Preoperative Planning of a Pedicled Anterolateral Thigh (ALT) Flap for Penile Reconstruction with the Multidetector CT Scan

Abstract

Recently, perforator flap surgery has been introduced in phalloplasty procedures. Especially the anterolateral thigh (ALT) flap has found its application as a pedicled flap for the penile reconstruction. Adequate shaping of the flap and the need of transferring the shaped flap on its pedicle to the pubic area requires precise localisation and preoperative evaluation of the perforators. Also preoperative measurement of the subcutaneous fat tissue is necessary to allow adequate patient selection and optimal shaping of the phallus. The objective of this report is to demonstrate the usefulness of a multidetector CT scan (MDCT) in the preoperative planning of patients undergoing an ALT flap phalloplasty. Between September 2009 and July 2011, 13 patients were operated for ALT phalloplasty and had preoperative perforator mapping with the MDCT. An algorithm was set up to select the best perforator. Indocyanine green angiography was used in 5 patients to confirm the perforator selection. A mathematical formula was developed to calculate the necessary flap width from the flap thickness. Accurate identification of the main perforators was achieved in all patients with a very satisfactory concordance between the MDCT scan and surgical findings. Indocyanine green angiography confirmed the MDCT perforator selection in all cases. The flap size could be determined preoperatively in all patients by measuring the thickness of the subcutaneous fat layer. Preoperative evaluation of ALT perforators and the subcutaneous fat tissue layer is feasible with an MDCT scan and provides precise data to make an adequate patient and perforator selection and determine the exact flap size.