Dr. Coon has extensive experience in all major phalloplasty techniques, including radial forearm flap (RFF), anterolateral thigh (ALT), myocutaneous lat dorsi (MLD) and abdominal phalloplasty. About 95% of his phalloplasty patients undergo urethral lengthening, which has a high success rate with the latest techniques. The majority of these patients travel to Massachusetts for their procedure and systems are in place to help find housing as well as virtual follow-up after returning home. The multidisciplinary BWH phalloplasty team includes urologists and gynecologists.

Dr. Coon is recognized as a leader in phalloplasty revision procedures, which only a few surgeons perform. He has one of the largest series of “redo” salvage phalloplasties for patients who had major complications during their initial surgery elsewhere. He has developed new surgical techniques for complex cases and outcome metrics (Post-Phalloplasty Urinary Function Test). He was also one of the Johns Hopkins surgeons involved in performing the world’s most comprehensive penis and perineal transplant in 2019.

About Phalloplasty

Phalloplasty is a reconstructive surgical procedure for the creation of a penis. It is indicated in cases of congenital genitourinary abnormalities (bladder exstrophy), after penile trauma or injury and for transgender men. Phalloplasty is a multi-staged procedure that may include a variety of different procedures, including creation of the penis, lengthening the urethra so you are able to stand to urinate, creating the tip (glans) of the penis, creation of the scrotum, and placing an erectile device and testicular implants to enable penetrative sex. It is important to note that each staged surgical plan is unique to each patient and may or may not include some or all of the above procedures.

The phalloplasty surgical approach is largely determined by patient goals.  Examples of these goals include standing to urinate, light-touch sensation, orgasm sensation, scar visibility, length/width of penis, and ability for penetrative sex.  A patient whose number one priority is to stand to urinate and have erogenous sensation may have a different surgical plan than someone who does not care about sensation as a goal for surgery.

Phalloplasty staging is most commonly staged out accordingly:

Stage one: 

Penis is created from donor site (forearm, thigh, flank, etc.), and if urination through the penis is part of the surgical plan, the penile urethra is formed using a tube-in-tube method. This new urethra is created but not connected to the bladder. A blood supply to the new penis is created by suturing together tiny 1-2mm arteries and veins under a surgical microscope and nerves are coapted to provide sensation. Recovery time varies depending on the surgical plan. If forearm is chosen as the donor site, a dermal regeneration template can be placed at this initial surgery to help improve scar appearance and reduce scar contracture.

Stage 1.5:

When a dermal regeneration template is placed in stage 1, an additional surgery is needed to remove the material and place a skin graft on the forearm donor site.  This procedure is typically done as a 1-2 hour outpatient procedure.

Stage 2: 

During this surgery, additional functional components are addressed according to the surgical plan decided on prior to the first surgery.  In this stage, the surgical team addresses the following:

  • Urethral hook-up: if a patient decides on urethral lengthening, the penile urethra is created in stage 1, but not connected to allow it to completely heal prior to use. In stage 2, the perineal urethra is completed and this is connected back to the native urethra and bladder to allow voiding through the tip of the penis once the patient has healed from surgery. 
  • Creation of scrotum:  for patients who need a scrotum, a V-Y scrotoplasty is most commonly used to create one. Tissue expander devices are occasionally necessary if there is a shortage of tissue.
  • Vaginectomy: Many trans patients opt for closure/removal of their native vagina; however, this is not a necessity in phalloplasty staging unless urethral lengthening is being performed.
  • Creation or revision of the tip of the penis:  At this time, the surgical team will create or revise the glans of the penis to create the most natural looking aesthetic result.

The vaginectomy procedure is performed by one of our urologist or gynecologist team members, while the other procedures are typically performed by Dr. Coon. It is important to note that since each surgical plan can vary, these steps can be combined a variety of ways.

Stage 3:

Typically the last surgery in the planned surgical process, in this stage the testicular implants and penile prosthetic device is placed.  This is usually an outpatient or overnight procedure. Erectile devices are placed by one of our reconstructive urologist team members. Both malleable and inflatable devices are offered.

It is important to understand that each stage is a major surgery and the complete staging process can often take more than 12 months to complete.  This allows the patient to heal from each stage, which helps minimize complications and improve outcomes.

These should be considered general staging guidelines and depending on a patient’s situation their individual plan may vary. In particular, revision patients presenting to Dr. Coon after complications from prior surgeries will typically require a unique surgical staging plan based on their particular surgical history.