Anterolateral Thigh (ALT) Phalloplasty

Who it’s for

People who cannot accept a forearm scar. Or whose forearms are unsuitable because of size, hair, injury or a job that will not tolerate the graft. That is the group ALT exists for. It also suits people who are not set on standing to pee. The urethra is the part of ALT that is hardest to get right.

The thigh has to be lean. The fat under the skin sets the thickness of the phallus. A surgeon can thin the flap only so far before its blood supply suffers. Surgeons will pinch and measure the thigh at consultation and many decline ALT above a BMI they set themselves. If your thighs are heavy, a forearm flap, a back flap or a metoidioplasty may be what is left.

Most surgeons want a hysterectomy done first, and a vaginectomy with it if the urethra is being lengthened. Two letters of support in most systems, and nicotine stopped completely, because a flap this thick already has blood working hard to reach the tip. See eligibility.

Before you book

Write down, in one line, why the forearm scar is the deal-breaker for you, and then write what you'd accept to avoid it. If the second line doesn't mention size and feeling, you're not ready to choose ALT yet.

How it’s done

Standing, the surgeon marks the flap on the front-outer thigh over the small vessels that branch up from the thigh's main artery. A handheld Doppler, an ultrasound probe that picks up the pulse, finds them. The nerve that gives the outer thigh its feeling, the lateral femoral cutaneous nerve, is marked too, so it can travel with the flap.

Under general anaesthetic the flap is lifted with its vessels and nerve attached. Where the vessels are long enough it is tunnelled under the skin of the groin and swung into position while still connected. That is the pedicled version, meaning the flap stays on its own stalk of vessels, and it is the point of ALT. If the stalk turns out too short, the surgeon disconnects the flap and rejoins the vessels under the microscope in the groin instead, as a free flap. Some surgeons thin the flap before rolling it.

The flap is rolled into a shaft. If a urethra is planned it almost never comes from the thigh. It is built from a second, thinner flap such as a strip of forearm, or from the labia and the tissue of the closed vagina, and the shaft is wrapped around it. The clitoris is buried at the base and its nerve joined to the flap nerve. The thigh is closed with a skin graft, or directly if the flap was narrow, and drains go in.

The week before

Practise getting from bed to bathroom without bending the leg the flap is coming from. Set up where you'll sleep so nothing needs a step or a stair. The thigh is what will stop you moving, not the groin.

ALT phalloplasty recovery

A week or so in hospital, most of it lying still while the flap is checked. The thigh is the surprise. It is stiff, sore and swollen, and for the first fortnight walking is a shuffle. The graft site on the thigh weeps and needs dressing, and the outer thigh is numb where the nerve went with the flap.

A catheter stays in for several weeks if the urethra was lengthened, with a second tube draining the bladder through the lower abdomen (a suprapubic catheter) on top of that in most programmes. Then it is a slow return. Feeling in the phallus takes a year or two to arrive, and later stages each bring a shorter recovery of their own.

In the first month

Set an alarm and walk to the end of the hall every two hours you're awake, from the first day home. The thigh stiffens fast if you let it sit, and the shuffle of the first fortnight turns back into a walk sooner if you keep it moving.

ALT phalloplasty scars

On the thigh, a skin-grafted patch on the front-outer surface, roughly the size of a large hand. It sits flatter and paler than the skin around it. On a narrow flap some surgeons close the thigh directly and leave a long straight line instead. Either way it is covered by shorts and, unlike a forearm graft, nobody sees it unless you choose.

On the phallus, a seam runs the length of the underside where the flap was rolled. There are scars at the base where it meets the groin. Both fade over a year or two. If a second flap was used for the urethra, that donor site adds its own scar, and it is worth asking where.

Sensation after ALT phalloplasty

The flap brings the lateral femoral cutaneous nerve with it, and that nerve is joined to one of the clitoral nerves at the base. Feeling grows in from the base towards the tip over the first year or two. Most people get protective sensation along the shaft, and erotic sensation comes mostly from the buried clitoris.

The honest expectation is less than a forearm flap gives. The thigh nerve is a poorer match for the job, and thick tissue takes longer to wake up. Some people end up with a shaft that feels touch well; some end up with feeling mainly at the base. The outer thigh where the nerve was taken stays numb in a patch, and that part is permanent.

Risks and complications

The early risk is the flap. A pedicled flap is less likely to fail outright than a free one. But a thick flap has a long way to push blood, and partial loss at the tip and wound breakdown along the seam are more common with ALT than with a forearm flap. The thigh can collect fluid under the graft, and the graft can fail in patches.

If a urethra is built, fistula and stricture rates are at least as high as any other technique. The join between a second-flap urethra and the shaft is the usual weak point. The long-term complaint is bulk. A phallus too thick to be comfortable or to fit an implant is common enough that debulking, a later operation to slim it, is planned into most ALT sequences.

Then the general risks of a long operation. Infection, clots, blood loss, and the anaesthetic itself. The risk specific to ALT is the trade itself.

A hidden scar is a real gain. Bulk and weaker sensation are real losses. Nothing at a consultation should make either half of that go away.

ALT phalloplasty results

At a year, a phallus that is usually thicker and often longer than a forearm flap gives, with a donor site nobody sees. Girth pleases people who chose ALT for it and disappoints people who did not. One or two debulking procedures are the norm rather than the exception. Standing to pee depends on whether a urethra was built and how it has behaved.

What tends to disappoint is proportion. A thick shaft on a lean frame can look out of scale until it has been slimmed, and the tip is the part most often reshaped. An erectile implant is needed for penetrative sex, and a bulky flap can make fitting one harder.

Alternatives to ALT phalloplasty

The question that decides it is what you cannot live with. If it is a visible forearm scar, ALT. If it is a shaft that may need slimming and may feel less, the forearm flap. If the thigh is too heavy for ALT and the forearm is off the table, the conversation moves to a metoidioplasty or to one of the less common donor sites. That is a conversation for the surgeon, not a website.

Combining ALT phalloplasty with other surgery

Stage one usually bundles the vaginectomy, urethral work and scrotoplasty with the flap. The hysterectomy is done months earlier by most programmes, and folded into stage one by some. Glansplasty, debulking and erectile implants follow as separate stages, because each needs the shaft to have healed and, for implants, to have feeling. See surgery order.

ALT phalloplasty cost

ALT is quoted much as a forearm flap is, and the two land in the same range. What moves the total is the urethra. A second flap for it means a second donor site and a longer operation, and some programmes quote it as a separate item. Ask whether debulking is included in the plan or billed as a revision, because with ALT it is usually needed rather than possible.

Ask for the quote per stage and what each stage covers. Hospital nights are the other lever. Stage one is a week in, and the difference between a hospital and a surgical centre shows up there.

Choosing a ALT phalloplasty surgeon

Fewer surgeons do ALT than forearm flaps, and the ones who do it well have a clear view of who it suits. The two numbers I would ask for are how many ALT phalloplasties they do a year and their rate of partial flap loss at the tip. I would want the second as a figure, because the tip is where a thick flap shows its limits.

In photos, ask to see a healed result at a year on a body like yours, side on, so you can judge the proportion. Ask to see the thigh too. Then ask "how do you build the urethra, and where does it come from?" A surgeon who has thought about ALT has a fixed answer to that, and a pause is information.

At the consultation

Ask "how many debulking procedures do your ALT patients average?" A surgeon who says none is not counting. One who gives you a number, and says when in the sequence they do it, has planned for the bulk rather than hoping it away.

Frequently asked questions

Will the phallus be too thick?

It may well be, and debulking is planned into most ALT sequences. Thigh fat sets the thickness and lean thighs give better results. See results.

Can I have urethral lengthening with ALT?

Yes, but almost never from the thigh flap itself. Most surgeons build the urethra from a second, thinner flap or from labial and vaginal tissue. See how it's done.

Is ALT safer than a forearm flap?

The pedicled version avoids the microsurgical join, so total flap loss is less likely. Partial loss at the tip and wound breakdown are more likely, because the flap is thick. See risks.

Will I be able to walk normally?

Yes, after healing. The thigh is stiff for a few weeks and a patch of the outer thigh stays numb, but muscle function is usually unaffected.