Words to know for navigating trans phalloplasty discussion
The post is NSFW, 18+.
When I was first researching having transgender bottom surgery, I got into a world with a ton of acronyms and abbreviations. It seemed like most people were speaking in code. Top surgery was so simple in comparison. I just asked the doctor which procedure I should get, and I got it. I did comparably very little research, compared to the solid year I spent in research every day for bottom surgery. I remember first thing I did was ask for help to understand the bottom surgery shorthand. I’ll repay the favor!
Here’s the common bottom surgery slang and terms you might not know, coming in fresh to the conversation. I’ll probably copy and paste this link to share the terms next time I run into someone in that same situation. This is by no means complete, but it should be a good starting point.
1. Basics of Trans Masc Bottom Surgery
2. Scrotoplasty, Vaginectomy, Urethral Lengthening
3. Donor Sites
4. Nerve hookup and burial
5. Wound Healing Technology
6. Erectile and Testicular Implants
The Basic of Trans Masc Bottom Surgery
Bottom surgery – I think this is square one. Bottom surgery is our shorthand for gender affirming surgery on your genitals and/or reproductive organs. Usually when people say this in groups of trans masc people (assigned female at birth), they mean either phalloplasty or metoidioplasty, but sometimes they also mean hysterectomy. As far as surgeries that yield a more typical dick than a tdick, your options are phalloplasty or metoidioplasty. Gosh, there was such an effort to shift the language to lower surgery for years, but we were not successful. I just don’t like it sounding like I went to a proctologist, haha. But it seems “bottom surgery” is here to stay, as the opposite to “top”.
Note: It is fair for anyone who has never had hormones to refer to their natal erectile tissue, that is, the clitoris as their dick. Dick is a mood, a frame of mind, and I support anyone’s right to classify their body as they see fit. If it is a dick to you, it is a dick. After testosterone, it’s more common to see people calling their organ there the dick, or tdick for dick that grew after testosterone. Sometimes spelled t dick or t-dick. All of these are dicks.
Phalloplasty – It literally means any kind of plastic surgery on a penis. So, cis people have phalloplasty much more often than trans men do. In our transgender context, however, phalloplasty means building a penis mostly out of donor tissues from other parts of your body. The abbreviation is phallo. In my opinion, it is bad manners to call a penis made by phalloplasty “the phallo”, although you will encounter this. I think it is polite to use “the phallo” to refer to the surgery you had.
Example: I had phallo in 2017, and Dr. Devin O’Brien-Coon was my phallo surgeon. My dick is from phallo.
NOT: Send pics of ur phallo, dude.
Metoidioplasty – The is another surgical option, which is usually only viable after good growth from testosterone. They release some of the ligaments which are supporting your dick. Depending on what you want, they can do a mons resection to lift up the penis to the typical elevated site on the mons. Sometimes they do liposuction on either side of the penis to give a more cisgender-typical appearance, on the former labia majora. The abbreviation is meta in the community and meto among surgeons.
Yo, let’s get off on the right foot and say there is no better surgery of the two. It’s very individual. It’s polite to keep your opinions about the other option to yourself and speak about your own personal priorities.
Scrotoplasty, Vaginectomy, Urethral Lengthening
Scrotoplasty is an option, where they build a scrotum from labia majora and sometimes labia minora as well, which can be bifid, split and in the natal position of the labia majora, or VY, joined and in the elevated cis natal position. Rather than an acronym, VY stands for the shape of the pedicle movement during surgery. Pedicle means the tissue is not completely disconnected from original nerves and blood supply when being moved.
When I asked Dr. Coon what VY scrotoplasty stood for, he looked like he was vogueing… flipping his hands from an upside down V to a Y. Allow me to pause and cherish this memory. Was it a dream? I think I was pantsless, which doesn’t indicate whether it was real or not anymore.
VY scrotoplasty in movement; I think I was trying to see how my ball sack moves.
Meta or meto can be combined with urethral lengthening, which routes pee through the penis, also known as urethral hookup when linking a constructed urethra to the natal urethra. Usually meta UL is done with a buccal graft from the inside of the cheek, or else from the lining of the vaginal canal.
Not to be confused with Aretha-ral. I had a friend who said it that way and I just kept thinking about Aretha Franklin…
UL is the abbreviation for urethral lengthening. UL is one of the trickiest parts of phallo, because there’s such a distance for the new urethra to go. But the payoff is STP, standing to pee, if it goes well. Sometimes people with meta UL can STP, but many cannot; it depends on whether the penis from meta is long enough to “clear the fly” of your pants.
I made a very bad “clear to fly”/”clear the fly” joke once, deliriously happy about getting ready to head home after six months in Bmore. I am sorry for this, to all who suffered hearing it. I am not sorry to TSA, who bother me and slow me down every time I travel.
Common complications of UL are stricture and fistula. In those conversations you will hear about the use of Foley catheters and suprapubic catheters, also called SP catheters. You’ll also hear about processes like learning to milk the urethra, my perhaps least favorite term ever, haha, for making sure no urine remains in the penis when you quit peeing. It’s a learning process.
Vaginectomy is removal of the vagina through cauterization of the lining and closing up. It might be optional, depending on what options you want with your meta. Vaginectomy is frequently abbreviated vnectomy. If you are having vnectomy, most surgeons will get you that you must have a hysterectomy. Which, by the way, doctors call hyst but we call hysto.
Trans etiquette moment: When I don’t know what someone’s comfortable terms are, I mirror back the language they use. E.g., If they said vaginectomy, I say vaginectomy. If they avoid the term, I say vnectomy. If they say “my junk” for their genitals, I do too. Dysphoria sucks and we are in this together. If you don’t like hearing a word, if it makes you uncomfortable, tell your surgeon not to use it; give any alternative word to fill in. Your body belongs to you, and you get to name it.
So, phallo penises are built from other tissues. There are a couple donor sites whereby the surgeon takes tissue. The most common abbreviations you will run across for donor sites are RFF, ALT, and MLD. There are other donor sites besides these three, less commonly and often with higher complication rates. In the US, RFF and ALT are most available, and some surgeons including Dr. Coon offer MLD.
RFF – Radial forearm free flap, or radial forearm for short. That’s where they took the skin, nerves, veins, and fat off my left arm, as a full thickness graft. Dr. Coon gave me an Allen test at my consult to check my blood flow in my right and left arm. People like this one because it has the lowest rate of complication and the best chances of good, erogenous sensation. Downside, more visible donor area.
ALT – Anterolateral thigh flap, the thigh graft. They take a full thickness graft from the thigh there. They can do it on a pedicle, connected to the original site in some ways, or it can be done as a free flap totally disconnected. People like the concealed donor site in most clothing. This can yield a larger penis than RFF. This can give larger penises than RFF on average. Body fat can be an issue, since it travels with the flap, so the donor site must be very lean.
MLD – Microvascular latissimus dorsi free flap, the back. Well, it’s also sort of under the arm, too. There are no nerve hookups to this site, which means that there are no donor nerves in the flap for the doctor to hook up to sensation nerve in the pelvis. The donor site can be closed with an incision rather than an “area”. This donor site is the most concealable.
This might be a time to postpone your plan for getting your kids’ footprints and names tattooed on your forearms, thighs, and flanks…
Nerve Hookup and Burial
A little more on nerve hookup— There are a lot of misconceptions on what this means. In RFF and ALT donor sites, there are nerve branches. There are, of course, also nerve branches in the pelvis. In moving the tissue, a microsurgeon can link the nerves of the arm to the pelvis nerves, or link the nerves of the thigh to the pelvic nerve. The microsurgical linking is called anastamosis. Beware of surgeons that do not offer nerve hookup for RFF or ALT. When the pelvic nerves regrow into the donor flap, that is a successful nerve hookup. Sometimes, people discuss failed nerve hookups. The nerves available for hookup in the pelvis are the ileoinguinal nerve and the dorsal penile branch of the genitofemoral nerve.
Myth busting: Did you know… Nerve hookup is not related at all to whether they bury the tdick below the phallo dick. You can have nerve hookup and leave your tdick exactly as it ever was, down below and exposed on your perineum.
Myth busting #2: Did you know… Nerve hookup is not linking the tdick to the phallo dick. Nerve hookup is linking donor nerve to site nerve.
Burial is often referred to as clitoral transposition in medical literature. Burial is moving the tdick below the new genitals. Depending on the spacing of your anatomy, it may land below the penis or below the scrotum or sort of in between. You may not need to have to have burial, if you’re not having UL. It can also be moved up to the spot above the scrotum and not be buried; sort of transposed but not buried. Surgeons denude the tdick, or take the skin off it, before burying it, so it becomes an organic sensitive part of your new anatomy within the tissue.
Sensation in the phallo dick comes from (1) nerve hookup and (2) burial. Even if nerve hookup is not successful, it’s very rare to lose sensation in the natal erectile tissue which is being buried, so most people can still have an orgasm through (1) or (2) or both, after phallo.
Resist making bad jokes about what a sensation your penis is. I have done this enough for my lifetime, plus seventy years.
Wound Healing Technology
At Johns Hopkins, where I had surgery, they are in favor of today’s advanced wound healing technologies which may not be available elsewhere. Other surgeons from other training may have different opinions about these technologies. Integra is a dermal regeneration template which is made of collagen, which they apply to the donor site after the tissue is removed for the formation of the penis. The purpose is to allow granulation tissue, meaning healing tissue, to develop before applying new skin to the donor site. This can help the healing and appearance of the donor site. I had Integra.
The new skin they apply to the donor area is called the split thickness graft. They shave a very thin layer of skin off a thigh or hip and apply that to where you gave up so much tissue. This only applies to RFF and ALT, not MLD. My split thickness donor site was my upper thigh/hip. I have heard than in England, they prefer to take a full thickness graft to go onto the donor site. There are pros and cons of either approach. If you have Integra, you get to have the sci-fi experience of wearing a wound vacuum sleeve to keep zero pressure on the wound at key stages of healing.
I asked Dr. Coon to put the split thickness donor site up higher so I could wear hot pants and daisy dukes. I mean the Lord saith, “Ask and ye shall receive.”
AlloDerm is an acellular dermal matrix; that is, a sheet of dermis someone donated as part of organ donation, living sheeting which has gone through a process to make it acellular. That way, when it is given to you, your body does not treat it as foreign. Your body’s cells colonize it, and it becomes your own body. It is usually spelled Alloderm in the community. I have Alloderm in the core of my penis. I had no complications from it. It also adds girth. Dr. Burnett, the chief urologist at Hopkins, wrapped more thick layers of Alloderm wrapped around my erectile implant before putting the implant in my body, so that my now-native tissues will be protected from pressure, as my tunica albuginea. Hopkins JHCTH seems to have a high opinion of the value of AlloDerm over a synthetic material for wrapping implants, since there is no risk of foreign body response long-term. Other surgical centers have different approaches. I am glad I could have this.
Once, I asked Dr. Coon if the organ donors knew their tissue would be donated to be my penis. He said, “I don’t know if they know now, but they didn’t before they died.” OMG, haha.
Erectile and Testicular Implants
I had an erectile implant put in my penis, so that I can have a natural erection within the length of my phallo dick, stiff enough for penetration. (See what I did there, natural, not unassisted?) Surgeons call these penile prosthesis, but that’s odd for the trans community, since it sounds like a packer to us. You’ll see the term erectile device or ED, which is also confusing because commonly ED stands for erectile dysfunction. That’s why I typically use “erectile implant”. I also had a testicular implant placed in my scrotum.
We have serious disambiguation issues around stiffies.
In implant conversation, you’ll see discussion of whether someone wants a pump, rod, or external device. Only the pump and rod are implanted.
There are medical external erectile device tools that can loop around and hold the penis stiff enough for penetration without another surgery. One example is a medical product called the Elator which some people elect over the typically final surgery of phalloplasty staging. There are other products and brands with varying levels of ‘medical’ quality. The Elator is custom sized. Some people use coban tape for some kinesic support under a condom, to have penetrative sex without an erectile device. Erection without a device external was important to me, so my decision was between pump and rod.
The pump operates through a reservoir, a hydraulic pump, a cylinder which hold the erection, and a button or mechanism to go flaccid. My model has a reservoir in my belly, pump and piston mechanism in one testicle, button to go soft on the cord like the vas deferens/epididymis, and cylinder as a penile corpora. It is called the Coloplast Titan One Touch. In the USA our other option for three-piece pump is the AMS 700 and 700 LX. There are also simpler pumps with two pieces. The three-piece pump is the firmest option. The brands and models available are different from one country to another.
Myth busting: Did you know… The pump refers to the hydraulic mechanism within the implant, not to an external penile pump for an erection.
The semirigid rod is an option with fewer pieces to break than the pump, which bends up or down for sexual use and gives the penis enough structure to use for sex. I have friends who have these and really like them, too. These have a reputation as durable. The ones available currently in the USA are the AMS Spectra and Coloplast Genesis.
I asked Dr. Burnett if he is working on a design for a new intrapenile prosthesis which would have an app for collecting data on the device’s use. He chuckled. I suggested maybe it could be smart home compatible. Voice operated, even. Oh, the implications.
Testicular implants or prostheses are either AARTs (brand), custom-carved solid silicone, or Torosa silicone custom-filled with saline by Coloplast, These are the options in the USA, anyway. I have had both, and they feel similar to me, but I like the saline I have now.
Secret: I love the texture of the balls. They’re perfect. They’re made of the same gummy bear stuff as nice breast implant. Never touched those? They’re like Swedish Fish!