Technical Description and Microsurgical Outcomes in Phalloplasty Using the Deep Inferior Epigastric Artery and Locoregional Veins.

Abstract

Sir: Danker’s team has recently published their valuable study of the recipient vessels in phalloplasty.1 Our plastic and reconstructive department had performed more than 300 phalloplasties in Shanghai since 1984,2 and we would like to share our experience on the topic regarding the article “Technical Description and Microsurgical Outcomes in Phalloplasty Using the Deep Inferior Epigastric Artery and Locoregional Veins.” Phalloplasty aims to construct a sensate phallus that can achieve sexual penetration and standing micturition. Although the donor-site injury is obvious for radial forearm free flap phalloplasty, it is still the most suitable technique for patients because of the stable blood supply, good sensation, and thin subcutaneous layer of fat, which can mostly be used to reconstruct the urethra through tube-in-tube technique in a one-stage operation.3 The cephalic vein provides the main backflow, and two venae comitantes are also necessary to keep sufficient blood flow balance of a reconstructed phallus. Previously, we have reported a new phalloplasty procedure in which a free forearm flap is combined with a dorsalis pedis flap. The deep inferior epigastric artery was used as the recipient vessel in these case series, and one of the 14 patients had partial flap loss in the distal part of the dorsalis pedis flap.4 We had a similar experience, namely, that most of the complications of free flaps were related to venous complications in phalloplasty. In our strategy, both for single forearm flaps and combined flaps, we usually dissect three veins, including the cephalic vein and the two venae comitantes of the forearm flap for anastomoses. In the recipient site, two venae comitantes of the deep inferior epigastric artery, together with the superficial epigastric vein, can be used to match the three veins from the forearm flap. We prefer the superficial epigastric vein over the greater saphenous vein because the superficial epigastric vein is closer to the deep inferior epigastric artery and the diameter is suitable for end-to-end anastomose. The deep inferior epigastric artery connected to the radial artery can provide a reliable arterial supply; meanwhile, a three-vein backflow system can minimize the risks of venous complications. In our experience, approximately 3 to 4 percent of patients had partial flap loss with this technique in radial forearm free flap phalloplasty. Last but not least, validated tools such as the SPY system (Novadaq Technologies, Inc., Richmond, British Columbia, Canada) are very helpful for observing the blood flow changes and the stages of the flap perfusion in the operation.5 For radial forearm free flap phalloplasty with tube-in-tube technique, the flaps fold twice for reconstructing the urethra and shaft, which would easily cause venous complications after surgery. Objective estimation of the flap perfusion after shaping would further decrease the rate of flap loss in phalloplasty. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Chen Cheng, M.D.Yingfan Zhang, M.D.Yang Liu, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryShanghai Ninth People’s HospitalShanghai Jiao Tong University School of MedicineShanghai, People’s Republic of China