Arch Hand Microsurg.  2023 Dec;28(4):302-307. 10.12790/ahm.23.0041.

Pedicled anterolateral thigh flap phalloplasty combined with radial forearm free flap urethral reconstruction in gender-affirming surgery: a report of two cases

• Kim K
• Lee D
• Jung S
• Chung CH
• Chang Y

• KMID: 2548603
• DOI: http://doi.org/10.12790/ahm.23.0041

Abstract

This case report presents two female-to-male (FTM) patients, aged 21 and 35 years, respectively, who underwent phalloplasty and urethral reconstruction at our institution. The patients’ requests included a phallus >9 cm, concealed donor-site scars, and the ability to void while standing. In the first case, a 4.5×13-cm radial forearm free flap (RFFF) taken from the nondominant side was retrieved and anastomosed to the deep inferior epigastric artery and vein. Simultaneously, a 10×16-cm pedicled anterolateral thigh (ALT) flap was relocated to the genital area and wrapped around the RFFF after nerve coaptation. The second case involved a 5.5×14-cm RFFF and a 20×13-cm pedicled ALT flap using a similar procedure. Both cases had stable double flaps with no complications, and Foley catheters were removed at 14 days and 3 months after surgery, respectively. Double-flap phalloplasty is thus a viable option for patients with a short forearm circumference or a preference for a less visible forearm scar.

Keyword

Gender dysphoria; Phalloplasty; Free tissue flaps; Microsurgery

Figure

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  Fig. 1. (A) A 4.5×13-cm free flap from the left forearm was retrieved for urethral reconstruction. (B) The radial forearm free flap (RFFF) flap was harvested after pedicle dissection. (C) The RFFF was placed on the recipient site for urethral anastomosis.

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  Fig. 2. A square design, measuring 10×16 cm, was marked on the right anterolateral thigh (ALT) preoperatively for ALT flap design.

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  Fig. 3. The pedicled anterolateral thigh flap was relocated to the genital area through a tunnel created underneath the rectus femoris and adductor muscles while avoiding tension or torsion on the vascular pedicle.

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  Fig. 4. Immediate postoperative photograph after the anterolateral thigh flap was wrapped around the radial forearm free flap with no tension or torsion on the vascular pedicle. (A) Dorsal view. (B) Ventral view.

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  Fig. 5. (A) A 5.5×14-cm left forearm free flap was retrieved for urethral reconstruction. (B) The radial forearm free flap was elevated. (C) The elevated flap was shaped into a tube-in-a-tube structure.

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  Fig. 6. A square design, measuring 20×13 cm, was preoperatively marked on the right anterolateral thigh (ALT) for ALT flap design.

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  Fig. 7. Immediate postoperative photograph after the anterolateral thigh flap was carefully positioned around the radial forearm free flap without any tension or twisting on its vascular pedicle. (A) Ventral view. (B) Dorsal view. (C) Frontal view.

Reference

References

1. Schechter LS, Safa B. Introduction to Phalloplasty. Clin Plast Surg. 2018; 45:387–9.

2. Morrison SD, Shakir A, Vyas KS, Kirby J, Crane CN, Lee GK. Phalloplasty: a review of techniques and outcomes. Plast Reconstr Surg. 2016; 138:594–615.

3. Monstrey S, Hoebeke P, Selvaggi G, et al. Penile reconstruction: is the radial forearm flap really the standard technique? Plast Reconstr Surg. 2009; 124:510–8.

4. Fang RH, Lin JT, Ma S. Phalloplasty for female transsexuals with sensate free forearm flap. Microsurgery. 1994; 15:349–52.

5. Monstrey S, Hoebeke P, Dhont M, et al. Radial forearm phalloplasty: a review of 81 cases. Eur J Plast Surg. 2005; 28:206–12.

6. Leriche A, Timsit MO, Morel-Journel N, Bouillot A, Dembele D, Ruffion A. Long-term outcome of forearm flee-flap phalloplasty in the treatment of transsexualism. BJU Int. 2008; 101:1297–300.

7. Gillies H, Millard R. The principles and art of plastic surgery (Vol. II). Boston, MA: Little, Brown & Company;1957.

8. Lumen N, Monstrey S, Ceulemans P, van Laecke E, Hoebeke P. Reconstructive surgery for severe penile inadequacy: phalloplasty with a free radial forearm flap or a pedicled anterolateral thigh flap. Adv Urol. 2008; 2008:704343.

9. Boczar D, Huayllani MT, Saleem HY, et al. Surgical techniques of phalloplasty in transgender patients: a systematic review. Ann Transl Med. 2021; 9:607.

10. van der Sluis WB, Smit JM, Pigot GLS, et al. Double flap phalloplasty in transgender men: surgical technique and outcome of pedicled anterolateral thigh flap phalloplasty combined with radial forearm free flap urethral reconstruction. Microsurgery. 2017; 37:917–23.