Penile reconstruction: combined use of an innervated forearm osteocutaneous flap and big toe pulp

Phalloplasty: The dream and the reality

Phalloplasty has come a long way as Plastic Surgery has evolved over the years. The complication ridden multistage tube pedicles popularized by Gillis were, with the advent of microsurgery, replaced by radial forearm flaps. The composite osteo-cutaneous version of this flap promised ‘All for one and one for all’ assuring both a reliable urinary conduit and a phallus stiffener. Prelamination and prefabrication to make the neo-urethra came with the promise of reducing both fistula and strictures but that did not happen and flap failure rates increased. Penile stiffeners of various types have been introduced; the artificial ones were associated with high infection and failure rates and are best inserted after the neo-penis regains some sensitivity. With the introduction of perforator flaps the Anterolateral thigh flap in its sensate pedicled form has started replacing the Radial forearm free flap as the first choice flap because of a hidden donor area and lack of microsurgical expertise requirement. Being sensate it tolerates a stiffener better. It is now possible to reconstruct an aesthetically pleasing glans as well, thus meeting both the aesthetic and functional desires of the patient. Complications encountered in this reconstructive effort include flap failure, urethral fistula, urethral stricture and stiffener related problems.

The innervated free toe web flap for clitoris reconstruction

Clitoris reconstruction is often used in transgender reassignment. Most techniques now reconstruct the clitoris using glans pedicled on the dorsal phallic neurovascular bundle. Other techniques of clitoris reconstruction re-shape retained elements of the proximal segment of the corpora cavernosa, as well as techniques mobilising local flaps. We are presenting a new technique for clitoris reconstruction using an innervated free web space flap. The operative technique and outcome are illustrated and discussed in this case report.

Glans, urethra, and corporeal body reconstruction by free osteocutaneous forearm flap transfer

A 30-year-old man presented with short penile corporeal bodies hosting a 3-cm fibular graft, absence of glans, and proximal penile hypospadias. The patient underwent a forearm flap transfer with an "umbrella-like" skin flap for glans and urethra reconstruction and a radial bone strut to allow for rigidity. The postoperative course was uneventful and the patient was followed-up with fluximetry tests at 2 weeks, 4 weeks, 2 months, and 6 months, showing no stenoses and normal stable values. Masturbation started at month 3 postoperatively and intercourse began at month 4, with both resulting in orgasm. At 6 months postoperatively, touch sensation, pain, and sensibility to heat were present, but sensibility to cold was absent. Light touch pressure was detected with 4.74 Semmes-Weinstein monofilament, and static two-point discrimination was 20 mm at the neoglans. One year postoperatively, a stable increased length up to 9 cm at rest and 13 cm at erection with a satisfactory anatomic definition could still be proved.