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Phalloplasty Stage Two

Michael's Day to Day, Matter of Fact Account

by Michael
Article appeared in Polare magazine: August 2000 Last Update: October 2013 Last Reviewed: February 2014

The penis has now been completed. All that remains is to detach the blood vessels which are still supplying blood to the phallus.

This is a huge operation which can take from five to seven hours, there is a lot of trauma to the body both physically and emotionally ...

Okay, this is the big one, the last and final stage where the penis is fashioned from a flap from the forearm. The arm is used, because the blood and nerve supply is excellent for the penile graft. This stage can be done three to six months after the first stage which I described in the previous article.

For this operation you have to be in the best physical, mental and emotional state that you can be in. If you are a smoker, please try to cut down or if you can, give cigarettes up completely two or three months before the surgery date. If you're carrying a bit of excess weight, try and lose it, cut out junk food and go slow with alcohol. Exercise and work at being in the best physical shape as possible. This preparation is very important.

This is a huge operation which can take from five to seven hours, there is a lot of trauma to the body both physically and emotionally, approach this as if you are running the marathon of your life. You should prepare yourself mentally in the same way. Put your mind in order the same way you put your body in order.

Learn some meditation techniques to de-stress yourself so that if a problem arises you are able to cope more easily. Make sure you have no work problems, money worries, try to have everything in order. Organise a support network with your partner, family and friends so that whilst in hospital and recuperating at home you have help if it is needed. Some of these things I did, but a lot I didn't and paid the price quite highly.

I moved to Victoria in late January thinking that two months was plenty of time to organise all of the above. I was so wrong. Even though through the kindness of people I had just met, my accommodation problems were solved, I still hadn't stopped smoking and I was very stressed out over a lot of things, so that by the time I entered hospital I was physically and emotionally exhausted and in no fit state to cope with what was to come. Please organise your life well before surgery so that the healing process can proceed smoothly.

In Victoria this procedure is now well advanced and a lot of the problem areas have been solved. The Surgical team have performed about fourteen of these procedures with a high success rate.

The most common problems are Strictures (scarring) and Fistulas (leaks). For myself I had minimal problems in these areas and am delighted with the end result. This was the last stage of my journey towards completions and the start of the rest of my life. I was very aware of my physical state but was very confident that these would be no major problems with this operation.

The penis has been fashioned and is now detached from the arm.

I returned to Peninsular Private Hospital on the 6th April and met up with all my old friends there, it was good to see them all again and to know that they were there to support me on all levels.

The operation was scheduled for 7:30am the next morning so all preparation work was done that night. The anaesthetist explained what he would be doing during the operation as well as the pain relief regime post surgery.

I had asked Dr. Hunter-Smith (David), if one of the nurses, Sue, could take photos of the operation because I was very interested in knowing what was going to be done. When I was wheeled into theatre he told me he would video it for me if I wanted. That was the last thing that I remembered. Thankfully I have the photos and video and have been able to see what was done.

Once asleep a tourniquet is put round the upper arm to cut down the blood supply to the donor site. Dr. Ceber then draws a diagram, like a pattern, on the arm, measuring very precisely according to the size you have asked for. He then proceeds to cut and fashion the penis.

This is all done with some blood vessels still attached to the arm so that it stays alive. The soft skin on the underside of the arm is rolled into a tube to form the urethral extension. A penile catheter is inside this tube to keep it open while it heals. It is placed in the centre of the skin flap which is now ready to be formed into the penis.

The head has been defined and once the shaft is sewn up, the head is joined and stitched. Once this has been completed it is detached from the arm and handed to David who has been preparing the site in the groin to receive the penile graft.

The arm is now ready for the skin graft which has been taken from the upper thigh. This skin is stretched until it looks like mesh. This enables it to cover the wound site completely so that it adheres to the exposed muscle. The graft is attached by staples and once completed the arm is dressed and splinted for support.

This procedure takes about four hours. Meanwhile, David has already started attaching the penis. This is a long involved process and requires micro-surgery for it to be successful. The two urethral ends are joined then the blood vessels and arteries and nerve ends.

The penis itself is stitched onto the body. Drain tubes are put in place and a supra-pubic catheter is attached. Once all this is done it is closed up. I had requested that larger testicular implants replace the ones I had in the first stage surgery as I felt they would be more in proportion to the size of the penis. This was the final part of the operation.

It was about 9:30pm when I woke in my room. It had been a long day for all of us. I was on a drip infusion of pain killers and hourly observations are taken of the penis to check for warmth, skin return and to make sure that it is kept straight and supported. This support is done with foam rubber.

The arm and hand are also checked to make sure there is no loss of sensation and that the fingers move and do not go numb. The first few days were quite a blur because of the pain killers but as these were eased off, I became more aware of what was happening. Staples are used on most of the wound sites and on day six the drain tube in the groin and the staples were removed.

Day eight and the remaining drain tube and the penile catheter is removed. All this was relatively painless. I was up and moving around very gingerly as I was suffering from a type of chronic fatigue. This really slowed the healing process for me so that I took everything very slowly. I didn't want anything to go wrong. I wasn't in a hurry to rush off anywhere and felt that if I took my time, everything would be more successful.

The raw patch at the base of the penis has caused problems in the past in some patients. Dr Hunter-Smith decided to wait until this area had healed before I attempted urinating.

Day nine and the plaster and dressing came off my arm and it was redressed. At this point it has to be kept dry.

Day ten - I was able to go to the bathroom so that I could soak the dressing off my leg, keeping the arm dry. This was relatively easy and was not too painful if done slowly. The graft site looks like a burn and once the dressings are removed an operation site dressing (plastic skin) is put on and left in place. It is more uncomfortable than painful.

At this point I had virtually no use of my hand and arm and needed a lot of help to bath and dress etc. It was also very painful at times. The pain seemed to come from nowhere. It was throbbing at times, then the pain would disappear as quickly as it came.

Once you are up and walking around the penis must be supported. It must not be bent at all as there is the danger of kinking off one of the two main arteries that feed the penis. One artery takes blood into the penis and the other takes it out. It is very important not to damage them. Sue devised a sling that I could wear so that I could walk around easily and no one would know why I was in hospital.

Day thirteen - I soaked the dressing off my arm in the bath and it was then washed and dressed daily. The healing process was already underway and it improved rapidly. By this stage I had been on antibiotics for two weeks and again suffered a thrush infection down below. If you are susceptible to this problem, be aware that it is possible to get repeated infections in that area.

Day nineteen - and the staples were removed from my arm. A bit painful but healing very well and already starting to fill out. Some of the stitches were removed from the base of the penis and a small raw patch at the base was treated three times a day with solu-gel to hasten healing. This is where, in some patients, problems have arisen. By now the patient has started to urinate and as the raw patch corresponds externally with the urethral join internally, leaks have occurred. David wanted to wait until this had healed before I attempted to pee.

Day twenty-five - the remaining stitches are removed from the base of the penis and I was able to walk without the sling. The next day sounds, which are long metal rods, are passed through the urethra to dilate it - not a pleasant experience.

Day twenty-seven - I attempted to pee but had a leak from the original site from the repair done in November last year. I was very disappointed, back to the theatre again, and another wait of ten days.

Day thirty-four and five days after the repair, sounds were again passed to dilate the urethra. This stretching is very important to stop scar tissue building up and keep the urethra open. This was now done daily, some pain was experienced each time.

David passed some dye through the urethra to check the repair. It was successful. There were no leaks anywhere.

By now I had been on the catheter for thirty-nine days. I was having problems with it constantly and had a bladder infection. This catheter had been resited when David did the repair but because of the infection, it was constantly blocking. It was treated with intra-venous antibiotics and cleared up quickly.

Day thirty-nine and the eleventh day of the repair. Pee day had arrived! After this length of time on the catheter, it is very difficult to pee, let alone pee from my new penis. It is a matter of clamping off the catheter, and trying to go naturally without straining and it took me the whole day before I had a successful result. It was very exciting and such a relief that this was really happening after all this time. The catheter remains attached until you are voiding large amounts through the penis and the residual left from the catheter is quite small. Dilation is done 7every day over this period and was still painful.

Day forty-four - it was time to leave hospital. It had been six weeks this time. I had gone through a lot, physically and emotionally. There had been times when I was ready to give up, when I couldn't be even a little bit enthusiastic about what I now had. I went through many emotional stages which I feel everyone needs to be aware of.

I went through a grieving process many times and found that a lot of old "stuff" came up. Things I thought I had dealt with years ago came up again, and the issues that were happening now had to be dealt with. I had a period of depression but thankfully had a lot of support from the nurses in hospital and once home, from the people I was staying with. They helped me get through it all. I don't think that I will ever be able to repay them adequately.

The nursing staff were very supportive and were always there in every way. Again as in the past, Sue came to the rescue many times as did David. They were aware of my fears and really understood my apprehension at each stage of the process and let me go at my own pace.

It is now nearly four months since my surgery and my arm has healed and is filling out. I have full use of it and except for some numbness around the wrist, I have no problems with it at all.

I am very pleased and proud of my penis and it is great to have the feeling of freedom that comes with it. At this stage there is still no feeling in it. This can take up to six months to happen. Before you can have the penile implant inserted full feeling in the penis must have returned.

This has been my story, the problems that occurred where also mine. Yours may not be the same. Progress has and is being made very rapidly and I am glad if some progress has been made from my experiences. I hope that I have been able to answer many questions and give you all enough information so that you can make the choice that is right for you.

The Surgeon draws a pattern of the penile shape on the forearm. From this pattern he is able to remove the exact amount of flesh required for the penis. Surgeons are cauterising the veins on the forearm while they are removing the flesh from the arm. Still working on removing tissue on the forearm. At this stage, the urethral tube has been made with a penile catheter inserted to keep the passage open whilst healing. The shaft of the penis is now being stitched up. The phallus is still attached to the arm via blood vessels so that the flesh is kept viable. The shaft has been completely joined and the surgeons are preparing to close the head. The shaft has been joined and stitched. While still attached to the arm, the head of the penis is now closed up. At the head end of the penis, you can see the ridge that defines the tip of the penis. This is was created before the shaft was joined. This shows the phallus shaft completely joined as well the ridge that defines the penis head shape is clearly visible just above the surgical instrument. Also showing is the penile catheter tube protruding from the tip of the head of the penis. The fully formed penis is still attached to the forearm. The penis has now been completed. All that remains is to detach the blood vessels which are still supplying blood to the phallus. The penis has been fashioned and is now detached from the arm. This is the machine that stretches the skin to a mesh like appearance which allows complete coverage of the wound site on the arm. The skin graft taken from the thigh is removed in two pieces. The skin has been stretched until it has a mesh like appearance. This is done in this way so the grafted skin adheres well to the wound site. Both skin grafts are now attached by staples. The stapler is visible in the surgeon's hand. Arm has been dressed and splinted for support. This shows the site where the penis will be attached. This photo shows the beginning of the attachment of the penis to the body. Clamps are visible on the right hand side of the photo. Blood vessels and arteries are attached to the penile graft with microsurgery. The surgeon has now attached both urethral ends. The abdomen and testicular implants are visible on the left hand side of the photo, with the phallus being supported by the surgeon. The gauze that helps to form the ridge at the head of the phallus remains in place for six days. The penile shaft is now fully attached to the area of the pubic bone. The dressings will shortly be applied and the patient is returned to recovery. The penile catheter is visible at the top of the photo as well as the gauze supporting the ridge. Dressings and support are being applied to the penis before the patient is returned to the ward. This is another view of the penis. Back in the Ward: This shows the foam rubber supporting the penis. Nurses are specialising in this type of nursing care at the hospital in Victoria. Staples have been used on the incision sites. Suprapubic catheter is attached just below the navel and the drain tube is below the incision line. Day 6: Staples have been removed and dressings applied. Drain tube has also been removed. Day 9: The plaster and dressings have been removed from the forearm. Wound is clean and granulating well. Day 10: The dressings were removed from the thigh donor site, in a bath. An op-site dressing is applied. The raw patch at the base of the penis has caused problems in the past in some patients. Dr Hunter-Smith decided to wait until this area had healed before I attempted urinating. Day 14: Staples are clearly visible along the perimeter of the graft. The healing process is well underway. Another view of the wound on the arm. Day 19: Staples have been removed. The small raw patches are from small adhesions to the dressing when it was removed. These healed very quickly. Day 40: As you can see, the arm is well healed and has continued to do so. Day 47: Self explanatory! The redness from the graft site on the left thigh has now faded considerably.

Polare Magazine is published quarterly in Australia by The Gender Centre Inc. which is funded by the Department of Family & Community Services under the S.A.A.P. program and supported by the N.S.W. Health Department through the AIDS and Infectious Diseases Branch. Polare provides a forum for discussion and debate on gender issues. Unsolicited contributions are welcome, the editor reserves the right to edit such contributions without notification. Any submission which appears in Polare may be published on our internet site. Opinions expressed in this publication do not necessarily reflect those of the Editor, The Gender Centre Inc., the Department of Family & Community Services or the N.S.W. Department of Health.

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