Shaft-Only Phalloplasty with Vaginal Preservation (Chen-Berli / Moorefield)
Shaft-only phalloplasty with vaginal preservation is a customised gender-affirming genital procedure that creates a neophallus from a donor flap while intentionally preserving the vaginal canal — without urethral lengthening (UL).[1] Designed for transmasculine and nonbinary individuals who desire a phallus capable of penetrative intercourse (with future erectile prosthesis) while retaining vaginal receptive function and avoiding the high complication burden of urethral reconstruction.[1][2]
This page covers the canonical Chen / Berli OHSU 2021 vulvoscrotoplasty variant alongside the Moorefield 2024 Y-to-V advancement variant (vaginal preservation without scrotoplasty / without clitoral burial). For the broader variant-GGAS framework, see Non-Binary / Nullification Gender-Affirming Surgery. For the downstream erectile-prosthesis component, see Penile Implant After Phalloplasty.
Concept and Indications
Standard phalloplasty typically includes vaginectomy (colpocleisis), scrotoplasty, urethral lengthening, and clitoral burial.[3] Shaft-only phalloplasty with vulvoscrotoplasty departs from this paradigm in 4 key ways:[1]
- No urethral lengthening — native urethral meatus remains in its anatomic position; voiding continues in the seated position. Eliminates the most complication-prone component of phalloplasty — UL reconstruction carries fistula / stricture rates of 27–73% in standard phalloplasty.[4][5][6]
- Vaginal preservation — canal left patent for continued receptive vaginal intercourse.[1]
- Vulvoscrotoplasty — labia majora reconfigured into a scrotum-like structure framing the preserved vaginal introitus, creating a masculinised perineal appearance while maintaining vaginal access.[1]
- Clitoral management — clitoris may be buried beneath the neophallus or left exposed, depending on patient preference and variant chosen.[1][7]
Primary indications: nonbinary individuals who desire both phallus and vagina; patients who wish to avoid urethral complications; those who prioritise preservation of natal erogenous sensation and vaginal function.[8]
Patient Goals and Decision-Making
Brown 2025 survey (n = 248 individuals considering phalloplasty or metoidioplasty) — significant differences between transgender men and nonbinary individuals in surgical goals:[8]
| Goal | Transgender men | Nonbinary |
|---|---|---|
| Retaining vaginal canal | Less prioritised | Significantly more prioritised for receptive penetration and gender-identity affirmation |
| Standing urination | Strong priority | Less prioritised |
| Being seen as male | Strong priority | Less prioritised |
| Dysphoria resolution | Strong priority | Less prioritised |
| Tactile and erogenous sensation | Top priority | Top priority |
Findings underscore the clinical rationale for offering vaginal-preserving options.[8]
Variant A — Chen / Berli OHSU 2021 (Canonical Vulvoscrotoplasty)
Published as a technical description in 4 patients.[1]
Stage 1 — Shaft-only phalloplasty
- Flap harvest — most common donor sites:
- Radial forearm free flap (RFFF) — gold standard for phalloplasty overall: thin, pliable, reliable neurovascular anatomy; microsurgical anastomosis; conspicuous forearm donor scar.[3][9]
- Anterolateral thigh (ALT) pedicled flap — avoids microsurgery; concealable scar; often bulky requiring later debulking; higher flap and urethral complications vs RFFF in standard phalloplasty (Ascha 2018) — though urethral concern is moot in shaft-only.[10][11]
- Superficial circumflex iliac artery perforator (SCIP) flap — newer pedicled alternative; De Gelder 2025 10-year experience: primary donor-site closure in 100%; no microsurgery; potentially lower shaft sensation.[12]
- Phallus construction — flap shaped into a tube (shaft only — no neourethra incorporated). Since UL is omitted, flap design is simplified vs tube-in-tube.
- Neurotisation — flap sensory nerve coapted to one or both dorsal clitoral nerves and/or the ilioinguinal nerve for protective and potentially erogenous sensation.[7]
- Phallus inset — at pubic region, typically at or above the clitoral position.
Stage 2 (or concurrent) — Vulvoscrotoplasty with Vaginal Preservation
- Labial reconfiguration — labia majora mobilised and reconfigured into a bifid or unified scrotum constructed around the preserved vaginal introitus (not after vaginectomy as in standard scrotoplasty).[1]
- Vaginal canal preservation — intact and patent; introitus accessible between or posterior to the neo-scrotal structures.
- Clitoral burial — beneath the base of the neophallus (standard in Chen-Berli).[1]
- Testicular implants — staged ~6 mo later into the neo-scrotal compartments.[1][3]
Subsequent stages (optional)
- Glansplasty — sculpting of the distal neophallus to simulate a glans.
- Erectile prosthesis — semi-rigid or inflatable penile prosthesis (typically 9–12 mo post-phalloplasty); see Penile Implant After Phalloplasty.[3]
- Tattoo — medical tattooing for colour matching and aesthetic refinement.
Variant B — Moorefield 2024 Y-to-V Advancement (Vaginal Preservation Without Scrotoplasty / Without Clitoral Burial)
Published in Plast Reconstr Surg 2024 as a refinement of the Chen-Berli approach for patients who wish to retain a more natal-appearing vulva and direct clitoral access.[7]
How Moorefield differs from Chen-Berli (3 critical departures)
| Element | Chen-Berli (Variant A) | Moorefield (Variant B) |
|---|---|---|
| Scrotoplasty | Yes (labia majora → scrotum around vaginal introitus) | No (labia preserved in natal-appearing configuration) |
| Clitoral management | Optional burial beneath neophallus | Degloved and inset at ventral phallus base — exposed |
| Hood-redundancy management | Not specifically addressed | Y-to-V advancement + reduction labiaplasty |
Designed for patients who want direct clitoral access for stimulation and a more natal-appearing vulva rather than a masculinised perineum.[7]
6-step Moorefield technique
- Shaft-only phalloplasty — same flap construction as Chen-Berli; no neourethra incorporated; single-tube design (no tube-in-tube).[1]
- Clitoral degloving and repositioning — clitoral shaft degloved (prepuce separated from underlying clitoral body); degloved clitoral shaft inset at the ventral base of the neophallus in an exposed position for direct erogenous access. Creates a specific aesthetic problem — degloving leaves redundant prepucial tissue that, if unaddressed, produces an unsightly excess at the phallus base.[7]
- Y-to-V adjacent tissue transfer (the core innovation) — redundant clitoral-hood tissue marked in a Y-shaped pattern and excised; remaining flaps advanced and closed in a V configuration. This obliterates the dead space created by degloving, tightens tissue at the phallus base, and creates a smooth transition between neophallus and underlying vulvar anatomy. The Y-to-V principle is a well-established plastic-surgery tool for tissue rearrangement and scar lengthening, adapted here to the GAS context.[7][18]
- Reduction labiaplasty — labia minora trimmed and resuspended anteriorly, improving aesthetic contour and creating a streamlined appearance that integrates with the phallus base; labia repositioned to frame the preserved introitus.[7]
- Vaginal preservation — canal left completely intact and patent.[7][1]
- Neurotisation — phallus neurotised with options:[7]
- Unilateral clitoral nerve — one dorsal clitoral nerve sacrificed for coaptation to the flap nerve; contralateral dorsal clitoral nerve preserved to maintain direct clitoral erogenous sensation. This is critical — provides the neophallus with potential erogenous sensation while preserving direct clitoral sensation through the contralateral nerve.
- Ilioinguinal nerve — alternative or additional recipient providing protective sensation.
Neurotisation and sensation — Moorefield-specific framework
Unilateral-clitoral-nerve-sacrifice rationale. In standard phalloplasty with clitoral burial, the clitoris is buried beneath the phallus and both dorsal nerves may be coapted, with erogenous sensation accessed indirectly through pressure on the neophallus transmitted to the buried clitoris.[19] In Moorefield, erogenous sensation is available through two pathways: (1) direct stimulation of the exposed non-buried clitoris via the preserved contralateral dorsal clitoral nerve, and (2) neophallus sensation via the coapted flap nerve.[7][19]
Sensory-outcomes evidence (broader phalloplasty literature):
- Ferrin 2026 SR on neurorrhaphy in phalloplasty — nerve coaptation consistently improves sensation; significant heterogeneity in techniques and reported outcomes.[20]
- Orgasmic ability — in the largest published series of phalloplasty sensory outcomes, 100% of patients reported the ability to achieve orgasm attributed to preservation of the clitoris and its innervation beneath the neophallus. Moorefield's exposed-clitoris position with at least one intact dorsal nerve would be expected to maintain orgasmic capability, though specific data for this variant are not yet available.[19]
- Tactile sensation — RFFF provides the best tactile sensation among donor flaps; average pressure thresholds 11.1 g/mm² at the phallus tip (slightly less than control male values but sufficient for protective sensation).[19]
- Zack 2025 sexual-health-outcomes SR — erogenous-sensation ratings 53–100% across phalloplasty studies; orgasm during masturbation reported in 50–93% of patients.[21]
Patient selection — Moorefield-specific
Suited for patients who:[7][8]
- Desire a phallus for gender affirmation and/or future insertive intercourse (with erectile prosthesis).
- Want to preserve the vagina for receptive intercourse and/or reproductive potential.
- Do NOT want scrotoplasty — prefer natal-appearing vulva.
- Want the clitoris exposed for direct stimulation rather than buried.
- Do not prioritise standing urination — accept seated voiding through the native meatus.
- Want to minimise complication risk — by avoiding both UL (27–73% fistula/stricture) and vaginectomy (Nikkels 2019 n = 143: 10% major perioperative + 12% major postoperative + 35% minor postoperative).[5][22]
Brown 2025 patient-priorities data directly maps to the Moorefield variant — nonbinary patients prioritise vaginal-canal retention; both groups rate tactile and erogenous sensation top priority.[8]
Moorefield-specific advantages
- Preserved direct clitoral access — exposed clitoris allows direct stimulation, potentially enhancing sexual satisfaction for patients who value clitoral orgasm.[7]
- Dual erogenous pathways — both exposed clitoris (preserved contralateral dorsal nerve) and neurotised neophallus.[7][19]
- Avoidance of scrotoplasty complications — no scrotal wound dehiscence, implant extrusion, or asymmetry.
- Elimination of urethral complications — same as Chen-Berli.[15]
- Avoidance of vaginectomy morbidity — Nikkels 2019 colpectomy complication burden.[22]
- Aesthetic refinement — Y-to-V specifically addresses redundant-tissue problem that would otherwise result from degloving without burial.[7]
- Fewer surgical stages — no UL, no vaginectomy, no scrotoplasty.
Moorefield-specific limitations and considerations
- No standing urination.
- No testicular implants (no scrotal compartment).
- Aesthetic compromise for patients who desire a fully masculinised perineum.
- Clitoral exposure at the ventral phallus base may be subject to friction or irritation (not specifically reported).
- Unilateral clitoral nerve sacrifice — direct clitoral sensation relies on contralateral nerve alone; while bilateral innervation generally tolerates unilateral sacrifice well, theoretical risk of diminished clitoral sensation.[7][20]
- Extremely limited evidence — single technical note without reported outcomes data, complication rates, or PRO satisfaction measures.[7]
Shaft-Only vs Standard Phalloplasty Comparison
| Feature | Shaft-Only + Vulvoscrotoplasty | Standard Phalloplasty |
|---|---|---|
| Urethral lengthening | No | Yes |
| Standing urination | No (seated) | Yes (goal in ~91.5%) |
| Vaginectomy | No (vagina preserved) | Yes (typically) |
| Scrotoplasty | Yes (around vaginal introitus) | Yes (after vaginectomy) |
| Urethral complication rate | Eliminated | 27–73% (fistula / stricture)[5] |
| Erectile prosthesis | Possible | Possible |
| Penetrative (insertive) intercourse | With prosthesis | With prosthesis |
| Receptive vaginal intercourse | Preserved | Not possible |
| Clitoral sensation | Preserved (± buried) | Typically buried |
| Number of stages | Fewer | More (urethral staging) |
Outcomes (Chen-Berli Series — Preliminary)
Published OHSU experience: 4 patients with shaft-only phalloplasty + vaginal preservation + vulvoscrotoplasty.[1] Given the extremely small sample size, outcomes are preliminary:
- All 4 patients had successful phallus construction with flap survival.
- Vaginal patency maintained in all cases.
- Specific complication rates, PROMs, sexual function data, and long-term follow-up not yet published in detail.[1]
Complications and Considerations
Because UL is omitted, the most morbid component of standard phalloplasty is avoided. Berli 2025 Big Ben two-stage UL series (n = 73) reported total urologic complication rate 27% (stricture 8%, fistula 16.4%) with 96% achieving standing urination — shaft-only phalloplasty eliminates these urethral complications entirely.[13]
Remaining complications relevant to shaft-only phalloplasty:
- Flap-related — partial or total flap loss 3.4–7.8% in standard phalloplasty depending on flap type; wound dehiscence, hematoma, infection.[10]
- Donor-site morbidity — forearm scarring and potential functional deficits (RFFF); thigh contour deformity and need for debulking (ALT).[14][11]
- Vaginal-preservation-specific — Claeys 2025 SR found that both phalloplasty and metoidioplasty carried a higher risk of urethral complications when the vagina was preserved — but this applies primarily to procedures that include UL. For shaft-only without UL, this risk is not applicable.[15]
- Persistent vaginal cavity issues — in standard phalloplasty with vaginectomy, incomplete obliteration causes recurrent UTIs, pelvic pain, post-void dribbling. In vaginal-preserving procedures, the vagina is intentionally left open → not a "complication" per se but ongoing gynecologic care remains necessary.[16]
- Erectile prosthesis complications — ~27.9% in phalloplasty (infection, erosion, mechanical failure); see Penile Implant After Phalloplasty.[5]
Broader Context — Variant Gender-Affirming Genital Surgery
Claeys 2025 SR (variant GGAS; 23 case series — 17 masculinising, 6 feminising) confirmed patients choose these procedures primarily out of:[15]
- Personal desire
- To avoid complication risk (e.g., UL complications)
- Because they lack dysphoria about certain natal genital structures
The review emphasised that complications in masculinising surgeries primarily arise from the extended urethra, which can be mitigated through primary perineal urethrostomy or, as in the Chen-Berli approach, by omitting urethral lengthening entirely.
Ascha 2024 described the broader framework of individually customised procedures (vagina-preserving phalloplasty, phallus-preserving vaginoplasty, genital nullification) in 16 patients — reinforcing that these procedures may better affirm the identities of gender-diverse patients while preserving desired sexual function.[17]
Evidence Gaps
Published literature on shaft-only phalloplasty with vulvoscrotoplasty remains extremely limited — a 4-patient technical description (Chen-Berli) and a few related case reports (Moorefield).[1][7]
Key unanswered questions:
- Long-term vaginal patency and function after vulvoscrotoplasty.
- Sexual function outcomes (both insertive with prosthesis and receptive vaginal).
- PROMs and satisfaction data.
- Aesthetic outcomes and revision rates.
- Optimal flap choice specifically for shaft-only (without neourethral-construction constraint).
- Feasibility and outcomes of erectile prosthesis placement in this configuration.
- Conversion rates to other procedures (e.g., later vaginectomy or UL).
References
1. Chen W, Cylinder I, Najafian A, Dugi DD, Berli JU. An option for shaft-only gender-affirming phalloplasty: vaginal preservation and vulvoscrotoplasty. A technical description. Plast Reconstr Surg. 2021;147(2):480–483. doi:10.1097/PRS.0000000000007579
2. Peters BR, Dhami J, Bonapace-Potvin M, Sineath C. Options and indications in gender-affirming phalloplasty. Clin Plast Surg. 2025;52(4):495–506. doi:10.1016/j.cps.2025.06.006
3. Berli JU, Knudson G, Fraser L, et al. What surgeons need to know about gender confirmation surgery when providing care for transgender individuals: a review. JAMA Surg. 2017;152(4):394–400. doi:10.1001/jamasurg.2016.5549
4. Veerman H, de Rooij FPW, Al-Tamimi M, et al. Functional outcomes and urological complications after genital gender-affirming surgery with urethral lengthening in transgender men. J Urol. 2020;204(1):104–109. doi:10.1097/JU.0000000000000795
5. Hu CH, Chang CJ, Wang SW, Chang KV. A systematic review and meta-analysis of urethral complications and outcomes in transgender men. J Plast Reconstr Aesthet Surg. 2022;75(1):10–24. doi:10.1016/j.bjps.2021.08.006
6. Paganelli L, Morel-Journel N, Carnicelli D, et al. Determining the outcomes of urethral construction in phalloplasty. BJU Int. 2023;131(3):357–366. doi:10.1111/bju.15915
7. Moorefield AK, Veith JP, Mills A, et al. Vaginal preservation in shaft-only phalloplasty: Y-to-V advancement technique for clitoral hood redundancy and reduction labiaplasty. Plast Reconstr Surg. 2024;154(1):186e–189e. doi:10.1097/PRS.0000000000010932
8. Brown LK, Butcher RL, Kinney LM, Nigriny JF, Moses RA. New insights into the goals of transgender male versus non-binary individuals considering metoidioplasty and phalloplasty gender-affirming surgery. J Sex Med. 2025;22(3):526–535. doi:10.1093/jsxmed/qdae193
9. Yao A, Ingargiola MJ, Lopez CD, et al. Total penile reconstruction: a systematic review. J Plast Reconstr Aesthet Surg. 2018;71(6):788–806. doi:10.1016/j.bjps.2018.02.002
10. Ascha M, Massie JP, Morrison SD, Crane CN, Chen ML. Outcomes of single-stage phalloplasty by pedicled anterolateral thigh flap versus radial forearm free flap in gender-confirming surgery. J Urol. 2018;199(1):206–214. doi:10.1016/j.juro.2017.07.084
11. Xu KY, Watt AJ. The pedicled anterolateral thigh phalloplasty. Clin Plast Surg. 2018;45(3):399–406. doi:10.1016/j.cps.2018.03.011
12. De Gelder A, Young-Afat D, Claes K, et al. Use of the superficial circumflex iliac artery perforator flap for urethra and/or shaft reconstruction in gender-diverse persons: 10-year single-centre experience. Plast Reconstr Surg. 2025;155(6):1036e–1044e. doi:10.1097/PRS.0000000000011830
13. Berli JU, Ferrin PC, Buuck C, et al. Long-term urologic outcomes using the Big Ben method for phalloplasty. Plast Reconstr Surg. 2025. doi:10.1097/PRS.0000000000012010
14. Harris TGW, Manyevitch R, Wu WJ, et al. Pedicled anterolateral thigh and radial forearm free flap phalloplasty for penile reconstruction in patients with bladder exstrophy. J Urol. 2021;205(3):880–887. doi:10.1097/JU.0000000000001404
15. Claeys W, Wolff DT, Zachou A, et al. Variant genital gender-affirming surgery: a systematic review. BJU Int. 2025;135(1):40–53. doi:10.1111/bju.16513
16. Jackson Q, Yedlinsky NT, Gray M. Lifelong care of patients after gender-affirming surgery. Am Fam Physician. 2024;109(6):560–565.
17. Ascha M, Rigsby S, Shoham M, et al. Individually customized gender-affirming genital procedures: techniques and considerations. J Sex Med. 2024;21(9):827–834. doi:10.1093/jsxmed/qdae075
18. Alter GJ. Labia minora reconstruction using clitoral hood flaps, wedge excisions, and YV advancement flaps. Plast Reconstr Surg. 2011;127(6):2356–2363. doi:10.1097/PRS.0b013e318213a0fb
19. Selvaggi G, Monstrey S, Ceulemans P, et al. Genital sensitivity after sex reassignment surgery in transsexual patients. Ann Plast Surg. 2007;58(4):427–433. doi:10.1097/01.sap.0000238428.91834.be
20. Ferrin PC, Burghardt E, Xu J, Peters BR. Optimizing neurorrhaphy to improve sensation in phalloplasty: a systematic review. Int J Impot Res. 2026;38(4):324–332. doi:10.1038/s41443-025-01021-w
21. Zack J, Goldstein B, Okamuro K, et al. Sexual health outcomes following gender-affirming phalloplasty: a systematic review. J Sex Med. 2025:qdaf166. doi:10.1093/jsxmed/qdaf166
22. Nikkels C, van Trotsenburg M, Huirne J, et al. Vaginal colpectomy in transgender men: a retrospective cohort study on surgical procedure and outcomes. J Sex Med. 2019;16(6):924–933. doi:10.1016/j.jsxm.2019.03.263