Radial Forearm Phalloplasty Research Articles

Analysis of the Radial Forearm Phalloplasty Donor Site: Do Dermal Matrices Improve Donor Site Morbidity?

The radial forearm free flap is frequently chosen for phalloplasty; however, flap size required for phalloplasty is associated with a large scar burden and functional concerns. We sought to investigate donor site functionality, aesthetics, and volume deficits in a cohort of individuals who underwent radial forearm phalloplasty (RFP) with donor site skin grafting alone or dermal substitute and subsequent skin grafting. Donor site functionality was assessed using the quick Disabilities of Arm, Shoulder, and Hand (qDASH). Patient- and clinician-reported aesthetics were assessed using the Patient and Observer Scar Assessment Scale (POSAS). An Artec Leo three-dimensional scanner was used to measure volumetric differences from the donor site forearm and contralateral forearm. Fifteen patients who underwent RFP agreed to participate. No statistically significant differences were identified between different donor site closure methods regarding qDASH, patient-reported POSAS, or total volumetric deficits. A blinded clinician reported that POSAS approached significance at 4.7 for biodegradable temporizing matrix (BTM), 4.2 for Integra, and 3.0 for split-thickness skin graft (P = 0.05). No statistically significant differences were identified regarding distal, middle, or proximal volume deficits; however, a trend was observed regarding total volumetric deficits with BTM experiencing the lowest deficit (10.3 cm3) and skin graft experiencing the highest deficit (21.5 cm3, P = 0.82). The addition of dermal matrix (BTM or Integra) to the treatment algorithm for RFP did not show statistically significant improvement in donor site volume deficits, patient-reported scar appearance (POSAS), or functionality (qDASH).

(038) Optimizing Innervation in Radial Forearm Phalloplasty: Determination of Ideal Nerve Coaptations via Donor:Recipient Axon Ratios

Abstract Introduction There is currently no standardized approach to innervation in radial forearm phalloplasty. This includes both the number and the combination of nerve coaptations that are performed. It is also under-recognized that the nerve coaptations executed in phalloplasty are equivalent to sensory nerve transfers. It is well documented that a key component of a successful nerve transfer is a sufficient donor:recipient (D:R) axon ratio. Evidence suggests a minimum ratio of greater than 0.3:1 and an optimal ratio of greater than or equal to 0.7:1 to best optimize nerve regeneration and outcomes. Axon counts and donor:recipient axon ratios have not yet been performed for the sensory nerves used in phalloplasty surgery. Objective The purpose of this study was to obtain axon counts for the donor and recipient nerves used in radial forearm phalloplasty in order to calculate donor:recipient axon ratios for each possible sensory nerve transfer. This information will inform which nerve coaptations are most ideal in radial forearm phalloplasty based on both axon counts and donor:recipient axon ratios. Methods Following IRB approval and informed consent, five transmasculine patients who underwent gender-affirming phalloplasty at our institution had nerve specimens (5 mm) taken from five different sensory nerves that are routinely transected during surgery – the lateral antebrachial cutaneous (LABC), medial antebrachial cutaneous (MABC), posterior antebrachial cutaneous (PABC), ilioinguinal, and dorsal nerve of the clitoris. Histomorphometric evaluation was performed to determine mean axon counts for each nerve respectively. Donor:recipient axon ratios were then calculated for each possible combination of donor and recipient nerves. Results Mean axon counts for the recipient nerves were 6957 (LABC), 1866 (MABC), 1712 (PABC). Mean axon counts for the donor nerves were 2301 (ilioinguinal), and 5141 (dorsal nerve of clitoris). Calculated D:R axon ratios were as follows: clitoral:LABC 0.739, clitoral:MABC 2.754, clitoral:PABC 3.002, ilioinguinal:LABC 0.331, ilioinguinal:MABC 1.233, and ilioinguinal:PABC 1.344. Conclusions Based on both mean axon counts and D:R ratios, the clitoral nerve is the more powerful donor nerve available in phalloplasty and should be considered for use as a primary donor. All D:R ratios exceed 0.3:1. However the best matches based on D:R ratios and clinical size match appear to be clitorial:LABC and ilioingiinal:MABC or ilioinuinal:PABC. If using MABC or PABC to coapt into the clitoral nerve, there should be consideration for using only part of the clitoral nerve to prevent unnecessary levels of clitoral denervation or neuroma formation given significant excess of donor axons available compared to recipient pathways for regeneration. The ilioinguinal nerve is likely under-powered to consistently re-innervate the LABC. In general, most coaptations are highly favorable for functional levels of nerve regeneration. This also suggests additional factors beyond successful nerve regeneration may contribute to optimal sensory outcomes following phalloplasty surgery. Disclosure No

Donor and Recipient Nerve Axon Counts in Gender-affirming Radial Forearm Phalloplasty: Informing Choice of Nerve Coaptations.

Five transmasculine people who underwent gender-affirming radial forearm phalloplasty had nerve specimens processed with histomorphometric evaluation to determine axon counts and approximate donor-to-recipient axon ratios. Mean axon counts for recipient nerves were 6957 ± 1098 [the lateral antebrachial (LABC)], 1866 ± 590 [medial antebrachial (MABC)], and 1712 ± 121 [posterior antebrachial cutaneous (PABC)]. Mean axon counts for donor nerves were 2301 ± 551 [ilioinguinal (IL)] and 5140 ± 218 [dorsal nerve of the clitoris (DNC)]. D:R axon ratios using mean axon counts were DNC:LABC 0.739 (0.61-1.03), DNC:MABC 2.754 (1.83-5.91), DNC:PABC 3.002 (2.71-3.53), IL:LABC 0.331 (0.24-0.46), IL:MABC 1.233 (0.86-1.17), and IL:PABC 1.344 (0.85-1.82). The DNC is the more powerful donor nerve with greater than two times the axon count of the IL. The IL nerve may be under-powered to re-innervate the LABC based on an axon ratio consistently less than 0.7:1. All other mean D:R are more than 0.7:1. DNC axon counts may be excessive for re-innervation of the MABC or PABC alone with D:R of more than 2.5:1, potentially increasing risk of neuroma formation at the coaptation site.

MP02-15 UROLOGIC OUTCOMES FOLLOWING METOIDIOPLASTY AND PHALLOPLASTY GENDER AFFIRMING SURGERY (MAPGAS) WITH URETHRAL LENGTHENING: A MODIFIED DELPHI CONSENSUS STUDY

You have accessJournal of UrologyCME1 Apr 2023MP02-15 UROLOGIC OUTCOMES FOLLOWING METOIDIOPLASTY AND PHALLOPLASTY GENDER AFFIRMING SURGERY (MAPGAS) WITH URETHRAL LENGTHENING: A MODIFIED DELPHI CONSENSUS STUDY Gaines Blasdel, Mang L. Chen, Jens Berli, Geolani Dy, Daniel Dugi, Miroslav Djordjevic, Marta Bizic, Lee Zhao, Loren Schechter, Richard Santucci, Jeremy B. Myers, Isak Goodwin, Dmitriy Nikolavsky, Toby Meltzer, Andrew Watt, Joseph Pariser, Bradley Figler, William Kuzon, Miriam Hadj-Moussa, Benjamin McCormick, Lee Brown, John F. Nigriny, and Rachel A. Moses Gaines BlasdelGaines Blasdel More articles by this author , Mang L. ChenMang L. Chen More articles by this author , Jens BerliJens Berli More articles by this author , Geolani DyGeolani Dy More articles by this author , Daniel DugiDaniel Dugi More articles by this author , Miroslav DjordjevicMiroslav Djordjevic More articles by this author , Marta BizicMarta Bizic More articles by this author , Lee ZhaoLee Zhao More articles by this author , Loren SchechterLoren Schechter More articles by this author , Richard SantucciRichard Santucci More articles by this author , Jeremy B. MyersJeremy B. Myers More articles by this author , Isak GoodwinIsak Goodwin More articles by this author , Dmitriy NikolavskyDmitriy Nikolavsky More articles by this author , Toby MeltzerToby Meltzer More articles by this author , Andrew WattAndrew Watt More articles by this author , Joseph PariserJoseph Pariser More articles by this author , Bradley FiglerBradley Figler More articles by this author , William KuzonWilliam Kuzon More articles by this author , Miriam Hadj-MoussaMiriam Hadj-Moussa More articles by this author , Benjamin McCormickBenjamin McCormick More articles by this author , Lee BrownLee Brown More articles by this author , John F. NigrinyJohn F. Nigriny More articles by this author , and Rachel A. MosesRachel A. Moses More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003213.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Metoidioplasty and Phalloplasty Gender Affirming Surgery (MaPGAS) performed with urethral lengthening should be customized to the individual patient. Urologic risks remain high, despite an array of surgical options. Due to a dearth of high-quality, primary outcomes studies, setting patient expectations is difficult. This study aims to explore MaPGAS surgeon consensus on expected outcomes. METHODS: A purposive sample of MaPGAS surgeons were invited to participate in a two round, modified Delphi, web-based study. Participants in the second round were asked for agreement with statements developed via round one Delphi results, community driven outcomes of interest, and literature review. Responses were anonymous. Statement consensus was defined a priori as ≥70% agreement and was calculated by the number agreeing with the statement divided by the total number routinely evaluating the outcome. Participants provided free text comments on disagreement, which were categorized into viewing statements as conservative (statement overstates complications, understates desired outcomes), or conversely as optimistic. RESULTS: Twenty-one MaPGAS surgeons were invited and 16 (76%) completed the survey. Thirteen (81%) performed metoidioplasty and 14 statements (93%) reached consensus (Table 1). Thirteen (81%) performed radial forearm (RF) phalloplasty and 8/12 (67%) statements reached consensus, while 10 (63%) performed anterolateral thigh (ALT) phalloplasty and 8 /12 statements (67%) reached consensus (Table 2). CONCLUSIONS: Greater consensus exists regarding metoidioplasty outcomes as compared to phalloplasty outcomes. Variations in experience, surgical technique, and outcomes evaluated may contribute to lack of consensus on MaPGAS outcomes. Source of Funding: 1R21DK124733-01 © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e17 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gaines Blasdel More articles by this author Mang L. Chen More articles by this author Jens Berli More articles by this author Geolani Dy More articles by this author Daniel Dugi More articles by this author Miroslav Djordjevic More articles by this author Marta Bizic More articles by this author Lee Zhao More articles by this author Loren Schechter More articles by this author Richard Santucci More articles by this author Jeremy B. Myers More articles by this author Isak Goodwin More articles by this author Dmitriy Nikolavsky More articles by this author Toby Meltzer More articles by this author Andrew Watt More articles by this author Joseph Pariser More articles by this author Bradley Figler More articles by this author William Kuzon More articles by this author Miriam Hadj-Moussa More articles by this author Benjamin McCormick More articles by this author Lee Brown More articles by this author John F. Nigriny More articles by this author Rachel A. Moses More articles by this author Expand All Advertisement PDF downloadLoading ...

Dual Innervation in Anterolateral Thigh (ALT) Phalloplasty: Consider the Femoral Perforating Nerves.

Background:Sensation following anterolateral thigh (ALT) phalloplasty is traditionally viewed as inferior to sensation following radial forearm phalloplasty, potentially due to fewer nerve coaptations performed. Neural anatomy of the ALT is well described, with branches of the femoral nerve innervating the medial flap. The purpose of this article is to draw attention to these nerves as a potential source of additional coaptation in ALT phalloplasty allowing for dual flap innervation.Methods:A PRISMA literature review was conducted to assess nerve coaptations used in ALT phalloplasty. Anatomic location and territory of the nerves of the thigh in ALT phalloplasty cases are reviewed.Results:Seventeen articles discuss ALT phalloplasty innervation, and 16 mention the use of only one nerve coaptation with the lateral femoral cutaneous nerve. In our experience performing ALT phalloplasty, perforating branch(es) of the femoral nerve are the first nerve(s) encountered on the medial border of the ALT flap lying on the fascia over the sartorius. With a flap design where the urethra is based laterally, the femoral perforating nerves can innervate a significant portion of the phallic shaft (medial flap), where sensation is most desired.Conclusions:It is common practice to perform only one nerve coaptation in ALT phalloplasty with the lateral femoral cutaneous nerve. However, perforating branches of the femoral nerve consistently innervate medial skin of the ALT. The authors propose that the femoral perforating nerves, when present, can be used as additional nerves for coaptation in ALT phalloplasty to allow for dual innervation.

Modification of the single‐tube radial forearm phalloplasty technique to allow for urinary meatal reconstruction: A report of two cases

The free radial forearm flap is the gold standard technique for transgender phalloplasty due to superior complication rates compared to other methods. However, reconstruction of the urinary tract, including urethral lengthening and creation of a pars pendula urethra within the flap, carries a high rate of complications. The risk of complications and a lack of desire for standing urination are reasons patients elect for single-tube phalloplasty. However, to date, single-tube phalloplasties lack creation of a urinary meatus, which affects the aesthetics of the reconstruction. The purpose of this report is to describe a technique for creating an aesthetic urinary meatus in single-tube phalloplasty. We herein describe the technique in the use of two healthy transgender males (ages 31 and 39). Both patients did not desire micturition through the neophallus, but still desired the appearance of a meatus at the tip of the neophallus. Single-tube radial forearm phalloplasty was performed for both patients. The radial forearm flaps for each patient were 14 × 15 cm. Meatoplasty was performed at the time of flap elevation utilizing an intact 1 × 4cm intact strip of ulnar sided skin during flap tubularization. This strip of skin was then invaginated to create a neomeatal pouch. The postoperative course was uncomplicated for both patients following at 5-day hospital stay for flap monitoring. Follow up time was 7 and 8 months. The neomeatal pouch persisted in both patients and the patients were satisfied with the appearance of the tips of the neophalluses.

Nerve morbidity at the radial forearm donor site following gender-affirming phalloplasty

In the radial forearm phalloplasty multiple nerves are harvested to provide phallic sensation, resulting in iatrogenic nerve injuries. Despite this, nerve morbidity following this procedure has been minimally assessed. The purpose of this study was to assess donor site nerve morbidity following radial forearm phalloplasty. Patients who underwent gender-affirming phalloplasty at our institution between 2016-2020 using the radial forearm were included. Pain characteristics were assessed with a modified Mackinnon Pain questionnaire consisting of 33 items, including visual analog scales (VAS) for reporting of pain and impact on aspects of quality of life (QoL), as well as 20 descriptive pain adjectives and a 21-item questionnaire to capture overall pain experience. A total of 37 patients were included. 31 had minimal-mild pain (VAS scores 0-3), and 6 patients had moderate-severe pain (VAS scores 4-10). The mild pain group reported a mean 2.74 (0-7) pain descriptors and reported minimal impact on QoL metrics. The moderate-severe pain group reported mean 6.33 (2-15) pain descriptors and reported significant impacts on QoL metrics. Significant differences were observed with decreased QoL (p=0.018), increased sadness (p=0.009), increased frustration (p=0.030), increased anger (p=0.0496), and decreased hopefulness (p=0.0496) in the moderate-severe pain group along with interference of pain with sleep (p=0.002). In a cross-sectional analysis of 37 patients who underwent gender-affirming radial forearm phalloplasty, the majority (31) experienced a minimal degree of donor site nerve pain. Six patients suffered from more significant nerve pain that was associated with a decreased QoL. Treatment and prevention of this nerve pain represent important areas for future exploration.

PD22-02 SURGICAL OUTCOMES OF URETHRAL REVISION SURGERY AFTER GENDER AFFIRMING, SINGLE STAGE RADIAL FOREARM PHALLOPLASTY

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) II (PD22)1 Sep 2021PD22-02 SURGICAL OUTCOMES OF URETHRAL REVISION SURGERY AFTER GENDER AFFIRMING, SINGLE STAGE RADIAL FOREARM PHALLOPLASTY Mang Chen, Amanda Chi, Brad Figler, Rachel Moses, Bauback Safa, and Andrew Watt Mang ChenMang Chen More articles by this author , Amanda ChiAmanda Chi More articles by this author , Brad FiglerBrad Figler More articles by this author , Rachel MosesRachel Moses More articles by this author , Bauback SafaBauback Safa More articles by this author , and Andrew WattAndrew Watt More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002011.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urethral strictures and fistulas are common after gender affirming phalloplasty with urethral lengthening. We report our experience in urethroplasty and fistula repairs after single stage radial forearm (RF) free flap phalloplasty. METHODS: We retrospectively reviewed a high volume, single center database of 128 transmen who underwent index, single stage RF phalloplasty between October 2017 and January 2021. Urethral fistulas and strictures were characterized by repair technique, length, and location, which is further categorized as the pars pendulans (PP) urethra, pars pendulans-pars fixa (PP-PF) urethral anastomosis, and pars fixa (PF) urethra. RESULTS: In total, 25% (32/128) of patients with a median follow up of 21.5 months needed urethral revision surgery for solitary fistula (3/128), stricture (21/128), and combination stricture and fistula (8/128). Solitary fistulas developed at the PP-PF (1), PF (1), and PF-native urethra anastomosis (1). These were repaired in one stage using fistula tract excision, primary urethral closure, and dermal autograft interposition without evidence of recurrence. Remaining fistulas were successfully repaired at time of urethroplasty. Strictures developed in 29 patients and were identified in the distal PP (4), PP-PF (18), and PF (12) urethra, with a mean length of 1.4cm (range 0.5 mm-3 cm); 6 patients had more than 1 stricture. Urethroplasty techniques utilized include staged Johanson (4), Heineke-Mikulicz (HM) (18), excision and primary anastomosis (3), and substitution (10) urethroplasty—with 8 patients needing buccal mucosal graft (BMG), and 2 needing split thickness skin grafts. Of the 29 patients undergoing stricture repair, 8 (28%) developed recurrent strictures requiring additional substitution (3) and HM (4) urethroplasty, and dilation (1). Two of the 8 (25%) required a third urethral intervention. No patients required a perineal urethrostomy, and no fistula recurrences were seen in those that needed simultaneous fistula repair. CONCLUSIONS: In a single center series of gender affirming RF phalloplasty, 25% of patients developed urethral strictures and/or fistulas requiring urethral revision, most frequently at the PP-PF anastomosis. Urethroplasty and fistula repair was successful in 75% of patients. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e380-e380 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mang Chen More articles by this author Amanda Chi More articles by this author Brad Figler More articles by this author Rachel Moses More articles by this author Bauback Safa More articles by this author Andrew Watt More articles by this author Expand All Advertisement Loading ...

QS4: Genital Neurosensory Outcomes After Innervated Radial Forearm Phalloplasty

Purpose:Radial free forearm flap (RFFF) phalloplasty is the most commonly-used technique for gender-affirming phalloplasty procedures. Microsurgical coaptation of the free flap nerves to branches of the genital nerves aims to provide patients with a sensate neophallus. Return of sensation in the neophallus is poorly understood and has yet to be well characterized in the literature. This study serves to describe sensation in the neophallus, which will assist in setting patient expectations for recovery and improving operative technique and planning, especially in selection of nerves for coaptation.Methods:A total of 14 patients undergoing RFFF were tested for pressure sensation in the neophallus postoperatively. Testing was conducted via 1-point static (1PS) testing using the Pressure Specified Sensory Device (PSSD). A 100g monofilament was used to screen the neophallus for sensation beginning at 3 cm distal to the base and advancing distally by 1 cm until the patient reported no sensation; the PSSD was then applied at the last point the patient reported sensation for precise pressure measurements. These measurements were taken on the right and left ventral and dorsal shaft 1 cm from the ventral and dorsal midlines, respectively. The right and left urethral meatus was also measured for sensation (representing the ulnar-most skin of the RFFF). Measurements were taken at intervals beginning as early as 1 week postoperatively; the longest patient follow-up thus far has been 17 months.Results:Of the 14 patients, 13 had tactile pressure sensation at their most recent measurement (range 1-17mos). The remaining patient did not have a measurement beyond one month postoperatively. Of the 14 patients, consistent long-term follow-up measurements were currently available for 7. Among these patients, return of any sensation was measured at an average of 69 days (12-160 days) postoperatively. The earliest time point at which a patient had any sensation was two weeks postoperatively while another patient had sensation through the full length of the neophallus measured at 2.5 months postoperatively; subsequent measurements of this patient showed a decreased threshold (increased sensitivity) for pressure sensation over time.Conclusions:Preliminary data suggests that innervation of the RFFF neophallus can be accomplished via microsurgical nerve coaptation and that recovery of sensation may occur much faster in some patients than previously thought possible. Further follow-up and a larger patient cohort is necessary to fully characterize nerve recovery and regeneration in gender-affirming phalloplasty patients.

The radial forearm flap with a prelaminated urethra: analysis of complications based on the Clavien-Dindo classification

All patients undergoing gender reassignment surgery in our department between 1 January 2011 and 30 June 2017 using a radial forearm phalloplasty with a prelaminated urethra for gcS were included in this study. The total number of patients was 39. The complications after colpectomy, urethral prelamination, phalloplasty, implantation of testicular implants and glans-plasty were assessed. The follow-up after phalloplasty ranged between 6 and 80 months and was 32 months on average. Complications were classified according to Clavien Dindo. Phalloplasty was uneventful in 5 out of 39 patients (12.8 %). In 22 patients (56.4 %) a grade I complication occurred. Four patients (10.3 %) sustained a grade II complication, 16 (41 %) had a grade IIIb complication and one patient had a grade IV complication (2.6 %). Twenty-eight out of 39 patients (71.8 %) developed urethral fistulas in the direct postoperative course. However, only 8 of these patients (20.5 % of the total population) required surgical revision due to fistulas. Five patients developed a urethral stenosis (12.8 %) requiring surgical revision; in two of them this happened several times (8 stenoses in total). Flap losses occurred in two patients (5.1 %). Radial forearm phalloplasty with a prelaminated urethra has become a well-established procedure in female-to-male gender reassignment surgery. In our study, the rate of urological complications was significantly reduced to a level lower than those reported in previous studies. The number of fistulas was significantly reduced during our learning curve and by surgical modifications such as a visor flap at the site of the urethral anastomosis. This large series provides a database of complications classified according to Clavien Dindo for comparison with future techniques and innovations.

Post-Operative Use of Furosemide Is Associated with Decreased Urinary Complications after Transgender Free Radial Forearm Phalloplasty

Post-Operative Use of Furosemide Is Associated with Decreased Urinary Complications after Transgender Free Radial Forearm Phalloplasty

V85 - From pubis to phallus: A complete demonstration of the three stages of radial artery forearm phalloplasty formation

V85 - From pubis to phallus: A complete demonstration of the three stages of radial artery forearm phalloplasty formation

Masculinizing Genital Gender Confirmation Surgery.

This article is the third in a 3-part series focused on the comprehensive treatment of gender dysphoria. Multidisciplinary gender dysphoria care may involve a combination of counseling, social gender transition, hormone therapy, and gender confirmation surgery (GCS) to maximize physical characteristics congruent with a patient's gender identity. Nonoperative management of gender dysphoria was covered in part 1. The focus of part 2 was feminizing GCS. In part 3, surgical considerations for masculinizing GCS are summarized, including a review of different phalloplasty techniques. This installment also includes information about adjunctive procedures, therapies, and products used by transgender men and women to express their gender identity. To provide an overview of both genital and nongenital masculinizing gender confirmation procedures. To review phalloplasty techniques, preoperative considerations, complications, and outcomes. To summarize ancillary services and procedures available to transgender patients to facilitate their gender presentation. A review of relevant literature through May 2017 was performed via PubMed. To summarize ancillary products and services used by transgender patients and to review surgical considerations for masculinizing genitoplasty. A variety of nonsurgical ancillary services exist for transgender patients to aid their transition. A variety of phalloplasty procedures have been developed for transgender men who seek genital GCS. Most surgeons prefer radial forearm phalloplasty, including the authors whose surgical technique is described. Each phalloplasty approach is associated with its own benefits, drawbacks, and complications. A variety of ancillary services and procedures that help transgender men and women communicate their gender identity in society is available and is an important adjunct to medical or surgical treatment of gender dysphoria. Pre-operative, intra-operative, and post-operative considerations of masculinizing genital gender confirmation procedures were reviewed. Hadj-Moussa M, Agarwal S, Ohl DA, etal. Masculinizing Genital Gender Confirmation Surgery. Sex Med Rev 2019;7:141-155.

Phalloplasty in Female-to-Male Transsexuals by Gottlieb and Levine's Free Radial Forearm Flap Technique-A Long-Term Single-Center Experience Over More than Two Decades.

The free radial forearm flap phalloplasty is the most utilized method for penile reconstruction. Among the techniques described in the literature, evidence for the flap design after Gottlieb and Levine is poor. From January 1993 until December 2015, 402 phalloplasties were performed in our clinic. Among the 247 free radial forearm flap phalloplasties, 232 free radial forearm flap phalloplasties were performed after Gottlieb and Levine in 229 patients. Operation and patient-specific characteristics were evaluated. This study presents the highest number of free radial forearm flap phalloplasties after Gottlieb and Levine. The rate of total flap failure was 3%; 46% of the patients were heavy smokers. Urinary fistulae and strictures are common. The revision rate for urinary fistulae and/or strictures was 1.3 per patient. The number of postoperative complications, such as bleeding (14.2%), thrombosis of the flap requiring revision (11.2%), or delayed wound healing (16.8%) was considering the high rate of nicotine abuse (45.9%) reasonable. The free radial forearm phalloplasty in the design by Gottlieb and Levine is well established at our institution and has proven safe and reliable since 1993. The operative results are satisfactory for both patients and surgeons even in the presence of relevant comorbidities and heavy smoking. We acknowledge the long ordeal and psychological pressure that our patients suffer from, before presenting in our outpatient clinic.

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

Immediate pedicled gracilis flap in radial forearm flap phalloplasty for transgender male patients to reduce urinary fistula

Radial forearm phalloplasty is accompanied by high rates of fistula formation. We examined the effect of placing a pedicled gracilis myofascial flap around the urethral anastomosis at the time of radial forearm flap transfer on the development of postoperative urethrocutaneous fistula. Fifteen patients underwent phalloplasty with urethroplasty between June 2012 and October 2015, and they met the inclusion and exclusion criteria for the study. We retrospectively reviewed patients' medical records and extracted patient demographic data, prelamination technique used (mucosa, skin graft, both, or neither), and whether or not a gracilis myofascial flap was harvested at the time of flap transfer and used to reinforce the native-neourethral anastomosis. The chi-squared test was used to evaluate the association between the presence of a gracilis flap and fistula formation. Four patients received a gracilis flap as part of their primary phalloplasty operation. None of these patients developed a fistula. Eleven patients did not receive a gracilis flap at the time of initial surgery and seven developed a fistula. In our patient series, inclusion of a pedicled myofascial gracilis flap at the time of radial forearm phalloplasty with urethroplasty was associated with an absence of fistula formation. Therefore, we have since made inclusion of this flap a standard practice for all transmales undergoing phalloplasty with urethroplasty.

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.

Pre-fabricated radial forearm phalloplasty with cadaveric bone graft

Pre-fabricated radial forearm phalloplasty with cadaveric bone graft

Penile Reconstruction with the Radial Forearm Flap: An Update

Many methods and many free or pedicled flaps have been used in phalloplasty. None of these techniques is able to completely fulfill the well described goals in penile reconstruction. Still, the radial forearm glap is currently the most frequently used flap and thus universally considered the gold standard. Since 1992, we have performed the largest series of 316 radial forearm phalloplasties to date performed by a single surgical team. From these extensive data we critically evaluate how this current supposed gold standard can meet the requirements of an ideal penile reconstruction. We assessed outcome parameters such as number of procedures to achieve complete functional result, aesthetic outcome, tactile and erogenous sensation, voiding, donor site morbidity, scrotoplasty and sexual intercourse. While currently no controlled randomized prospective studies are available to prove the radial forearm flap is truly the 'gold standard' in penile reconstruction, we believe that our retrospective data support the radial forearm phalloplasty as a very reliable technique for the creation of a normal looking penis and scrotum. While full functionality is achieved through a minimum of 2 procedures, the patients are always able to void standing, and in most cases to experience sexual satisfaction. The relative disadvantages of this technique are the residual scar on the forearm donor site, the rather high number of initial urinary fistulas, the potential for long-term urological complications and the need for a stiffener or erection prosthesis. From our experience, we strongly feel that a structured multi-disciplinary cooperation between the reconstructive-plastic surgeon and the urologist is an absolute requisite to obtain the best possible technical results.

Die Radialisphalloplastik mit präformierter Harnröhre – ein Erfahrungsbericht der letzten 6 Jahre

Several methods for complete phalloplasty are reported in the current literature. However, a unique technique has not been established in specialized centers so far. The radial forearm phalloplasty and the free fibular flap are the most common procedures for neophallus construction. There are 3 modifications for the radial forearm flap: the double folded "tube into tube" flap with a central vascularized urethra, the radial forearm flap with a vascularized urethra in the ulnar part of the flap and the radial forearm phalloplasty with a prelaminated neo-urethra using a full thickness skin graft. A series of 19 phalloplasties was performed between 2003 and 2010 in our department. The first cases of the series were conducted using the "tube-into-tube-technique" with the central urethra. However, the surgical concept was changed for the majority of cases (n=15) due to complications and not satisfying esthetic results. The phalloplasties were performed using the technique with a prelaminated urethra from 2005 on. The urethra prelamination was carried out using a full thickness skingraft 6 months before the actual phalloplasty procedure. Skin harvest was performed during mastectomy in the ideal case but otherwise alternatively from the lower belly. The complication rate in our series was comparable to the results of other authors. The esthetic results were very satisfying and the donor side morbidity was kept as minor as possible. All other techniques for radial forearm phalloplasty require the elevation of an additional 3.5-4 cm wide and 14-18 cm long adipocutaneous stripe at the forearm, which is used for construction of the urethra.