The basic procedures have similarities (except in extreme cases of micro/macropenis), although surgery on cisgendered men can be simpler, since the urethra still ends in the front of the genital area, whereas the urethras of transmen end near the vaginal opening and have to be lengthened considerably. The lengthening of the urethra is a difficult part of total phalloplasty, and also the one where complications often occur.
An erectile prosthesis can be inserted into the neophallus to replace the erectile tissue and enable sexual penetration. This is usually done in separate surgery for healing reasons. There are several types of erectile prostheses, ranging from malleable rod-like medical devices so the neo-penis can either stand up or hang down, to elaborate pumping systems. Penile implants require a neophallus of appropriate length and volume in order to be a safe option. The long term success rates of implants in a reconstructed penis have been poor. Good sensation of the reconstruction can help reduce the risk for the implant eventually eroding through the skin. It is for this reason that living bone was first used inside the reconstruction. Long-term follow-up studies from Germany and Turkey of more than 10 years now prove that these reconstructions maintain their stiffness without late complications.
There are three different techniques for phalloplasty:
Good references for these issues may be found in the Journal of Plastic and Reconstructive Surgery by the authors, Papadapolous and Biemer, Sengezer, Sadove and McRoberts, and Hage.
Belgrade University School of Medicine admits in the British Journal of Urology, Volume 100, Issue 4, that the four stages of this total phalloplasty method of penile reconstruction over a period of 9-18 months is one of the most demanding tasks in genital reconstructive surgery but the benefits for patients are great.
It satisfies the 12 major aesthetic and functional goals of modern penile reconstruction — a penis that: 1) is large, with substantial volume; 2) enables safe insertion of a prosthesis; 3) is hairless; 4) has satisfactory aesthetic appearance; 5) has normally colored skin; 6) has both penile tactile and erogenous sensation; 7) has a competent neo-urethra with a meatus at the top of the glans; 8) can have sexual intercourse; 9) leaves no conspicuous, disfiguring scars at the donor site; 10) has very low occurrence of disease or other complication; 11) achieves patient satisfaction; and 12) improves quality of life.
Not a major medical goal, but important to many patients, total phalloplasty using the MLD flap enables the person to urinate standing up. This is true of all modern operations. Suitable candidates for this surgery which creates a penis up to 7 inches (18 cm) long with a circumference up to 5.9 inches (15 cm) include: 1) patients with congenital anomalies such as micropenis, epispadias, and hypospadias; 2) FtM transsexual patients; and 3) victims of minor to serious iatrogenic, accidental or intentional penile trauma injuries (or total emasculation) caused by motor vehicle accidents (but not plane crashes), child abuse, animal bites, gun shots, burns, electrocution or self-mutilation.
For transmen getting a procedure not using the MLD flap, the urethra up to this point is formed by many doctors from the inner labia. Often, this is done in a separate procedure; sometimes a full-scale metoidioplasty is done a few months before the actual phalloplasty to prevent complications or make intervention easier when they occur.
Sensation is retained through the clitoris which is at the base of the neo-phallus; also, often a large nerve in the graft is connected to nerves either from the clitoris or other nearby nerves. In addition, nerves from the graft and the tissue it has been attached to usually connect after a while, thereby allowing additional sensation.
The forearm and leg flaps are the most common surgical techniques for total phalloplasty today. They remain the state of the day for both function and aesthetics. Muscle Flap procedures need long term publications of their function and aesthetics before making extreme claims of their popularity and superiority.