Radial Forearm Free Flap Phalloplasty Research Articles

Penile reconstruction following penile necrosis by radial forearm free flap phalloplasty

Penile reconstruction following penile necrosis by radial forearm free flap phalloplasty

Phallopoièse par lambeau antébrachial radial libre dans la chirurgie de réassignation sexuelle femme à homme

The aims of this article are to provide an overview of the technique of phalloplasty by radial forearm free flap in the context of female-to-male gender reassignment surgery, with a specific focus on surgical technical details and the prevention of postoperative complications. In the light of our 30 years of experience in caring for female-to-male transgender individuals and conducting a critical review of the literature, we exhaustively present our technique of radial forearm free flap phalloplasty in female-to-male gender reassignment surgery. The technique of radial forearm free flap phalloplasty, utilizing a one-stage approach for neourethral and neophallus construction based on the "tube within a tube" principle, not only achieves an aesthetically pleasing appearance of the neophallus resembling a normal penis with tactile and erogenous sensitivities but also yields a functional neourethra and satisfactory penile rigidity using implants for standing voiding and sexual intercourse. This intricate surgical procedure demands not only meticulous execution of all surgical maneuvers but also high-level postoperative care. Despite refinements in technique over recent decades, aesthetic sequelae at the donor site of the flap remain subject to criticism, and postoperative complications, particularly of vascular and urological nature, remain significant. Future optimization of the surgical technique for this procedure will be imperative to minimize postoperative complications and establish a true technical "gold standard" for phalloplasty in female-to-male transgender individuals.

(520) The Use of Gracilis Muscle Flap in Radial Forearm Free Flap Phalloplasty to Decrease Urethral Fistula Rate: Initial Outcome

Abstract Introduction `- Chang and Hwang, in 1984, described the technique of Radial Forearm Free Flap Phalloplasty (RFFFP). It is now considered to be the standard surgery for phallic reconstruction. Urethral fistula is the most common complication reported in RFFFP and may reach up to 60-70%. Most commonly, the fistula site is at the anastomosis between the native urethra and the neo-urethra. Objective `- to study the impact of gracilis muscle flap wrapping around the native urethra/neo-urethral anastomosis on decreasing the fistula rate. Methods `- A prospective study was conducted at our urology department, from January 2018 till December 2020. - Patients presenting with a micropenis (Stretched penile length <7 cm) underwent RFFFP with gracilis muscle flap wrapping. - The free-flap was harvested from the non-dominant forearm. Under microscopic guidance, the radial artery was anastomosed with the inferior epigastric artery, the cephalic vein with the great saphenous vein, and the medial and lateral antecubital nerves with the ilio-inguinal and the dorsal penile nerves respectively. - A pedicled gracilis muscle flap was then wrapped around the neo-urethera/native urethral anastomosis to assess its possible role in decreasing the postoperative urinary fistula rate. Results `- Nineteen patients were included in the study with a median age of 26 years (16 - 43) and a BMI of 24 (22-25). The median hospital stay of 14 days (14 - 21) and the median follow-up was 11 months (4 - 13). The median cold ischemia time was 90 mins (70 - 100), estimated blood loss was 500 cc (400 - 500) and operative time was 11 hrs (10 - 12). - A viable phallus was achieved in 13 patients (overall free flap survival 68.4%). - Of the successfully viable phallus cases, 8 cases (42.1%) were complicated by complete disruption of the urethra and the remaining five cases (26.3%) had complete urethral tube. - One case of them developed a fistula at the neo-urethera/native urethral anastomosis, one case had a distal fistula and one case had a ring stricture at the site of anastomosis. - The gracilis muscle flap prevented urethral fistula formation in 4 out of 5 cases (80%) with complete urethral tube. Conclusions `- The use of pedicled garcilis muscle flap wrapping around the neo-urethra/native urethral anastomosis during RFFP might be helpful in reducing the urinary fistulae rates at this site. However, larger comparative studies are needed. Disclosure No

(037) Contemporary Surgical and Functional Outcomes of Anterolateral Thigh Flap for Penile Reconstruction

Abstract Introduction The radial forearm free flap phalloplasty is the most commonly used flap for penile reconstruction. The anterolateral thigh (ALT) free flap was proposed in 2006 as an alternative due to the twin advantages of a more easily hidden scar and improved flexibility in the length of the flap. A pedicled variant of the ALT flap was proposed the same year thus offering greater security of vascular supply for suitable patients. Previous reports have highlighted higher rates of flap loss and low rates of integrated urethra. Objective The aim of the study is to report the contemporary surgical outcomes of ALT phalloplasty. In addition, the functional outcomes of the ALT flap phalloplasty are reported for the first time. Methods All patients undergoing ALT flap phalloplasty were included in the study between 2009 and 2021. Data were extracted from a comprehensive prospective database and the medical records. Functional outcomes were assessed by non-validated questionnaire. Results Seventy-six patients underwent ALT flap phalloplasty with a mean follow-up of 34 months (SEM ± 3.05). Median age of the patients was 32 (IQR 26 – 46) and body mass index was 24 (SEM ± 0.61). A significant minority had a previous phalloplasty (22%). In addition, 7% of patients had other co-morbidities including diabetes and peripheral vascular disease. Over half of all flaps (n=41) were designed with an integrated urethra and 6.6% (n=5) required free flap transfer. The average length of stay was seven days (SEM ±0.47). Post-surgery, five (6.6%) patients experienced total flap loss, with a further three (3.9%) experiencing partial loss. Urethral complications were common with eleven (26.8%) patients developing fistulae and three (7.3%) developing strictures. Fifty-three (69%) patients completed the functional outcomes questionnaire. Forty-three (81%) were generally satisfied with their phalloplasty, while thirty-four (65%) felt they had a good cosmetic outcome. Twenty-eight (53%) had sensation in at least half of their phallus. Eight (17%) experienced troublesome post-micturition dribbling. Conclusions Presented is one of the largest cohort of patients following genital gender affirmation surgery using the ALT flap phalloplasty. Over half of all patients successfully had an integrated urethra (gold standard for urethral reconstruction). Functional outcomes (an important determinant for the choice of a flap) are reported for the first time showing 81% of patients are satisfied despite a challenging cohort with almost a quarter of patients undergoing salvage following previous failed phalloplasty. Disclosure No

The outcome of gracilis muscle flap wrapping around the neourethra-native urethral anastomosis after radial forearm free flap phalloplasty on the incidence of fistula formation

ABSTRACT Introduction The radial artery-based free-flap phalloplasty (RFFP) is accompanied by high rates of fistula formation and urological complications. We thought to investigate the impact of pedicled gracilis muscle flap wrapping around the urethral anastomosis on the occurrence of fistula at the neourethra-native urethral junction. Materials and Methods Prospective study was conducted at the urology department of Cairo University Hospitals. Patients presenting with micropenis (stretched penile length ≤7 cm) underwent RFFP. The RFF was harvested from the non-dominant forearm after ensuring of good collateral supply to the hand. All patients underwent RFFP with pedicled gracilis muscle flap wrapping. Under microscopic guidance, the radial artery was anastomosed with the inferior epigastric artery, the cephalic vein with the great saphenous vein and the medial and the lateral ante-brachial nerves with the ilioinguinal nerve and the dorsal penile nerve, respectively. Data were reviewed for demographics and perioperative outcomes. Results Nineteen patients were included in the study with a median follow up of 11 months (3, 22). Median age of 26 yrs (16, 43), hospital stay was 7 days (7, 30) and. Indications for RFFP were: micropenis (40%), post-surgery crippled penis (25%), amputated penis (20%), aphallia (5%), epispadias (5%) and gender dysphoria (5%). Median ischemia time was 88 mins (60, 120), ebl was 600 cc (300, 2000) and operative time 11 hrs (8, 14). Intraoperative complications were a case of transection of the radial artery during graft harvesting, failure to tubularize the graft and significant blood loss during vaginectomy. Overall success rate was 70%. 5 cases had a complete success, only one case had a fistula at the neo-uretheral native urethral anastomosis, one patient had a distal fistula and another patient had a ring stricture at site of anastomosis. 8 cases were complicated by complete disruption of the urethra. 6 cases were complicated by total graft loss (2 cases due to arterial causes and 4 cases due to venous congestion). No donor site morbidity was noted. During follow up patients reported shortness in the mean length of the phallus was 2.1cms. All patients reported recovery of both general and erogenous sensations in the neo-phallus. The recovery of the general sensation (tactile stimulation and two-point discriminations) ranged between 2 to 4 weeks post-operatively while recovery of the erogenous sensation occurred between 8 to 16 weeks. Conclusion The use of pedicled garcilis flap during RFFP resulted in a fistulae rate of 20%. Disclosure Work supported by industry: no.

Radial Forearm Free Flap Phalloplasty in Female-to-Male Transsexuals - A Comparison Between Gottlieb and Levine's and Chang and Hwang's Technique

BackgroundPhalloplasty is a crucial part of female-to-male genital gender-affirming surgery, however, up to date, there is still no standardized phalloplasty technique. AimTo evaluate the outcome of a single-center series of phalloplasties using the free radial forearm flap variations by Chang and Hwang vs by Gottlieb and Levine on a similar number of transgender patients. MethodsBetween 2018 and 2020, 45 female to male transgender patients underwent phalloplasty using a neuro-microvascular free radial forearm flap in our department. Twenty patients underwent phalloplasty by the use of the Chang and Hwang design, whereas 25 patients were subjects to a phalloplasty according to Gottlieb and Levine technique. Patients’ demographics, procedural characteristics, postoperative complications, and outcome of both groups were retrospectively evaluated and compared with each other. ResultsPatients’ demographics were similar in both groups. We did not observe relevant differences concerning postoperative complications comparing the two groups, except for the statistically significant lower rate of partial flap necrosis in the Gottlieb and Levine group. No statistically significant risk factors for an increase in complication rate could be identified. Urethral fistulas were the leading cause of revision. Clinical ImplicationOptimizing a phalloplasty surgical technique and contributing to establish the gold standard in phalloplasty. Strengths & LimitationThis retrospective study presents the first comparison between the free radial forearm flap phalloplasty by Chang and Hwang and by Gottlieb and Levine performed at the same department on a similar number of transgender patients published so far. ConclusionThe Chang and Hwang design is associated with a lower rate of urologic complications (fistulas, stenosis) while the Gottlieb and Levine design has a statistically significant lower incidence of partial flap necrosis. Future prospective trials are needed to establish the gold standard in phalloplasty.Spennato S, Ederer IA., Borisov K et al. Radial Forearm Free Flap Phalloplasty in Female-to-Male Transsexuals - A Comparison Between Gottlieb and Levine's and Chang and Hwang's Technique. J Sex Med 2022;19:661–668.

Arteriovenous Fistula Rescues Radial Forearm Phalloplasty: A Case Report on Patients with Microvascular Obstruction

Background:Radial forearm free flap phalloplasty (RFFFP) is the most common surgery performed for genital reconstruction of female-to-male transgender patients. However, up to 19% require anastomotic re-exploration. The postoperative creation of an arteriovenous fistula (AVF) to bypass obstruction and salvage RFFFP was first reported in 1996 and has subsequently been reported by 1 high-volume center in Belgium.Methods:Here, we present 2 cases in which intraoperative microvascular obstruction threatened the viability of the RFFF of transgender phalloplasty patients. In each patient, an AVF was created between the radial artery and cephalic vein in the distal flap either after being transferred out of the operating room, as has previously been described, or during initial operation.Results:In both cases, the creation of a distal AVF salvaged the neophallus. Importantly, the patient that had been transferred out of the operating room before reintervention suffered partial flap necrosis compared with no flap loss in the patient who had an AVF created during initial surgery. One AVF was ligated 18 days postoperative, whereas the other was never formally closed.Conclusions:These cases demonstrate that AVF can be reliably used for RFFFP salvage both intraoperatively and for reintervention. They also suggest that earlier detection of persistent vascular compromise and utilization of AVF can further minimize flap loss. Finally, in contrast with the prior explanation of this technique, timing of AVF ligation may be less critical than previously described. Microsurgeons are reminded that this technique may save complicated flaps in the uncommon case of microcirculatory flap obstruction.

Pedicled Anterolateral Thigh and Radial Forearm Free Flap Phalloplasty for Penile Reconstruction in Patients With Bladder Exstrophy.

Male patients with exstrophy-epispadias complex have a congenitally short penis. Adolescent and adult patients often desire penile reconstruction to enable penetrative intercourse. When penile lengthening using local tissue and/or skin graft is unsuitable, phalloplasty is performed. We provide updated experiences using radial forearm free flap and pedicled anterolateral thigh flap phalloplasty techniques over a 6-year period in exstrophy-epispadias complex patients. Consecutive patients who underwent radial forearm free flap or pedicled anterolateral thigh flap phalloplasty between 2013 and 2019 were reviewed. A total of 11 patients were identified, including 8 with classic bladder exstrophy and 3 with cloacal exstrophy. In each case, flap dimensions, donor and recipient vessels and nerves, complications, outcomes and subsequent surgical procedures are reported. A radial forearm free flap was performed in 6 patients and a pedicled anterolateral thigh flap in 5. Flap survival was observed in all cases and 5 patients subsequently received an inflatable penile prosthesis. Among patients undergoing a pedicled anterolateral thigh flap, there was 1 mortality from acute pulmonary embolism, and the other 4 required at least 1 debulking procedure. Phalloplasty is an important procedure in patients with exstrophy-epispadias complex with severe penile inadequacy. Both techniques have favorable long-term outcomes, although the pedicled anterolateral thigh flap frequently requires a later debulking procedure. The radial forearm free flap is preferred but if the radial forearm is overly thin and the risk of inflatable penile prosthesis extrusion is high, the pedicled anterolateral thigh flap is an acceptable alternative.

Transgender Surgery: Female to Male

Gender-confirming surgery is a life-altering and medically necessary set of procedures for some people suffering from gender dysphoria. For transgender men, there are a variety of surgical interventions available for masculinization, including facial, chest, trunk, and genital surgeries. Facial and truncal masculinizations are rarely sought. Chest masculinization is the most common procedure in transgender men and consists of bilateral mastectomy through various approaches dependent on the breast size and laxity with minimal complications. Metoidioplasty and phalloplasty are the most common genital procedures (the radial forearm free flap phalloplasty being the most common) but have significant complication profiles. Up to 40% of those undergoing genital masculinization suffer from urethral fistula or stricture. Current advances consist of neurotization of the phallus and implant placement. Future studies on patient-reported outcomes and long-term follow-up are needed. This review contains 16 figures, 3 tables, and 62 references. Key Words: chest masculinization, gender affirmation, metoidioplasty, penile implant, phalloplasty, radial forearm free flap, scrotoplasty, transgender, urethral fistula, vaginectomy

Urethral Complications After Transgender Phalloplasty: Strategies to Treat Them and Minimize Their Occurrence.

Radial forearm free flap phalloplasty (RFFP) is the current standard of care for most FTM gender confirmation surgeries. This procedure is associated with a rate of urethral stricture as high as 51%, which falls only to 23-35% even among the most experienced contemporary surgeons. While some modifications have been proposed to combat this high complication rate, it still remains a major source of lasting morbidity. The method involves literature review of RFFP literature. Lowest stricture rates are found when neourethra is made with a long, meticulously constructed tube of well-vascularized perivaginal/periurethral and labia minora tissue. In cases of urethral stricture, urethroplasty is required in 94-96% of patients. Surgery should be delayed until all acute inflammation has subsided. Urethroplasty is technically challenging and fails in up to 50% of cases. Repeated surgery or salvage urethral exteriorization procedures, which can leave the patient with lifelong perineal urethrostomy, are often required. Patient and physician knowledge regarding the high burden and poor treatment options for urethral stricture after phalloplasty is incomplete, and patient acceptance of this reality is crucial for honest understanding of the potential complications of this increasingly common but extremely complex surgery. Clin. Anat. 31:187-190, 2018. © 2018 Wiley Periodicals, Inc.

Total vaginectomy and urethral lengthening at time of neourethral prelamination in transgender men.

For transgender men (TGM), gender-affirmation surgery (GAS) is often the final stage of their gender transition. GAS involves creating a neophallus, typically using tissue remote from the genital region, such as radial forearm free-flap phalloplasty. Essential to this process is vaginectomy. Complexity of vaginal fascial attachments, atrophy due to testosterone use, and need to preserve integrity of the vaginal epithelium for tissue rearrangement add to the intricacy of the procedure during GAS. We designed the technique presented here to minimize complications and contribute to overall success of the phalloplasty procedure. After obtaining approval from the Institutional Review Board, our transgender (TG) database at the University of Miami Hospital was reviewed to identify cases with vaginectomy and urethral elongation performed at the time of radial forearm free-flap phalloplasty prelamination. Surgical technique for posterior vaginectomy and anterior vaginal wall-flap harvest with subsequent urethral lengthening is detailed. Six patients underwent total vaginectomy and urethral elongation at the time of radial forearm free-flap phalloplasty prelamination. Mean estimated blood loss (EBL) was 290±199.4ml for the vaginectomy and urethral elongation, and no one required transfusion. There were no intraoperative complications (cystotomy, ureteral obstruction, enterotomy, proctotomy, or neurological injury). One patient had a urologic complication (urethral stricture) in the neobulbar urethra. Total vaginectomy and urethral lengthening procedures at the time of GAS are relatively safe procedures, and using the described technique provides excellent tissue for urethral prelamination and a low complication rate in both the short and long term.

Author Reply

Since 1-stage phallic reconstruction using the radial forearm free flap was reported in 1984 by Chang and Hwang 1 Chang T.S. Hwang W.Y. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg. 1984; 74: 251-258 Crossref PubMed Scopus (323) Google Scholar and Kao et al, 2 Kao X.S. Kao J.H. Ho C.L. Yang Z.N. Shi H.R. One-stage reconstruction of the penis with free skin flap: report of three cases. J Reconstr Microsurg. 1984; 1: 149 Crossref PubMed Scopus (30) Google Scholar the radial forearm free flap has become the most frequently used flap in penile reconstruction. Massanyi et al reported positive results using this technique in patients with exstrophy. 3 Massanyi E.Z. Gupta A. Goel S. et al. Radial forearm free flap phalloplasty for penile inadequacy in patients with exstrophy. J Urol. 2013; 190: 1577-1582 Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar The technique of phallic reconstruction using radial forearm free flap is universally considered the standard technique for penile reconstruction. 4 Hage J.J. Bout C.A. Bloem J.J. Megens J.A. Phalloplasty in female-to-male transsexuals: what do our patients ask for?. Ann Plast Surg. 1993; 30: 323-326 Crossref PubMed Scopus (85) Google Scholar , 5 Fang R.H. Kao Y.S. Ma S. Lin J.T. Phalloplasty in female-to-male transsexuals using free radial osteocutaneous flap: a series of 22 cases. Br J Plast Surg. 1999; 52: 217-222 Abstract Full Text PDF PubMed Scopus (100) Google Scholar , 6 Monstrey S. Hoebeke P. Dhont M. et al. Radial forearm phalloplasty: a review of 81 cases. Eur J Plast Surg. 2005; 28: 206-212 Crossref Scopus (59) Google Scholar , 7 Monstrey S. Hoebeke P. Selvaggi G. et al. Penile reconstruction: is the radial forearm really the standard technique?. Plast Reconstr Surg. 2009; 124: 510-518 Crossref PubMed Scopus (191) Google Scholar

Prelamination of Neourethra with Uterine Mucosa in Radial Forearm Osteocutaneous Free Flap Phalloplasty in the Female-to-Male Transgender Patient.

Radial forearm free flap phalloplasty is the most commonly performed flap for neophallus construction in the female-to-male (FtM) transgender patient. Urological complications, however, can arise quite frequently and can prevent the patient from urinating in the standing position, an important postsurgical goal for many. Using mucosa to construct the fixed urethra and to prelaminate the penile urethra has been successful in reducing urologic complications, particularly strictures and fistulas. Until now, only buccal, vaginal, colonic, and bladder sites have been described as sources for these mucosal grafts. We present the successful use of uterine mucosa for prelamination of the neourethra in an FtM patient who underwent hysterectomy and vaginectomy at the prelamination stage of a radial forearm phalloplasty. Three months postoperatively, the patient was able to void while standing and showed no evidence of stricture or fistula on retrograde cystogram. These results suggest that uterine mucosa may be used for prelamination of the penile neourethra in patients undergoing phalloplasty.

Radial Forearm Free Flap Phalloplasty for Penile Inadequacy in Patients with Exstrophy

Male patients with bladder and cloacal exstrophy are born with demure genitalia and often desire phalloplasty during late adolescence or early adulthood. Radial forearm free flap phalloplasty was used successfully for congenital aphallia in a few small series. We present a series of patients treated with phalloplasty using a radial forearm free flap after the repair of bladder and cloacal exstrophy. We reviewed the records of 10 patients who underwent radial forearm free flap phalloplasty between 2007 and 2012. Indications for phalloplasty were classic bladder exstrophy in 8 cases and cloacal exstrophy in 2. Nine patients underwent prior urinary diversion and 1 underwent urethroplasty at phalloplasty. In each case we reviewed the details of prior exstrophy repair, flap size, donor and recipient vessels, complications, need for subsequent surgeries and self-reported sensation. The graft survived in all 10 patients. Short-term complications requiring surgical intervention developed in 2 patients. Five patients subsequently underwent placement of a penile prosthesis and 2 devices were removed secondary to erosion. All 10 patients reported protective sensation and erogenous sensation with ability to achieve orgasm at last followup. Radial forearm free flap phalloplasty results in a sensate, cosmetic neophallus. No patient had long-term complications related to phalloplasty but complications related to penile prostheses continue to be a challenging aspect of phalloplasty. The long-term results of the forearm free flap are encouraging in this series of patients with bladder and cloacal exstrophy who desired phalloplasty.