Elsevier

European Urology

Volume 57, Issue 4, April 2010, Pages 715-722
European Urology

Sexual Medicine
Total Phallic Reconstruction in Female-to-Male Transsexuals

https://doi.org/10.1016/j.eururo.2009.05.018Get rights and content

Abstract

Background

The goal of total phallic construction is the creation of a sensate and cosmetically acceptable phallus. An incorporated neourethra allows the patient to void while standing, and the insertion of a penile implant allows the patient to resume sexual activities, thus improving quality of life.

Objective

To report our experience of total phallic construction with the use of the radial artery free flap in female-to-male transsexuals.

Design, settings, and participants

The notes of the 115 patients who underwent total phallic construction with the use of the radial artery–based forearm free flap between January 1998 and December 2008 were reviewed retrospectively.

Measurements

The surgical outcome, cosmesis of the phallus, complications, eventual need for revision surgery, and patient satisfaction were recorded during the follow-up.

Results and limitations

This technique allowed the reconstruction of a cosmetically acceptable phallus in 112 patients; 3 patients lost the phallus due to venous thrombosis in the immediate postoperative period. After a median follow-up of 26 mo (range: 1–270 mo), 97% of patients are fully satisfied with cosmesis and size of the phallus. Sensation of the phallus was reported by 86% of patients. Urethral strictures and fistulae in the phallus and join-up site were the most common complications, occurring respectively in 9 and 20 patients; however, after revision surgery, 99% of patients were able to void from the tip of the phallus while standing.

Conclusions

The radial artery–based forearm free flap technique is excellent for total phallic construction, providing excellent cosmetic and functional results.

Introduction

Gender reassignment surgery for the female-to-male transsexual (FTMT) involves subcutaneous mastectomy, hysterectomy, salpingo-oophorectomy, vaginectomy, total phallic construction, and placement of penile and testicular prostheses. The main goals of surgery are the creation of a cosmetically acceptable sensate phallus with the incorporation of a neourethra to allow voiding in a urinal and with enough bulk to allow the insertion of a penile prosthesis for sexual intercourse [1].

The classic method of penile reconstruction involves the use of abdominal flaps. The first total phallic construction was attempted in 1936 by Bogoras [2], who used a random pedicled oblique abdominal singular tube with no incorporated neourethra. Phallic rigidity was obtained by inserting rib cartilage inside the flap.

Maltz [3] and Gillies and Harrison [4] subsequently improved the Bogoras technique by creating a phallus which incorporated a neourethra using the tube within a tube concept. These procedures were multistaged, resulted in extensive scarring and disfigurement of the donor area, and produced a phallus with no sensation.

Further advances involved the use of infraumbilical skin and groin flaps [5], [6], [7], [8], [9], [10]. The main limitation of these techniques was the formation of an insensate and wedge-shaped phallus. Musculocutaneous thigh flaps, used when there was extensive abdominal scarring from previous surgery or radiotherapy, have also been abandoned due to poor results [11], [12], [13], [14], [15], [16].

With the advent of microsurgical techniques, a new era has started for total phallic construction. Originally described in 1982 by Song et al [17], the use of the radial artery free flap phalloplasty was first published in 1984 by Chang and Hwang [16], who used this technique successfully for total phallic reconstruction in seven patients who had previously had a penile amputation. The reconstructive procedure involved the creation of a tube within a tube using forearm skin, with the urethra fashioned from the non-hair-bearing area, and the whole flap was based on the radial artery.

After the success of this series, many teams adopted this technique and applied some modifications in flap design to improve the cosmesis of the neophallus and to minimise the overall complication rate and donor-site morbidity that can occur in 45% of cases [18]. Particularly, the shape of the forearm flap has been modified to improve the blood supply to the flap and to reduce the risk of meatal stenosis [19], [20], [21], [22], [23], [24]. Ulnar artery–based flaps have also been used to reduce the amount of hair-bearing skin that is incorporated [25].

Section snippets

Patients and methods

The notes of 115 FTMT patients who had undergone total phallic construction using the radial artery–based forearm free flap were reviewed. The median age at surgery was 34.9 yr (range: 20–55 yr).

The subordinate forearm was used in all patients. The vascular competency of the superficial and deep palmar arteries was checked with an Allen test, followed by duplex ultrasonography when in doubt.

The total phallic construction was done using a modified Chang and Hwang flap [16]. The process of total

Results

After a median follow-up of 26 mo (range: 1–270 mo), 67 patients had completed stage 3, 17 had completed stage 2, and 31 had phallus construction only.

Overall, 83 of the 84 patients (99%) who had urethral continuity were able to void from the tip of the phallus in a standing position. One patient developed an anastomotic stricture that will require further surgical management.

Complete phallus sensation was reported in 82 patients (71.5%); of the remainder, 17 patients (14.7%) reported sensation

Discussion

Since its original description by Song et al [17] and Chang and Hwang [16], penile reconstruction using the radial artery–based forearm free flap has proven to be superior to all other techniques. It guarantees a superior cosmetic result by forming a cylindrical phallus rather than the wedge-shaped infraumbilical and groin flap phalloplasty [5], [6], [7], [8], [9], [10] and is less prone to postoperative contracture than musculocutaneous flaps [11], [12], [13], [14], [15], [16]. It allows the

Conclusions

This series shows that the radial artery–based forearm free flap represents the gold standard technique for total phallic construction. It provides superior cosmetic and functional results and guarantees the highest satisfaction rates among patients.

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