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DOI: 10.1055/s-0030-1267215
© Georg Thieme Verlag KG Stuttgart · New York
Penile Reconstruction with the Radial Forearm Flap: An Update
Penis-Rekonstruktion mit A. radialis-LappenplastikPublication History
received 16.6.2010
accepted 13.9.2010
Publication Date:
11 August 2011 (online)

Abstract
Background: 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.
Patients and Methods: 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.
Results: 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.
Conclusion: 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.
Zusammenfassung
Einleitung: Viele Methoden und viele freie oder gestielte Lappenplastik werden zur Phalloplastik eingesetzt. Keine dieser Techniken kann die gut definierten Zielvorgaben der Peniskonstruktion vollständig erfüllen. Bis heute ist die A. radialis-Lappenplastik der am häufigsten genutzte Lappen und wird generall als Gold-Standard angesehen.
Patienten und Methoden: Mit 316 radialen Unterarm Phalloplastiken seit 1992 präsentieren wir die umfangreichste Serie, die bis heute von einem einzelnen chirurgischen Team durchgeführt wurde. Anhand dieser umfangreichen Daten beurteilen wir kritisch, in wie weit der aktuelle Gold-Standard die Erfordernisse einer idealen Penis-Konstruktion erfüllt.
Ergebnisse: Wir bewerteten die folgenden Outcome Parameter: erforderliche Anzahl chirurgischer Interventionen bis zur vollständigen Funktionalität, ästhetisches Ergebnis, taktiles und erogenes Empfinden, Harnentleerung, Morbidität an der Donorseite, Skrotoplastik und Geschlechtsverkehr.
Schlussfolgerung: Obschon es aktuell keine randomisierten kontrollierten Studien gibt, die beweisen dass, die A. radialis-Lappenplastik tatsächlich der Gold-Standard zur Penis-Rekonstruktion ist, unterstützt unsere retrospektive Datenanalyse unserer Meinung nach, das die radiale Unterarm Phalloplastie eine sehr zuverlässige Technik zur Bildung eines normal aussehenden Penis und Skrotums ist. Volle Funktionalität wird durch ein Minimum von 2 Operationen erreicht, die Miktion ist stehend möglich, und zumeist kann auch sexuelle Befriedigung erlebt werden. Die relativen Nachteile dieser Technik sind die zurückbleibende Narbe am Unterarm, die eher hohe Anzahl initialer Harnfisteln, die Möglichkeit langwieriger urologischer Komplikationen und der Bedarf eines Versteifers oder einer Erektionsprothese. Unserer Erfahrung nach ist eine strukturierte multidisziplinäre Kooperation zwischen dem rekonstruktiv-plastischen Chirurgen und den Urologen eine absolute Voraussetzung, um bestmögliche technische Ergebnisse zu erzielen.
Key words
Transsexuality - urological plastic surgery - arteries - genitalia
Schlüsselwörter
Transsexualismus - urologische plastische Chirurgie - Arterien - Genitalien
References
- 1 Rogers BO. History of external genital surgery. In: Horton CE (ed) Plastic and Reconstructive Surgery of the Genital Area Boston, Little, Brown; 1973
MissingFormLabel
- 2
Bogoraz NA.
Plastic restoration of the penis.
Sov Khir.
1936;
303
MissingFormLabel
- 3
Bogoras N.
Über die volle plastische Wiederherstellung eines zum Koitus fähigen Penis (Peniplastica
totalis).
Zentralbl Chir.
1936;
22
1271-1276
MissingFormLabel
- 4
Gilles HD, Harrison RJ.
Congenital absence of the penis.
Br J Plast Surg.
1948;
1
8
MissingFormLabel
- 5
Orticochea M.
A new method of total reconstruction of the penis.
Brit J Plast Surg.
1972;
25
347-366
MissingFormLabel
- 6 Horton CE. Plastic & Reconstructive Surgery of the Genital Area. Boston, Little, Brown & Co; 1973: 117-161
MissingFormLabel
- 7
Hoopes JE.
Surgical construction of the male external genitalis.
Clin Plast Surg.
1974;
1
325-334
MissingFormLabel
- 8
Gilbert DA, Horton CE, Terzis JK. et al .
New concept in phallic reconstruction.
Ann Plast Surg.
1987;
18
128-136
MissingFormLabel
- 9
Hage JJ, de Graaf FH.
Addressing the ideal requirements by free flap phalloplasty: some reflections on refinements
of technique.
Microsurgery.
1993;
14
592-598
MissingFormLabel
- 10
Chang TS, Hwang WY.
Forearm flap in one-stage reconstruction of the penis.
Plas & Reconstr Surg.
1984;
74
215-258
MissingFormLabel
- 11
Koshima I, Tai T, Yamasaki M.
One-stage reconstruction of the penis using an innervated radial forearm osteocutaneous
flap.
J Reconstr Microsurg.
1986;
3
19-26
MissingFormLabel
- 12
Meyer R, Daverio PJ.
One-stage phalloplasty without sensory deprivation in female transsexuals.
World J Urol.
1987;
5
9-13
MissingFormLabel
- 13
Biemer E.
Penile construction by the radial arm flap.
Clin Plast Surg.
1988;
15
425-430
MissingFormLabel
- 14
Hage JJ, Bouman FG, De Graaf FH. et al .
Construction of the neophallus in female-to-male transsexuals: the Amsterdam experience.
J Urol.
1993;
6
1463-1468
MissingFormLabel
- 15
Harashima T, Ionque T, Tanaka I. et al .
Reconstruction of penis with free deltoid flap.
Brit J Plast Surg.
1990;
43
217-222
MissingFormLabel
- 16
Sadove RC, Sengezer M, McRobert JW. et al .
One-stage total penile reconstruction with a free sensate osteocutaneous fibula flap.
Plast & Reconstr Surg.
1993;
92
1314-1325
MissingFormLabel
- 17
Santanelli F, Scuderi N.
Neophalloplasty in female-to-male transsexuals with the island tensor fascia lata
flap.
Plast & Reconstr Surg.
2000;
105
1990-1996
MissingFormLabel
- 18
Monstrey S, Hoebeke P, Dhont M. et al .
Radial forearm phalloplasty: a review of 91 cases.
ANIR-ANHP (Official Journal of the Hellenic Society of Andrology).
2004;
6
193-199
MissingFormLabel
- 19
Sengezer M, Ozturk S, Deveci M. et al .
Long-term follow-up of total penile reconstruction with sensate osteocutaneous free
fibula flap in 18 biological male patients.
Plast & Reconstr Surg.
2004;
114
439-450
MissingFormLabel
- 20
Felici N.
A new phalloplasty technique: the free anterolateral thigh flap phalloplasty.
J Plast Reconstr Aesth Surg.
2006;
59
153-157
MissingFormLabel
- 21
Hage JJ, Bout CA, Bloem JJ. et al .
Phalloplasty in female-to-male transsexuals: what do our patients ask for?.
Ann Plast Surg.
1993;
30
323-326
MissingFormLabel
- 22
Fang RH, Kao YS, Ma S. et al .
Phalloplasty in female-to-male transsexuals using free radial osteocutaneous flap:
a series of 22 cases.
Brit J Plast Surg.
1999;
52
217-222
MissingFormLabel
- 23
Monstrey S, Hoebeke P, Dont M. et al .
Radial forearm phalloplasty: a review of 81 cases.
Europ J Plast Surg.
2005;
28
206-212
MissingFormLabel
- 24
Hage JJ, Monstrey S.
Free flap distel arteri-venous fistula: when to close it.
J Reconstr Microsurg.
1998;
14
407-410
MissingFormLabel
- 25
Lumen N, Monstrey S, Decaestecker K. et al .
Erectile implants in female-to-male transsexuals: our experience in 130 patients.
Abstract EAU 2008.
Eur Urol Suppl.
2008;
7
117
MissingFormLabel
- 26
Selvaggi G, Monstrey S, Hoebeke P. et al .
Donor site morbidity of the radial forearm free flap after 125 phalloplasties in gender
identity disorder.
Plast & Reconstr Surg.
2007;
118
1171-1177
MissingFormLabel
- 27
Hoebeke P, Selvaggi G, Ceulemans. et al .
Impact of sex reassignment surgery on lower urinary tract function.
Eur Urol.
2005;
47
398-402
MissingFormLabel
- 28
De Cuypere G, T’Sjoen G, Beerten R. et al .
Sexual and physical health after sex reassignment surgery.
Archives of Sexual Behavior.
2005;
36
679-690
MissingFormLabel
- 29
De Cuypere G, Elaut E, Heylens G. et al .
Long-term follow-up: psychosocial outcome of belgian transsexuals after sex reassignment
surgery. Suivi à Long Terme: Résultats sur le Plan Psychosocial de la Réassignation
de Sexe chez les Transsexuels Belges.
European J Sexual Health, Revue Européenne de Santé Sexuelle.
2006;
15
126-133
MissingFormLabel
- 30
Selvaggi G, Monstrey S, Ceuleman P. et al .
Genital sensivity after sex reassignment surgery in transsexual patients.
Ann Plast Surg.
2007;
58
427-433
MissingFormLabel
- 31
Weyers S, Selvaggi G, Monstrey S. et al .
2-stage versus one-stage sex reassignment surgery in female-to-male transsexual individuals.
Gynaecological Surg.
2006;
3
190-194
MissingFormLabel
- 32
Hoebeke P, De Cuypere G, Ceulemans P. et al .
Obtaining rigidity in total phalloplasty: experience with 35 patients.
J Urol.
2003;
169
221-223
MissingFormLabel
- 33
Selvaggi G, Hoebeke P, Ceulemans P. et al .
Scrotal reconstruction in female-to-male transsexuals: the novel scrotoplasty.
Plast & Reconstr Surg.
2008;
123
1710-1718
MissingFormLabel
- 34
Young VL, Khouri RK, Lee GW.
Advances in total phalloplasty and urethroplasty with microvascular free flaps.
Clin Plast Surg.
1992;
19
927-938
MissingFormLabel
- 35
Gottlieb LJ, Levine LA.
A new design for the radial forearm free flap phallic reconstruction.
Plast & Reconstr Surg.
1993;
92
276-284
MissingFormLabel
- 36
Fang RH, Lin JT, Ma S.
Phalloplasty for female transsexuals with sensate free forearm flap.
Microsurgery.
1994;
15
349-350
MissingFormLabel
- 37
Meyer WJ, Bockting WO, Cohen-Kettenis P. et al .
The standard of care for gender identity disorders, 6th version.
J Psychol Human Sexuality.
2001;
13
1-30
MissingFormLabel
- 38
Vriens J, Acosta R, Soutar D. et al .
Recovery of sensation in the radial forearm free flap in oral reconstruction.
Plast & Reconstr Surg.
1996;
98
64-69
MissingFormLabel
- 39
Matti B, Matthews R, Davies D.
Phalloplasty using the free radial forearm Flap.
Brit J Plast Surg.
1988;
41
160-164
MissingFormLabel
- 40
Rubino C, Figus A, Dessy LA. et al .
Innervated island pedicled anterolateral thigh flap for neo-phallic reconstruction
in female-to-male transsexuals.
J Plast Reconstr Aesth Surg.
2009;
62
e45-e49
MissingFormLabel
- 41
Davies DM, Matti BA.
A method of phalloplasty using the deep inferior epigastric flap.
Brit J Plast Surg.
1988;
41
165-168
MissingFormLabel
- 42
Felici N, Felici A.
A new phalloplasty technique: the free anterolateral thigh phalloplasty.
J Plast Reconstr Aesthet Surg.
2006;
59
153-157
MissingFormLabel
- 43
Bettocchi C, Ralph D, Pryor J.
Pedicled pubic phalloplasty in females with gender dysforia.
BJU Int.
2005;
95
120-124
MissingFormLabel
- 44
Baudet J.
Personal communication.
24th Alpine Workshop on Plastic and Reconstructive Surgery.
1997;
Arabba/Italy
MissingFormLabel
- 45
Sutcliffe PA, Dixon S, Akehurst RL. et al .
Evaluation of surgical procedures for se reassignment: a systematic review.
J Plast Reconstr Aesthet Surg.
2008 Jan;
25
1-13
MissingFormLabel
Correspondence
Prof. Dr. Stan Monstrey
Department of Plastic Surgery
Gent University Hospital
De Pintelaan 185
B 9000 Gent
Belgium
Email: stan.monstrey@ugent.be