MLD (Back) Phalloplasty

Who it’s for

People who want a hidden donor scar and a good-sized phallus, and who have made peace with limited shaft sensation. That is the honest profile. It is also where surgeons land when the forearm and thigh are unsuitable, because of size, hair, previous injury or a thigh too thick to roll into a tube. Or when someone has decided a forearm scar is not something they will live with.

Two groups should look elsewhere. If sensation in the shaft is the thing you want most, the forearm flap is the better-documented route and the thigh flap comes second. And if you rely on your lats, as a climber, a swimmer or a wheelchair user, losing part of the muscle on one side is a real cost. Weigh it before a date is set.

The usual phalloplasty conditions apply. Two letters of support in most systems, a hysterectomy first with most surgeons, a vaginectomy if the urethra is being lengthened, a BMI within the surgeon's range, and no nicotine for several weeks either side. The flap lives on small blood vessels for its first days, so surgeons are strict about that last one. See eligibility.

Before you book

Open a calendar and block out the stage-one trip and at least two return trips before you commit to the flap. MLD nearly always means travelling, and the people I have seen cope best with it had planned the second and third trips before the first.

How it’s done

You lie on your side. The surgeon marks a long oval on the back below the shoulder blade, over the latissimus dorsi. They lift it as one piece of skin, fat and muscle, keeping the muscle's artery, vein and nerve attached at its top end. The flap is shaped into a tube while still on its vessels, then the vessels are divided and it comes off the body.

The back is closed directly, with a drain in, and the surgeon turns to the groin. The clitoris is freed and buried at the base of the new phallus with its nerves intact. Then, under the microscope, the flap's artery and vein are joined to vessels in the groin, and its nerve to a nerve there. That join is the operation. It is the reason for the hourly checks afterwards and the reason experience matters so much.

The urethra is the part MLD does differently. A muscle flap is too bulky to roll into a tube within a tube. If you want to stand to pee, the urethral lengthening is built from a separate flap or graft, often in a later stage.

Some surgeons also join the muscle nerve so the phallus can twitch or lift a little on command. That is not an erection. For penetration you will still need an erectile implant once the flap has healed.

The week before

Practise getting in and out of bed without using your arms to push, and without rolling onto one side. With a wound on the back and a phallus at the front, that is how you'll be moving for a fortnight.

MLD phalloplasty recovery

About a week in hospital, most of it flat, with the phallus checked for colour and warmth every hour in the early days. The back is the part people underestimate. It is stiff and sore for several weeks. The shoulder on that side does not want to reach or pull, and there is a drain to manage. Finding a position to sleep in takes some working out.

At home it is slow and mostly upright. Short walks from early on, and physiotherapy for the shoulder once the wound allows. Lifting and pulling with that arm come back last. Sensation in the shaft, where it comes at all, arrives over a year or more and is mostly protective rather than fine touch.

In the first month

Check the back wound in a mirror, or have someone check it, each day when the dressing is changed. A soft bulge that's growing is a seroma, a pocket of fluid, collecting, and it's far easier to drain early than to let it stretch the scar.

MLD phalloplasty scars

One long scar on the back, running below the shoulder blade towards the side, roughly the length of a forearm. The back is closed edge to edge, so there is no skin graft and none of the patchwork look of a forearm donor site. In a T-shirt it does not show. Shirtless, it reads as a surgical scar and most people are asked about it far less than they expect.

It is red and raised for the first months and can widen, because the back is a high-tension area and the shoulder keeps moving it. Silicone gel from about week three, and not stretching the shoulder hard early, both help. The groin and perineal scars are the same as for any phalloplasty. Where a separate urethral flap is taken later, that adds a scar of its own.

Sensation after MLD phalloplasty

The nerve that comes with the flap supplies the muscle, not the skin. The shaft does not get a dedicated sensory nerve the way a forearm flap does. Some protective feeling grows in from the edges over a year or two, and some people report more than that. Fine touch along the shaft is not something to plan on.

Erotic sensation is a separate thing. The clitoris is buried at the base with its nerves intact, and orgasm is preserved for most people through it. If shaft sensation matters most to you, this is the section to read twice, and then the radial forearm page.

Risks and complications

The early risks are the free-flap ones. If the microsurgical join clots in the first days, the flap can lose its blood supply. That means an urgent return to theatre and, in the worst case, partial or total loss of the phallus. Published series for free-flap phalloplasty put total loss in the low single figures per hundred, and it is why the first week is spent flat with hourly checks. Wound breakdown, infection and clots are the others.

The donor site has its own list. A seroma under the back wound is common and sometimes needs draining more than once. The scar can widen. Some weakness or fatigue in the shoulder on that side is usual early on and improves with rehab, though a small amount can be permanent.

Later, the phallus can be bulky and need debulking. If a urethra is added it carries the same fistula and stricture risks as any urethral lengthening, at that stage rather than this one. Implants are somewhat harder to place in a muscle flap and some surgeons are cautious about them.

MLD phalloplasty results

At a year, a phallus of good size, often larger than a forearm flap could have given. The base sits naturally and the back scar disappears under clothing. The muscle bulk settles over the first year and the surgeon may thin it at the second stage. With a glansplasty and, later, an implant, it can be used for penetration.

What tends to disappoint is texture and feel. The shaft is firmer and less pliable than a forearm flap, and the skin of the back is thicker. Without a skin nerve it does not respond to touch the way people hope. The people I have seen happiest with this technique are the ones who wanted size and a hidden scar and said so from the start.

Alternatives to MLD phalloplasty

If you can have a forearm flap and sensation matters, have the forearm flap. If the forearm is out, because of the scar or because the arm is unsuitable, the thigh flap is the next question. That comes down to how thick your thigh is. MLD is the answer when both of those are closed or when you want a hidden scar more than you want feeling.

For someone who wants to avoid microsurgery altogether and does not need to stand to pee, the abdominal flap is the simpler route.

Combining MLD phalloplasty with other surgery

Stage one usually includes the vaginectomy and scrotoplasty if they have not been done. The hysterectomy is usually done earlier, on its own, though some programmes add it to stage one. Because the flap is raised from the back and the groin is worked on separately, two teams can operate at once. That is what keeps the theatre time within a day. See surgery order.

MLD phalloplasty cost

MLD is priced in the same band as the other free-flap techniques where a US surgeon offers it, which is not many places. Much of the published experience comes from Belgrade and other European centres, where the all-stage price for an international patient is a fraction of the US figure. Travel, several weeks in country for stage one, and return trips for later stages need adding to whatever the clinic quotes.

Ask what the headline figure covers. Urethral lengthening is a separate stage with this flap, and implants are always separate, so a quote for "the phalloplasty" may be stage one alone. Ask about the revision policy too, because debulking is common enough to plan for.

Choosing a MLD phalloplasty surgeon

This is a technique with a short list of surgeons, so the first question is volume. The two numbers I would ask for are how many MLD phalloplasties they do a year and their flap loss rate. I would want both from the surgeon, not the brochure. A surgeon doing a handful a year is learning on you.

The urethra is a separate decision with this flap. Some surgeons offer a later urethral stage with a different flap; some do not offer lengthening with MLD at all, and you want to know which before you book rather than after. Ask to see healed results at a year, with the back scar shown, and ask what happens on day two if the phallus goes dusky, the colour change that means the blood supply is in trouble.

At the consultation

Ask "how do you build the urethra with this flap, and at which stage?" The answer tells you whether standing to pee is part of their plan or an afterthought, and it varies more between MLD surgeons than anything else.

Frequently asked questions

Will I have sensation in the phallus?

Limited. The flap's nerve supplies muscle, not skin, so touch along the shaft is restricted. Erotic sensation through the buried clitoris is kept. See sensation.

Will I lose strength in my back?

Some, early on. Part of the latissimus dorsi is taken, so pulling movements on that side feel weak for months and mostly recover with rehab. See risks.

Can I stand to pee with MLD phalloplasty?

Only if a urethra is built from a separate flap or graft, usually at a later stage. Not every MLD surgeon offers that. See how it's done.

Why choose this over RFF or ALT?

A scar that clothing hides and a bigger flap to work with. It is the route when the forearm and thigh are unsuitable or unwanted, and shaft sensation is not your priority. See alternatives.