Comment on World's First Baby Born Through Natural Insemination by Father With Total Phalloplasty Reconstruction

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To the Editor:
It's great to hear the report by Gurjala et al on a baby born by a father with total phalloplasty reconstruction. Gurjala's team present a case in which they used a pedicled anterolateral thigh flap with sufficient bulk and stiffness, which ultimately functioned well enough to allow the patient to naturally father a child.1
Since Chang and Hwang established the technique of free forearm flap for 1-stage reconstruction of the penis in 1984,2 there has been more than 30 years' experience for phalloplasty reconstruction in our hospital. We would like to share our opinions on this topic.
First, the reproductive ability of patients with phalloplasty not only relied on a functioned penis but also the testicular function. For any acquired injury on penis, the testicular function may still remain. A well-functioned penis reconstructed by phalloplasty only provides an exit for sperm, so it should not be very surprising if patients father a child after phalloplasty. Chang and Hwang performed a phalloplasty reconstruction for 1 patient who experienced penis injury through 1-stage forearm flap in 1984, and the patient fathered a boy in 1987. Immonogenetics Collaboration Center, Shanghai Institute of Immunology, had proved that the patient was the boy's biological father through human leukocyte antigen analysis in April 15, 1987 (Fig. 1). The family sent their photo to us when the boy grew up (Fig. 2). Since 1984 till now, there has been totally 5 patients who had child after total phalloplasty reconstruction.
Second, a stiffener would be necessary for Asians in phalloplasty reconstruction.2–4 Autologous rib cartilage was the mostly used stiffener in our 1-stage operation. When the rib cartilage had to be removed because of infection, an obvious flap contracture would be found from 6 months after surgery in the reconstructed penis. It was delightful to know that the case in the study of Gurjala et al achieved good outcome without any stiffener. A sensate pedicled anterolateral thigh flap would be helpful in their techniques.
Although phalloplasty reconstruction had a long history, the procreation issues after surgery was not well reported since then. A well-functioned penis can be reconstructed through different techniques; however, the sex and reproductive function should be paid more attention so as to rebuild a phallus with both satisfactory appearance and ideal function.
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