Addressing the ideal requirements by free flap phalloplasty: some reflections on refinements of technique

Ideally, in phalloplasty one should aim at 1) a one-stage procedure that can be predictably reproduced, 2) creation of a competent neo-urethra to allow for voiding while standing, 3) return of both tactile and erogenous sensibility, 4) enough bulk to tolerate the insertion of a prosthetic stiffener, and 5) a result that is aesthetically acceptable to the patient. We consider 6) minimal scarring or disfigurement, and 7) no functional loss in the donor area further requirements for any ideal procedure. Thanks to ongoing refinements, microsurgical free flap phalloplasty techniques lead to the best results, both functionally and cosmetically. These refinements are presented and discussed, as are our experiences applying them.