does not survive.
WHY TO CHOOSE ALT (LEG) PHALLOPLASTY: The ALT (leg) phalloplasty has a blood supply that doesn’t require microsurgery. This avoids the low but real chance of a serious blood clot or other artery problem that can occur with RFF (arm) phalloplasty. This problem usually requires emergency surgery to fix when it happens, so lowering the chance for this complication with ALT surgery increases the safety of the operation.
LET YOUR BODY DECIDE: Everyone stores fat in the thighs, and how “thick” your thigh fat is matters for how successful an ALT phalloplasty you will have. If you have a very thick amount of tissue in the thigh, the phallus may be VERY THICK and require one or more additional procedures to make it the proper size. A good rule of thumb is that very thin people should consider avoiding an RFF (arm) phalloplasty, as there may not be enough tissue to “fill out” the phallus to its normal thickness. On the other hand, very heavy men, or those with a thick pad of fat over the thigh should consider avoiding an ALT (leg) phalloplasty as the phallus may be too thick/fat.
YOU CAN ALWAYS DECREASE SIZE: If the phallus is too thick after ALT surgery, you can have liposuction to reduce the size. Liposuction works very well to decrease the size of the phallus, by up to 30%. In some cases, if this is not enough, additional liposuction sessions may be required. Second or even third liposuction can be done, but each liposuction works less well and may reduce the size by only a further 20% or 10%.
CONSIDER SENSATION: We hook up nerves in both the RFF (arm) and ALT (leg) phalloplasty. A nerve from either flap is carefully preserved and hooked up to one of the sexual nerves of the clitoris using a microscope and tiny, tiny suture. This can have very good results, with up to 80% of people having good sexual sensation in their phalloplasty. A further 15% have sensation to light touching but not sexual sensation. Unfortunately, in 5% of cases the nerve just doesn’t grow and the phallus has no sensation at all. In general, there’s no significant difference in sensation between RFF and ALT phalloplasty.
Dr. Richard Santucci spent the last 18 years as one of the nation’s premier academic reconstructive urologist and now devotes his surgical talents full-time to transgender surgery at the Crane Center in Austin, Texas. Dr. Santucci offers Metoidioplasty, Phalloplasty, Orchiectomy, Vaginoplasty and Vulvoplasty.