How to Prepare For Your Phalloplasty Surgery

Numbers for Your Surgical Team

Urgent Issues or any Issues 5pm-8am, or Weekends:

  • Call 801-581-2121
  • Ask for the plastic surgery resident on call

Non-Urgent Issues/Questions Monday-Friday from 8am-5pm:

  • Penis-related issues: call plastic surgery at 801-581-7719
  • Urinary catheter issues: 801-213-2700 (option 2)

If you’re considering getting phalloplasty or “bottom surgery,” it’s important to know what to expect. We’ve made this guide for all patients who are considering phalloplasty.

Before your surgery, there are a number of things you’ll need to do to prepare.

This guide covers the following things:

Before Your Phalloplasty

What to Expect During Surgery

Recovery

Disclaimer

This document has information and/or instructional materials developed by the University of Utah Health’s Transgender Health team for the typical patient considering or undergoing phalloplasty. It may include links to online content that were not created by University of Utah Health’s Transgender Health team and for which the Transgender Health team does not assume responsibility.

Information in this document does not replace medical advice from your health care provider because your experience may be different than the typical patient.

Talk to your health care provider if you have any questions about this document, your condition, or your treatment plan.

How to Find Out If Your Insurance Covers Transgender Care

Before considering phalloplasty surgery, it’s important to find out if your insurance covers transgender health benefits.

We recommend that you call your insurance provider and ask if they cover specific procedures.

We’ve listed the CPT codes below in a PDF. Read the CPT codes to your insurance provider and ask if they cover these procedures.

Download a PDF of insurance codes

Hormone Therapy Before Surgery

All patients who are considering phalloplasty surgery must complete 12 months of continuous hormone therapy before getting surgery.

If you’ve already had hormone therapy for gender dysphoria for at least the past 12 months, we’ll need this information from your doctor.

Ask your doctor to send us the following information:

  • Patient’s legal name and preferred name
  • Patient’s date of birth
  • Date provider and patient relationship began, and frequency of interaction
  • Date the provider began prescribing hormone therapy
  • Has the patient undergone a minimum of 12 continuous months of hormone therapy for treatment of gender dysphoria?
  • Is the hormone therapy specifically for the treatment of gender dysphoria?
  • If there is a contraindication to hormone therapy, explain why

Letters of Support From Your Mental Health Professional

Before your phalloplasty, you’ll need to show you’ve had six months of well documented mental health care before your phalloplasty consultation (see letter guidelines below).

We need 2 letters of support:

  1. One letter from a clinically licensed mental health provider with knowledge of gender identity, WPATH Standards of Care, and ability to provide support for you having gender affirming surgery (link to our list of providers)
  2. One letter from your hormone prescriber (link to our list of providers)

Ask your health providers to email letters to:

Christie.Sandberg@hsc.utah.edu

Letter Guidelines:

We Need the Following Info From Your Mental Health Care Provider

  • Patient’s legal and preferred name
  • Patient’s date of birth
  • Date provider and patient relationship began, and frequency of interaction
  • Discuss the patient’s gender transition history
  • Does the patient have a diagnosis of Gender Dysphoria? Gender dysphoria includes:
    • A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics
    • A strong desire to be rid of one’s primary and/or secondary sex characteristics
    • A strong desire for the primary and/or secondary sex characteristics of the other gender
    • A strong desire to be of the other gender
    • A strong desire to be treated as the other gender
    • A strong conviction that one has the typical feelings and reactions of the other gender
  • Does the patient satisfy the WPATH criteria for metoidioplasty or phalloplasty? These criteria include:
    • Persistent, well documented gender dysphoria
    • Capacity to make a fully informed decision and to consent for treatment
    • Age of majority in a given country (18 years of age, in USA)
    • If significant medical or mental health concerns are present, they must be well controlled
    • 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones)
    • 12 continuous months of living in a gender role that is congruent with their gender identity;

Hair Removal Before Your Surgery

Some patients get hair removal before their phalloplasty surgery. During your consultation, we’ll help you decide whether you should have hair removal. It will depend on the part of your body.

Lifestyle Changes Before Surgery

Before having phalloplasty, your BMI will need to be less than 35.

You’ll also need to quit smoking.

If you are actively smoking at the time of your consultation, we will perform a cotinine urine/blood test 6 weeks before surgery. You must have a negative test, or we will reschedule/cancel your surgery.

Hysterectomy & Oophorectomy

Before having phalloplasty surgery, you’ll need to have surgeries for hysterectomy and oophorectomy (removal of your ovaries). You’ll need to have these surgeries at least 8 weeks before your phalloplasty surgery.

We won’t perform a hysterectomy or oophorectomy during your phalloplasty surgery.

Consultation for Phalloplasty

During your consultation, you’ll meet our surgeons and staff. You may meet one of our plastic surgery resident MDs (doctors). All of our staff have completed Transgender Sensitivity Training to educate and inform our team, and make your experience the best it can be.  

Please let us know if you have any concerns during your appointment (from registration at the front desk, to your consultation, to your parking). We want to improve wherever we can.

During your consultation, your surgeon will review and discuss your history, including when:

  • you first knew you were a transgender individual,
  • how long you have been living in the male gender role,
  • when you started hormones, and
  • who your mental health and primary care providers are.  

Your two letters of support from mental health professionals will be reviewed. Your medical and surgical history will be reviewed (past medical problems, surgeries you have had, medications you take, allergies you have to medications/latex/adhesives/foods, smoking status). 

Your surgeon will also ask about any risk factors for blood clotting issues (past deep vein thrombosis or pulmonary embolism), or bleeding problems (like hemophilia), or family/personal history of problems with anesthesia.  

You will be given a hospital gown/robe to wear. This allows your surgeon to perform a physical exam and allows you to cover any parts of your body that are not being examined. The gown helps us respect your privacy, but still be able to examine your body (it also keeps you warm!). 

Specifically, the exam will involve the standard heart and lung exam, as well as looking at your arms, abdomen, genital area, and legs. This is a very comprehensive exam with the goal of finding the best surgical options for you, and identifying any potential issues that may make one surgical option better than another. 

For example, the surgeon will perform an Allen test on your forearms. This involves applying pressure over the two arteries that supply your hand, and then sequentially letting go of each artery.  This test looks at the blood flow to your hand and can show if your whole hand is getting blood from each of these two arteries. If your hand gets blood from both the radial and ulnar arteries, a radial forearm phalloplasty is a potential option for you.  

Your abdomen will be examined for scars, hernias, and rashes. 

We’ll also look at your groin and leg pulses to get a sense of the blood flow to your legs. 

Your surgeon will also examine your clitoris, labia minora, and majora (the outer part of the vaginal area), and vagina.  

You and your surgeon will discuss the best surgical plan for you.  

With your written permission, we may also take pre-operative photographs. Photographs help us document any findings from your exam that will influence your surgical plan.  

Preparing for Your Phalloplasty

Diet

Eating a high protein diet in the month leading up to your surgery is generally a good idea. Your body uses protein as a building block for healing.

Albumin is a protein your body makes, and a marker of how good your nutrition has been over the last month. An albumin level of less than 3.5 grams per deciliter (g/dL) can be a sign of malnutrition. If this is your situation, you may want to talk in depth with a nutritionist to help your overall health and healing.  

Also, a daily multivitamin is also a good way to make sure your body has all the elements needed for healing.

Labs

You’ll need to get these labs before your surgery:

  • Complete Blood Count (CBC)
  • Comprehensive Metabolic Panel (CMP)
  • Type and screen

Bowel Prep Before Surgery

Please purchase these over the counter supplies at a pharmacy:  

  • Magnesium Citrate Oral Solution, 10 oz.  
  • Fleets enema  
  • Dulcolax tablets (bisacodyl tablets)

Two days before your surgery, stop eating these foods:

  • fruits with seeds,
  • peas,
  • red meats,
  • dairy,
  • beans,
  • nuts,
  • spicy or fried foods

On the day before your surgery:

  1. Take the magnesium citrate 24 hours before your surgery
  2. Stop eating solid food after lunch and drink only clear liquids
  3. Do not eat or drink after midnight
  4. Clear liquids that are OK to drink are: Water, tea, sports drinks, black coffee, clear broth, popsicles.  Don’t drink red or purple drinks
  5. Take two dulcolax tablets during the morning before your surgery
  6. Use one fleets enema during the afternoon the day before surgery

Surgery Day: What to Expect

When & Where to Show Up for Surgery

The day before surgery, a member of our pre-op team will call you to let you know what time and where to arrive. Most surgeries will require you to arrive by 6am.  

Unless we ask you otherwise, please show up to University of Utah Hospital’s main lobby, and then take the main elevators to the 3rd floor.  

From there you will take a left and walk to the Same Day Surgery area. The pre-op nurses will guide you to a pre-op room. 

How Long Does Phalloplasty Surgery Last?

Your surgery can take 6-8 hours, or more.

Your home support team will be able to stay in the surgical waiting room, and can give their contact information to the waiting room receptionist there. Our receptionist will contact your home support team when your surgery is over.

The Surgery Waiting Room phone number is 801-585-2280

Recovery After Your Phalloplasty: What to Expect

How Long Will I Stay in the Hospital?

Plan to stay in the hospital for at least 5 days after your surgery.  

For example, if your surgery is on a Monday, you should plan to stay through Saturday.  

You may need to stay longer if the surgery team has any concerns that require you to be cared for in the hospital. For example, you may need to stay longer in the hospital if you have:

  • infection,
  • phallus blood flow issues,
  • bleeding, or
  • you have a hard time eating or drinking because of nausea, pain control problems, or other issues.  

Your surgery team will discuss all plans with you.

Managing Pain

You will have a “pain button” or patient controlled anesthesia (PCA) button. This will let you control delivery of pain medicine when you need it. 

Days 1 & 2 in the Hospital

  • After your first 24 hours in the hospital you’ll slowly be given a diet to make sure you are not nauseated.  
  • You will be given sequential compression devices (SCDs) on your legs, which gently squeeze your legs and help prevent blood clots.  
  • You will be given a daily aspirin to help prevent small clots from forming at the blood vessel connections to your penis and groin area.
  • You’ll start taking home medications as soon as possible, depending on what these medications do.

Days 2 & 3 in the Hospital

For the first 2-3 days after your phalloplasty, you will stay in a special hospital unit where you will be checked on every 1-2 hours.  

The surgery and nursing team will check your phallus (penis’) color, capillary refill, temperature, and doppler signal.

A doppler machine will be at your bedside and is attached to a wire that ultimately is attached to a probe around the blood vessels that supply your penis. The doppler and frequent exams help your team make sure that your penis is getting enough blood flow. This helps us make sure that if there’s a problem with your phalloplasty, we catch it early and act quickly.

You won’t be allowed to eat or drink for the first 24 hours after your surgery. This is because you may need to return to the operating room in the case there’s a problem with your phalloplasty.  

We hope these frequent checks help you feel comfortable and that you’re getting the care you need.  

Blood Flow & Phalloplasty Surgery

Your penis will be elevated on a special dressing to make sure that blood flow isn’t blocked. As you can tell, blood flow is extremely important for a successful phalloplasty. We take great care to make sure your new penis is getting the blood flow it needs.

Days 3—5 in the Hospital

3 to 5 days after your surgery, you’ll be transferred a less acute surgical unit where you’ll be checked on less often.  

On day 5:

  • Your skin graft VAC dressing will be removed and then redressed with Xeroform gauze, kerlix gauze roll, and your splint
  • Your groin and scrotum drains will be removed
  • The doppler wire will be cut
  • You will be given supportive underwear (you can bring your own, but it must be OK’d by the surgery team to make sure it’s adequate)

You will be allowed to walk with assistance. Physical therapy may be involved in your care to help with this transition and give suggestions to help you get around. 

Urinating With a Catheter

A suprapubic catheter (a tube placed through your skin above your pubic bone and into your bladder) will drain your bladder for the first few weeks after surgery. The urology members of the team will manage this catheter. 

There will also be a red catheter in your penis which will hold your new urethra in an open position. Your surgical team will remove this catheter before you leave the hospital.

Drain Care

  • Your scrotal drain will usually be removed before you leave the hospital
  • The Penrose drain will usually be removed from your groin area while you’re staying in the hospital
  • The VAC dressing will usually be removed on post-op day #5
  • IV catheters will be removed before you leave the hospital

When Can I Leave the Hospital?

You may be discharged from the hospital when you meet discharge criteria:

  • Your penis looks healthy and your surgery team doesn’t have any concerns
  • Your pain level can be managed by making medicine by mouth (oral medicine)
  • You’re not too nauseous, and you can eat and drink enough
  • You can walk without needing help

What Prescriptions Will I Need After Leaving the Hospital?

You will be sent home with prescriptions for these medications:

  • pain medications
  • stool softeners
  • anti-nausea medications
  • antibiotics
  • aspirin for one month (then stop)

Supplies you may wish to purchase ahead of time:

  • Xeroform 5”x9” gauze, box of 50: can be found at specialty pharmacies or on Amazon (around $45/box)
  • Kerlix gauze bandage 4½ x 4⅛ yard rolls x 6 to 12 rolls: same as above.
  • Bacitracin-zinc ointment

How to Take Care of Your Penis, Scrotum, & Skin Graft After You Leave the Hospital

How to Take Care of Your Penis

Do these things to care for your penis after you get out of the hospital:

  • Keep your penis in an elevated position: Use your penis elevation dressing we gave you when you’re in bed, just like you did in the hospital
  • Support your penis at all times. Wear supportive underwear when walking (just like in the hospital)
  • Do not bend, kink, or sit on your penis
  • When sitting, don’t flex your hips more than 90 degrees. Do not sit with your thighs against your chest because this can squeeze the blood flow to your penis.
  • Rub bacitracin ointment to the cuts (incisions) on your penis twice a day
  • Watch for any changes in your penis’ color (purple, pale, red, etc.), temperature (hotter or cooler than you have felt in hospital), swelling, or drainage

Sex With Your Penis

Do not use your penis for any sexual activities until your surgeon says it’s safe and gives you permission. This includes no oral, vaginal or anal insertion. 

How to Take Care of Your Scrotum

  • Rub bacitracin ointment to the cuts (incisions) on your scrotum twice each day
  • Watch for any redness, drainage, or developing dark areas on your scrotum. Let your surgery team know if any of these things happen; they could be signs of infection or poor blood flow.  
  • It’s OK to get your scrotum wet in the shower.

How to Take Care of Your Skin Graft

Weeks 1 & 2 After Getting Out of the Hospital

Do these things every day:

  1. Remove your old dressing
  2. Look for any blisters or skin graft lifting off of your tissues
  3. Cover your skin graft completely with a single layer of yellow Xeroform gauze
  4. Then gently wrap your hand and forearm with Kerlix gauze roll
  5. Then replace your splint

Don’t get the skin graft wet until your surgeon tells you it’s okay (usually week 3).

Week 3 After Getting Out of the Hospital

If your surgeon okays it, you can stop arm dressings and leave your skin graft open to air.  

Start massaging any large scars on your forearm and groin.

It’s OK to start using a water-based moisturizer and gently rub it over your graft. Don’t shear your graft. Follow your surgeon’s instructions if your graft isn’t completely healed.  

How to Take Care of the Skin Graft Donor Site (on your thigh)

  • The area where the split-thickness skin graft was taken is usually covered with yellow Xeroform gauze.
  • When you go home, leave the Xeroform dressing on your leg open to the air (don’t cover it with a bandage or cloth).
  • Don’t put any moisturizers, creams, medications, or water on it, and DO NOT REMOVE THE DRESSING!! (it will bleed).
  • The Xeroform will become incorporated into a scab over the donor area. It will then peel up from the edges as it starts healing. You can trim the edges with scissors as needed, and they will eventually fall off on their own.  You can also use a hair dryer with low or no heat for 10 minutes twice a day to help dry the Xeroform/donor site.

As the Xeroform dressing is trimmed away at the edges, you can put a water based skin moisturizer to the uncovered areas to keep the new skin moist. You should rub lotion on the whole area after the dressing falls off. 

The area will look pink/purple at first, but over the course of the next 6-12 months your skin will become lighter colored, and look more like the skin around it.  It’s not unusual for the skin graft area to look slightly less or more pigmented than the surrounding skin, even after it’s healed.

Your Catheter

  • Your surgical team may remove your neo-urethra catheter before you leave the hospital
  • Your suprapubic bladder catheter will stay in place, to gravity drainage bag (leg bag)

Showering & Physical Activity After You Leave the Hospital

Showering

  • Keep the forearm skin graft dry; use a bag to cover it when you shower
  • Sponge bathe for the first week after you get out of the hospital
  • After one week, you can wash your penis gently with warm soapy water, and pat dry. Don’t submerge your penis, scrotum, groin area, or arm in water until your surgeon tells you it’s safe. No baths, hot tubs, swimming, etc.
  • The skin graft on the penis glans area may get wet after one week home, along with your penis
  • Generally, you can get your arm skin graft wet during week 3 of being home from the hospital

Physical Activity

  • Support and elevate your penis (as talked about above)
  • Get physical therapy for your hand/forearm (as noted below)
  • Don’t lift anything heavier than 5 pounds with your arm that had the skin graft
  • Don’t flex at your waist more than 90 degrees
  • Walk at least 4 times each day, for at least 10 minutes
  • Make sure you are urinating through the suprapubic catheter/leg bag system
  • Make sure you are moving your bowels at or close to your normal bowel habits (narcotic pain medications can cause constipation). Stay hydrated, and use the stool softeners we gave you to help prevent constipation.

Physical Therapy For Your Hand

  • Keep the splint that the hospital gave you on your hand until your hand therapy follow up appointment (2 weeks after you get out of the hospital). It’s OK to move your fingers, but don’t lift anything heavier than 5 pounds
  • Week 2-3 you’ll start working with a hand therapist to improve your range of motion at your fingers and wrist. Hand therapy usually lasts for 2-4 weeks, but depends on your progress.
  • Find a list of certified hand therapists in your area by visiting the Hand Therapy Certification Commission website
    • Click on “CHT Directory” and enter your zip code

Things to Watch For & When to Call Your Surgical Team

  1. Change in penis’ color, temperature, girth (this could be a sign of a problem with the blood flow into or out of your penis). If this happens, it’s very important to call us as soon as possible—Call the Main Hospital number at 801-581-2121, and ask for the “Plastic Surgery Resident On Call”)
  2. Increased swelling in your groin
  3. Your temperature by thermometer under your tongue is more than 100.40F (380C)
  4. Feeling “chills”
  5. Difficulty breathing, or pain with taking a deep breath
  6. Leg swelling or pain
  7. Groin swelling or increased pain
  8. Feeling light headed or “fainting”
  9. Your suprapubic catheter isn’t draining (Call the main University Hospital number at 801-581-2121, and ask for the “Urology Resident On Call”)
  10. Any questions you have about your care

Important Numbers to Call

Urgent Issues/Questions Anytime, or Any Issues 5pm-8am, or Weekends

  • Call the main University Hospital at 801-581-2121
  • ask for the “Plastic Surgery Resident On Call"

Non-urgent issues/questions Monday-Friday during daytime hours (8am-5pm):

  • Penis-related issues: Call the Plastic Surgery Office at 801-581-7719
  • Urinary catheter issues: 801-213-2700 (Option 2)

Your Plastic Surgeon: Isak Goodwin, MD

Your Urologist: Jeremy Meyers, MD; Jim Hotaling, MD