Total Phallic Reconstruction in Female-to-Male Transsexuals by the Pedicle Anterolateral (ALT) Flap

Abstract

Total phallic construction is an important step in surgical treatment of female-to-male transsexuals (FTMT) for gender reassignment. Female-to-male gender reassignment consists of subcutaneous mastectomy, hysterectomy, salpingooophorectomy, and vaginectomy which are performed typically prior to phallic construction and insertion of penile and testicular prostheses which can be done simultaneously or at a later stage. The ideal total phallic reconstruction should create an aesthetically acceptable, sensate phallus with the neourethra permitting voiding in a urinal and enough tissue to allow for insertion of a penile prosthesis permitting sexual intercourse [ 1 ]. However, selection of the reconstructive method depends largely on patients’ desires: some of the patients prefer a reconstruction without the neourethra; others may refuse insertion of a penile prosthesis. Historically, the fi rst penile reconstructions started in the late 1930s with random pedicled oblique abdominal tube fl aps with no neourethra and optional insertion of costal cartilage to obtain rigidity [ 2 ]. Later, in the 1940s, in order to reconstruct the neourethra, the “tube-within-a-tube” concept was added to the original Borgas’ technique [ 3 , 4 ]. With the advent of axial pattern fl aps, the groin fl ap was introduced into phallic reconstruction. Because it was wedge shaped and insensate, it never gained popularity [ 5 – 7 ]. Pedicle musculocutaneous fl aps from the thigh (gracilis) led to poor results and were abandoned [ 8 , 9 ]. In 1984 Chang and Hwang published a series of 7 total phallic reconstructions by the free radial forearm fl ap which revolutionized phallic reconstruction. This fl ap offered the possibility of reconstructing a well-vascularized, sensate penile shaft of generous dimensions and neourethra using the “tube-within-a-tube” principle from the non-hirsute skin in one stage, making possible an insertion of a penile prosthesis [ 10 ]. Later, the design of this fl ap has been modifi ed to improve the aesthetic results and to reduce the complication rate (mainly connected to meatal stenosis and urethral fi stulae) and the donor site morbidity. Other microvascular reconstructions include the island lateral arm fl ap [ 11 , 12 ], deltoid fl ap [ 13 ], pedicled TFL [ 14 ] fl ap, SCIP fl ap [ 15 ], Z. M. Arnež , MD, PhD (*) Department of Medicine , Surgery and Health University of Studies of Trieste , Strada di Fiume 447 , Trieste 34149 , Italy e-mail: zoran.arnez@aots.sanita.fvg.it