Gender-Affirming Phalloplasty with Anterolateral Thigh Flap

Abstract

ABSTRACT Introduction Anterior lateral thigh (ALT) flap is one of the options that can be employed within the context of gender-affirming masculinizing genital reconstruction. Objective Herein, we demonstrate our technique with ALT flap phalloplasty. Methods This is a 25-year-old trans male who desired voiding in standing position. Given the quality of his thigh skin (subcutaneous thickness <1cm) and concerns related to donor-site scarring, the shared decision was to proceed with phalloplasty with ALT flap constructed in a “tube within a tube” technique. Results The ALT flap was designed and outlined using acoustic Doppler followed by fluorescence angiography to confirm perforator location. A suprapubic tube (SPT) was inserted under direct cystoscopic guidance. Anterior vaginal wall flap (6cm x 3cm) was liberated. Vaginal flap was tubularized around the urethral catheter. Clitoris was de-epithelialized. A semilunar suprapubic skin incision was made. Clitoris was sutured to the pubic periosteum. Remaining vaginal mucosa was ablated with electrocautery. Colpocleisis was completed using concentric stitches. Then, he was taken out of lithotomy and the ALT flap was elevated. Subfascial dissection was performed to the intermuscular septum between the rectus femoris and the vastus lateralis. Descending branch of the lateral femoral circumflex artery was identified. Lateral femoral cutaneous nerve was dissected proximally. Flap was elevated on a single perforator and repeat fluorescence angiography confirmed intact perfusion. Urethra was reconstructed over an 18 Fr. council tip catheter and closed in a layered fashion. Urethral integrity was tested with methylene blue. Shaft skin was wrapped around the phallic portion of the urethra and closed in a layered fashion. The left ilioinguinal nerve was clipped for later coaptation with lateral femoral cutaneous nerve. The flap was passed beneath the rectus femoris, sartorius and then subcutaneously into the recipient site over the pubic symphysis. The anastomosis between the phallic urethra and elongated native urethra was performed over an 18 Fr. council tip catheter using interrupted stitches. Scrotoplasty was performed using labia majora flaps. Flap was then inset in a layered fashion. Donor site was closed by reapproximation and advancing the skin edges. A split thickness skin graft was harvested from the thigh and applied over the donor site. Donor site was dressed with wound VAC. The procedure lasted 12 hours with an estimated blood loss of 550ml. Patient was discharged to a skilled nursing facility on day 18. Urethral Foley catheter was removed in a month after documenting patency on retrograde urethrogram (RUG). SPT was removed a month later. He initially voided well but then started to notice weakening in stream and urine leak through phallic skin defect. RUG demonstrated distal phallic urethral stricture and a small urethrocutaneous fistula just proximal to it. Stricture was dilated with sounds. Patient was instructed to do intermittent self-calibration. Voiding improved, stricture did not recur and fistula healed spontaneously. No other urinary complications were encountered. Conclusions ALT flap remains a valid option for gender-affirming phalloplasty. It can be considered in patients with favorable body habitus who are concerned with donor-site scarring. Disclosure No