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Preexpanded Radial Forearm Free Flap for One-stage Total Penile Reconstruction in Female-to-Male Transsexuals
23 April 2009 (online)
The free radial forearm fasciocutaneous flap is a well-established option for a total penile reconstruction in female-to-male transsexual patients. Several modifications  of this reliable microsurgical method have been proposed and implemented since its first descriptions.  However, the limited width of the flap usually does not allow urethral reconstruction and prostheses implantation simultaneously, therefore necessitating a two-stage procedure. We propose preexpansion of the radial forearm fasciocutaneous free flap, which may substantially increase both length and width of the flap to enable successful one-stage total penile reconstruction.
Our technique was successfully employed in two cases of gender reassignment surgery for the creation of the neophallus. Two female-to-male transsexual patients underwent total penile reconstruction with preexpanded radial forearm fasciocutaneous free flap 2 months after bilateral mastectomy with free nipple-areola grafting, hysterectomy, and oophorectomy. During this first phase of gender reassignment surgery, a 300-mL oval-shape tissue expander was implanted under the fascia of the planned fasciocutaneous radial forearm free flap, which was partially dissected (Fig. [1A]). A forearm fascia was incised distally and ulnarly to allow expansion (Fig. [1B]). The tissue expander was gradually inflated with normal saline twice a week for 2 months on an outpatient basis (Fig. [1C]). After the desired expansion was accomplished (Fig. [1D]), the expander was removed (Fig. [2A]) and one-stage total penile reconstruction was performed with simultaneous urethral reconstruction (Fig. [2B]) and silicone prostheses implantation in both patients (Fig. [2C] and [D]). A 7-cm-long, knitted Dacron vascular graft normally used for femoral artery bypass procedures was used as silicone rod holder. We used the graft, which was 5 mm less in diameter than the silicone rod, to obtain a strong hold of the prostheses, which was inserted 7 cm inside the graft lumen (Fig. [2E], [F], and [G]). The proximal edge of the graft holder was sutured to the symphysis pubis with 2–0 nonresorbable sutures subperiosteally. Both flaps were anastomosed to the superficial and deep epigastric vessels, and the lateral antebrachial nerve, harvested within the flap, was coapted to the dorsal clitoris branch from the pudendal nerve for flap sensation. Healing was uneventful, and both flaps survived completely, showing excellent aesthetic and functional results, including micturition and sexual activity (Fig. [2H] and [I]). Donor site morbidity was acceptable. After 18 months, both patients demonstrated satisfactory long-term final results (Fig. [2J] and [K]). Preexpanded radial forearm fasciocutaneous free flap may enable one-stage total penile reconstruction, allowing simultaneous urethral reconstruction and prostheses implantation with satisfactory aesthetic and functional results.
Figure 1 (A) Oval-shaped expander prepared for implantation. (B) Expander implanted under the incised fascia of planned radial forearm free flap. (C) Expansion performed on an outpatient basis once a week. (D) Operative design for total penile reconstruction.
Figure 2 (A) Extraction of the expander. (B) Reconstruction of the urethra and (C) implantation of penile silicone prostheses in the same procedure. (D) Flap sutured before microvascular transfer. (E) Insertion of the silicone rod into graft holder. (F) Prostheses inserted 7 cm inside the graft lumen. (G) Close-up view at the most distal part of graft holder. (H) Satisfactory functional and (I) aesthetic results postoperatively. (J,K) Satisfactory long-term results 18 months after phalloplasty.
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