Anatomy of the pedicled anterolateral thigh flap for phalloplasty in transitioning-males

3D printing for an anterolateral thigh phalloplasty

BACKGROUND

Phalloplasty procedures are performed to create a phallus, typically as a gender-affirming surgery for treating gender dysphoria. Due to the controversial nature of this specific procedure, more innovation is needed to directly assist surgical teams in this field. As a result, surgeons are left to improvise and adapt tools created for other procedures to improve surgical outcomes. This study developed a patient-specific 3D printed model from segmented computed tomography (CT) scans to accurately represent the relevant vasculature necessary for anterolateral thigh (ALT) flap phalloplasty. The surgical procedure seeks to maintain intact vessels that derive from the descending branch of the lateral circumflex femoral artery, typically found traveling within the intermuscular septum between the rectus femoris and vastus lateralis.

METHODS

In this study, we created and printed 3D models of the leg and vasculature using two techniques: (1) a standard segmentation technique with the addition of a reference grid and (2) a bitmap method in which the total CT volume is colorized and printed.

RESULTS

The results gathered included the physician's view on the model's accuracy and visualization of relevant anatomy. Bitmap-printed models resulted in a high amount of detail, eliciting surgeons' undesirable reactions due to the excess of information. The hybrid method produced favorable results, indicating positive feasibility.

CONCLUSIONS

This study tested the ability to accurately print a patient-specific 3D model that could represent the vasculature necessary for ALT flap procedures and potentially be used in surgical reference and planning in the future. A surgeon performing phalloplasty procedures discussed their approval of both models and their preference for grid creation and application.

Variability of anterolateral thigh flap perforator locations - clinical implications

<b><br>Introduction:</b> The anterolateral thigh flap is an example of a free flap widely applied for reconstruction of tissues within various areas of the body.</br> <b><br>Aim:</b> The aim of the study was to determine the most common locations of the ALT flap perforators in men and women as well as to clarify any potential differences in the location of the vessel in male vs. female subjects.</br> <b><br>Material and method:</b> In years 2021-2022, a study was conducted at the Plastic, Reconstructive, and Aesthetic Surgery Clinic in a group of 90 volunteers (45 women and 45 men, a total of 180 lower extremities) to determine the location of the anterolateral thigh flap perforator against the flap surface using a portable Doppler probe.</br> <b><br>Results:</b> Variable locations were revealed for the anterolateral thigh flap perforator within the study. In women, the perforator is located more distally from the anterior superior iliac spine, most frequently within the inferolateral quadrant, while being located closer to the anterior superior iliac spine, and most frequently within the superolateral quadrant, in men. No perforator was found in 3.3% of the examined limbs. No statistically significant differences were observed between the course of the perforators within the left and right lower limbs in individual patients.</br> <b><br>Conclusions:</b> The location of the ALT flap perforator is subject to sexual dimorphism, which facilitates the investigation area being narrowed down to the well-defined locations of its most frequent occurrence when planning anterolateral thigh flap reconstructive procedures.</br>.

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

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.

Parallel Cross-Leg Free Flap with Posterior Tibial Artery Perforator Pedicle Propeller Cable Bridge Flap for the Treatment of Lower Extremity Wounds: A Case Series Report

BACKGROUND

A cross-leg flap can be used to treat severely injured lower limbs but associated with complications. Herein, we describe a technique of a parallel cross-leg free flap combined with posterior tibial artery perforator pedicle propeller cable bridge flap for the treatment of lower extremity wounds.

METHODS

The artery and veins of the free flap are anastomosed to the contralateral posterior tibial artery and vein, respectively. The vascular pedicle is wrapped with a posterior tibial artery perforator pedicle propeller flap. The legs are allowed to remain in a straight, relaxed position which is maintained with a bandage or Kirschner wire placed at the distal limbs. Pedicle division is performed around 21 days after flap creation, and the posterior artery is re-anastomosed and pedicled flap returned to its original position.

RESULTS

From June 2017 to March 2020, 7 patients with lower extremity wounds and tissue loss received reconstruction with this method. The recipient vessels for all flaps were the posterior tibial artery and vein. The average operation time was 5 hours. The average time to ambulation was 4 weeks, and the average follow-up time was 13.7 months. All flaps survived, and limb salvage was successful in all patients. Patients were not uncomfortable with the limbs held in position until pedicle division, and there were no complications. At the final follow-up, the function of all limbs was normal, and the esthetic appearance was acceptable to all patients.

CONCLUSIONS

The method described overcomes the disadvantages of traditional cross-leg flaps for the treatment.

"Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?"

BACKGROUND

The limitations of metoidioplasty and phalloplasty have been reported as deterrents for transgender and other gender expansive individuals (T/GE) desiring gender affirming surgery, and thus penile transplantation, epithesis, and composite tissue engineering (CTE) are being explored as alternative interventions.

AIM

We aim to understand the acceptability of novel techniques and factors that may influence patient preferences in surgery to best treat this diverse population.

METHODS

Descriptions of metoidioplasty, phalloplasty, epithesis, CTE, and penile transplant were delivered via online survey from January 2020 to May 2020. Respondents provided ordinal ranking of interest in each intervention from 1 to 5, with 1 representing greatest personal interest. Demographics found to be significant on univariable analysis underwent multivariable ordinal logistic regression to determine independent predictors of interest.

OUTCOMES

Sexual orientation, gender, and age were independent predictors of interest in interventions.

RESULTS

There were 965 qualifying respondents. Gay respondents were less likely to be interested in epithesis (OR: 2.282; P = .001) compared to other sexual orientations. Straight individuals were the least likely to be interested in metoidioplasty (OR 3.251; P = .001), and most interested in penile transplantation (OR 0.382; P = .005) and phalloplasty (OR 0.288, P < .001) as potential interventions. Gay and queer respondents showed a significant interest in phalloplasty (Gay: OR 0.472; P = .004; Queer: OR 0.594; P = .017). Those who identify as men were more interested in phalloplasty (OR 0.552; P < .001) than those with differing gender identities. Older age was the only variable associated with a decreased interest in phalloplasty (OR 1.033; P = .001). No demographic analyzed was an independent predictor of interest in CTE.

CLINICAL IMPLICATIONS

A thorough understanding of patient gender identity, sexual orientation, and sexual behavior should be obtained during consultation for gender affirming penile reconstruction, as these factors influence patient preferences for surgical interventions.

STRENGTHS AND LIMITATIONS

This study used an anonymous online survey that was distributed through community channels and allowed for the collection of a high quantity of responses throughout the T/GE population that would otherwise be impossible through single-center or in-person means. The community-based methodology minimized barriers to honesty, such as courtesy bias. The survey was only available in English and respondents skewed young and White.

CONCLUSION

Despite previously reported concerns about the limitations of metoidioplasty, participants ranked it highly, along with CTE, in terms of personal interest, with sexual orientation, gender, and age independently influencing patient preferences, emphasizing their relevance in patient-surgeon consultations. A. Parker, G. Blasdel, C. Kloer et al. "Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?". J Sex Med 2022;19:385-393.

Planned and Unplanned Delayed Anterolateral Thigh Flap Phalloplasty

Background:

Pedicled anterolateral thigh (ALT) flap phalloplasty can be limited by inadequate perfusion. Vascular delay increases perfusion, as delay causes blood vessel formation by limiting the blood supply available to a flap before transfer. We hypothesized that delayed ALT flap phalloplasty would decrease rates of partial flap or phallus loss and other postoperative complications when compared with previously reported complication rates of undelayed single-stage ALT phalloplasty in our practice.

Methods:

A retrospective medical record review was performed on all phalloplasty patients in our practice between January 2016 and September 2019. We found those patients who had completed delayed ALT flap phalloplasty with at least 6 months of delay and 12 months of follow-up. For these patients, we recorded postoperative complications, simultaneous surgeries, subsequent surgeries, and demographic characteristics.

Results:

Five female-to-male transsexuals underwent delayed ALT flap phalloplasty (two were unplanned procedures, three were planned). Planned delay: The average time between Stage 1 and Stage 2 was 6.5 months. Complications for the planned delay cohort were as follows: partial loss of the neophallus not requiring repair (33%), urethral stricture requiring surgical repair (33%). Unplanned delay: The average time between Stage 1 and Stage 2 was 9.1 months. The following complication was seen in the unplanned delay cohort: urethral stricture requiring surgical repair (50%).

Conclusions:

Vascular delay of ALT flap phalloplasty is a successful emergency salvage procedure. Planned delay of ALT flaps provided similar results compared with those previously reported by our practice with standard single-stage approach.

Total phallic construction techniques in transgender men: an updated narrative review

From 2012, the World Professional Association Transgender Health defined a structured therapeutic path and standards of care for transgender patients undergoing genital gender affirming surgery (GGAS). The main goal of GGAS in transgender males is to provide patients with an aesthetically appealing appearance of the neophallus that should allow standing micturition and enabling penetrative intercourse along with erogenous and tactile sensitivity. The optimal procedure should be safe, reproducible and performed in the fewest number of surgical stages. The ideal technique for total phallic construction (TPC) has not yet been demonstrated; TPC remains challenging and, from a functional point of view, it is also make more demanding as yet there are no perfect replacement materials for erectile and urethral tissues. Several procedures and different type of flaps (pedicled and free-flaps) have been proposed and investigated over time to address TPC with significant advances over the years especially after microsurgical procedures introduction. Due to its high complexity TPC is not free from complications. Local tissue ischaemic complications, complete and partial flap loss, donor site morbidity and urethral complications (fistulae and strictures) are reported. This narrative review aims to provide the readers with a contemporary overview of surgical procedures for TPC in transgender males focusing on key surgical steps, as well as surgical and functional outcomes.

Revisiting the Blood Supply of the Rectus Femoris: A Case Report and Computed Tomography Angiography Study

BACKGROUND

Rectus femoris necrosis is a rare but severe complication after anterolateral thigh flap (ALTF) harvesting. It has been previously reported that the blood supply of the rectus femoris (RF) often arises from the same source artery as the ALTF; however, precise descriptions of the relationship remain limited. This article revisits the blood supply of the RF based on computed tomography angiography (CTA) and analyzes the possible influence of the blood supply on the RF during ALTF harvesting.

METHODS

Between December 2017 and June 2018, CTA images of the bilateral lower extremities of 25 patients were studied. The RF length, number, and diameter of branches at the entry point into muscle, location, and overall branch vessel origins were recorded.

RESULTS

The average ± SD RF length was 384.73 ± 19.28 mm. There were 170 branches (mean ± SD, 3.4 ± 0.96 branches per thigh), mainly arising from the lateral circumflex femoral artery. The average ± SD diameter was 1.90 ± 0.51 mm. The first branch was located at 1/5 of the proximal site of the RF, and 91% of all branches were located above the midpoint. The RF vascularity can be classified into 2 types: type 1 (36% of sides) has branches that arise from a single artery (descending lateral circumflex femoral artery or femoral artery), whereas type 2 (64% of sides) has branches at the 1/5 proximal and 4/5 distal parts, which arise from different arteries.

CONCLUSIONS

Preoperative CTA can provide anatomic information about the RF's nutrient vessel(s) and helps to optimize ALTF design.

Phalloplasty Following Penectomy for Fournier's Gangrene at a Tertiary Care Center

Treatment of Fournier's gangrene often requires extensive surgical debridements that can ultimately necessitate penile amputation. Reconstruction can be challenging as these patients tend to have medical comorbidities deeming them poor microsurgical candidates. Fournier's gangrene resulting in penectomy is an infrequent occurrence, and treatment with phalloplasty is rarely described in the literature. Herein, we present a case of a 60-year-old male with poorly controlled diabetes mellitus who developed Fournier's gangrene in July 2017. His treatment course included multiple surgical debridements without resolution, eventually necessitating a penectomy. The patient elected for surgical reconstruction and underwent a phalloplasty procedure utilizing a radial forearm free flap. This case demonstrates a rare case of Fournier's gangrene resulting in penectomy with a unique reconstruction utilizing a radial forearm free flap in a poor microsurgical candidate.