FtM Penis Surgery: Stage 1 of 3
Ultimate FtM Bottom Surgery using Musculocutaneous Latissimus Dorsi Flap

Overview  |  Introduction  |  Stage 1  |  Stage 2  |  Stage 3  |  Revisions

Musculocutaneous Latissimus Dorsi (MLD) Flap plastic surgery phalloplasty, popularly referred to as “Perovic Total Phalloplasty”, is an excellent solution for both adult and child patients that need extreme male genital modification, including:

The major phalloplasty advances developed by the Sava Perovic Foundation have enabled the creation of a large penis (neophallus) that:

Patients can choose the penis size they want up to 7 inches (18 cm) long with a circumference up to 5.9 inches (15 cm). Much longer and much larger is possible but usually inadvisable.

It allows “easy” urethroplasty and enables safe, effective penile prosthesis implantation regardless of whether the person chooses a big penis or average penis size.

Phalloplasty female to male photos: phalloplasty surgery results 7 inches (18 cm) long with 5.9-inch (15 cm) diameter

For young boys, a longer then normal penis for the particular age of a child is created because a neophallus does not follow normal genital growth in the child, only somatic growth, so must be adult-size from the start.

For decades, surgeons have been using a radial muscle from the forearm of patients to create a rather ineffective neophallus.

This old technique, sometimes called forearm free flap phalloplasty, is still widely used by plastic surgeons.

In some areas is it still marketed as “The Gold Standard”.

But in reality it has many serious drawbacks, including:

Penile implants can be safely inserted into Perovic Total Phalloplasty patients

The goal of modern Perovic Total Phalloplasty is optimizing long-term sexual, cosmetic and voiding outcomes — a penis that looks good and works well.

For example, patients are able to urinate standing up — true point-and-shoot-like-a-fire-hose capability.

This penile reconstruction has THREE stages.

Three to six months must be allowed between the first and second stages and again between the second and third stages to allow healing and get the best possible final surgical result.

All aspects of this complex and pioneering procedure were first approved by the ethics committee of the University of Belgrade's School of Medicine.

Informed consent for the surgical treatment has always been obtained from all patients.

By early 2008, Professor Perovic and Dr Djinovic had performed this procedure on more than 80 patients.

Phalloplasty female to male photos: Total Phalloplasty results in better than average penis length and full penile erection with penile implants following transsexual surgery

More than than 60 of the patients were FtM transsexuals.

And many people think Total Phalloplasty the best FtM bottom surgery, providing the ultimate gender reassignment surgery results.

However, the Professor said: “Total Phalloplasty is indicated in [natal] men without a penis or with a micro penis insufficient for sexual intercourse, as well as for transsexual patients.”

This procedure is one of the most demanding, complex and challenging tasks in genital reconstructive surgery but the benefits for patients are great.

The the creation of a new penis using the musculocutaneous latissimus dorsi flap, called the MLD flap, for has achieved results significantly superior to those of most of the past century and all other comparable procedures.

The latissimus dorsi used in this phalloplasty is the broadest muscle of the back comprised of a pair of flat, triangular-shaped muscles across the middle & lower back.

Perovic Total Phalloplasty is among the most demanding tasks in genital reconstructive surgery but creates a superior new penis

Overweight is the biggest obstacle to a good result.

Dr Djinovic advises that: “The patients should not be obese in order to be able to create a normal size penis — not too thick — and they should prepare the donor area skin by intensive massage in order to increase skin elasticity and to enable us to close the donor site defect directly.

“The massage is best done by a professional.

“All skin should be treated in directions shown by the arrows on the full-screen version of the photo on the right.”

This is a key part of the process. Read our advisory on donor site preparation and study the training video.

The MLD flap massage should be done at least one month before surgery. It should be superficial and involve only skin and subcutaneous tissue.

Dr Perovic said: “If the subcutaneous fat is thicker then 3 cm it is very hard to tubularize it and create the penis.

“Also that penis would be too thick for sexual intercourse.

“In these cases
[high BMI] we advise patients to lose weight.

“O
r, if it is difficult for them, then we advise liposuction of the donor regions 1-2 months before surgery in order to decrease its thickness.”

World's best FtM transsexual surgery with latest FtM prosthetics: Perovic Total Phalloplasty Stage Three

In the ‘Free Flap Reconstruction of Head and Neck Defects’ report of the Medical Branch Department of Otolaryngology at the University of Texas, doctors Muller, Newlands & Pou report:

Decreased flap perfusion, hypercoagulation, and impaired wound healing have been associated with smoking.

“Thus, smoking should be discontinued for at least one week prior to surgery and forbidden in the postoperative period.

Obesity may also decrease the success of free tissue transfer
as the increased adipose tissue makes dissection of the vascular pedicle more difficult and interferes with the microvascular anastomosis, insetting, and flap tailoring after transfer.

Patients older then 50 with hypertension must get a color doppler of the blood vessels in the legs (femoral vessels) before surgery.

Patients are admitted to the medical facility one day before surgery for standard pre-operative analyses, diet control, and bowel preparation.

MLD flap Perovic Total Phalloplasty using the musculocutaneous latissimus dorsi flap

Since 1999, this plastic surgery phalloplasty has been performed successfully with a remarkable level of success.

Patients have ranged in age from 10-years-old to middle-age.

All patients have been satisfied with the function of the penile implants.

Until the present, no patients have reported any muscular weakness after surgery.

Scarring at the donor-site is usually moderate.

FtM Phalloplasty female to male operation causes only moderate scarring

More than 80% of patients have been satisfied with the appearance of the area from which the MLD flap was taken.

Because all the tissues of the upper torso have relaxed and wound-tension is minimal when Stage Three is performed, donor site scar revision is sometimes done then to achieve a pencile-line scar and better aesthetics.

Hospital stay after the first stage is usually seven days or less.

Only about 7% of patients have experienced any complications.

All of which have been successfully treated with minor surgery.

FtM gender reassignment Perovic Total Phalloplasty Stage Three is the ultimate FtM surgery

One patient suffered partial flap necrosis in mid-2008 due to a unique vascular drainage problem.

The MLD flap gets an excellent blood supply because of a large and reliable subscapular artery and its two branches, the circumflex scapulae and thoracodorsal artery, as well as two concomitant veins which join to form a single large thoracodorsal vein.

Insufficient blood circulation in donor tissue makes it inappropriate for a neophallus.

Dr Perovic explained: “At the time of flap elevation it appeared OK, but the problem started later — after surgery.

“It
[the neophallus] was struggling for several weeks to survive which was very unusual.

“When a flap fails it becomes necrotic very soon after surgery, not like in his case.”

Corrective surgery is done for free.

Some necrosis has occurred. A couple of flaps have failed. But all patients, 100%, have eventually received a satisfactory surgical result, even in cases where the flap failed because the patient hid pre-existing conditions from the surgeons such as sickle cell anemia.

Dr Djinovic is now able to identify insufficient vascularization immediately upon removing the MLD flap. If this is encountered, the:

Phalloplasty female to male photos: FtM Total Phalloplasty is the crowning female to male operation

Almost all reasons for unexected postponement of surgery are totally preventable by the patient (except insufficient vascularity):

MLD Flap Perovic Total Phalloplasty using the musculocutaneous latissimus dorsi flap

Any of these problems would delay surgery at least six weeks or longer. In recent years, patients have come well informed and well prepared so postponement of surgery has been very rare.

Sava Perovic Foundation's high rate of success and low incidence of complications are unique and not standard for flap transfers.

Other surgeons experience a much higher rate and greater variety of complications including,:

A treatable infection after penile prosthesis implantation occurs in a small percentage of Stage Three patients.

Plastic surgery phalloplasty Sava Perovic Foundation superior penile surgery

In cases of natal male penis injury, treatment should be immediate to prevent complications caused by delay such as infection, curvature, erectile dysfunction, missed urethral injury and chronic pain.

However, severe penis injuries can be associated with injury of adjacent organs and the scrotum, pelvis and buttock so staged treatment may be recommended.

Suitable candidates for this surgery include:

Phalloplasty female to male photos: Perovic Total Phalloplasty

Dr Djinovic advises FtM transsexuals to be aware that: “Most of the surgeons/gynecologists who perform oophorectomy and hysterectomy do NOT perform vaginectomy because it is a risky procedure with possible bleeding and many other complications.

“All they do is close the vagina leaving only a small opening for drainage of its secretion.

“But the problem is that when persons with this are sexually aroused, they have abundant secretion and a lot of wetting.

“We perform vaginectomy routinely and advise it for all patients before Perovic Total Phalloplasty.”

The glans is designed over the distal 5 cm of the flap.

Originally, a one centimeter wide skin strip between the future glans and penile shaft is de-epithelialized to imitate the coronal sulcus.

Actual glansoplasty is now usually done as a component of Stage Three unless the patient's requirements are not standard.

Perovic Total Phalloplasty: urinate standing up, have sexual intercourse and have an orgasm

Only a small strip of muscle around the blood vessels is isolated, to decrease flap bulkiness and allow its safe tubularization.

During Stage One surgery, while one surgeon is constructing the neophallus, a second surgeon prepares the recipient site simultaneously and a third prepares the skin graft for the Stage Two Step One urethroplasty.

After surgery, the new penis is elevated off the abdominal wall for 7–10 days using a specially-constructed dressing, which is important to prevent pedicle kinking.  Read more … Total Phalloplasty Stage 2




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