Weight Management and Phalloplasty

Why weight management matters for phalloplasty

By Alex Friedman, PA-C, Crane Center

It should be intuitive that surgery does not come without risks, and ways to prevent and reduce risks to patient’s health are paramount in any surgical practice. One major risk factor, in preparation for elective surgery, that is consistently addressed is patient weight. While being underweight has surgical risks there are more risks with being overweight. Often Body Mass Index (BMI) is used by surgical practices to provide an overall picture of a patient’s healthy weight—the CDC considers underweight with BMI <18.5 and overweight with BMI >30.  Without getting too far into the weeds on this issue, it should be noted that using BMI does have limitations as it only accounts for two variables-height and weight. Nonetheless, it is a general consensus among surgeons that a BMI greater than 35 is a relative prognosticator for increased surgical risks. We wanted to highlight some of the top reasons why obesity plays a role in our decision for phalloplasty:

1. Increased wound healing complications: obesity can disrupt the normal function of major organs and immune system and impair your body’s ability to effectively manage wound inflammation and overall healing. In addition, excessive fat and skin surrounding incisions can put pressure on surgical areas further compromising healing. Phalloplasty surgery consists of multiple incisions that are under considerable vascular and mechanical stress, and the combination of the above factors are extremely impactful on the health of a new phallus.

2. Risks for revision surgery: as you can imagine from the above, if there are wound healing issues due to obesity in the creation of a neophallus then there is a high chance of complications for revision surgeries if there are fistulas or strictures.  Delayed wound healing from a phalloplasty can ultimately delay any revision surgery, which in turn can delay or exclude future procedures such as implant surgery.  

3. Anesthesia risk: you likely won’t ever remember who your anesthesiologist was during your surgery, but they have a key role in your surgical process—namely keeping you alive which is nice of them. However, obesity complicates that key task as it can affect proper oxygenation during and after surgery, appropriate dosing and delivery of medication, placement of breathing tube, and duration of surgery time with increased time to wake up.

4. Landing spot for phallus: cosmesis of the phallus is also an important consideration along with health risks. The placement of the phallus over the pubic bone is not arbitrary and its location a centimeter in one direction can be very impactful from a patient’s perspective. Obesity can complicate the placement of the phallus with excess fat and skin over the pubic bone, which can either project the phallus out or result in a sagging phallus below a naturally appearing location. 

5. Limits option for donor site: increased body habitus is generally a contraindication for ALT phalloplasty due to increased distance to recipient structures and thickness of donor site tissue. Even with preclusion to an ALT, obesity carries risks for a RFA phalloplasty with more complicated dissection of the vessels into the groin for anastomosis of the phallus.

We find that most patients are eager to make lifestyle choices to improve their chances of an optimal outcome and appropriate choice of donor site.  In addition, while BMI is a good indicator of prognosis we highly recommend a consultation with one of our Board Certified surgeons to discuss your options and preferences.

Alex Friedman PA-C is a certified Physician Assistant specializing in

Reconstructive Plastic and Urologic Surgery, and brings over half a decade of

experience working in Aesthetic and Reconstructive Plastic Surgery. Alex

works primarily assisting Dr. Michael Safir in the Crane Center San Francisco

office. He is a graduate of the University of California of Davis and Samuel

Merritt University in Oakland.