1
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Marquez JL, Nuckles B, Tausinga T, Foley B, Sudbury D, Sueoka S, Zang C, Lewis P, Goodwin I. Analysis of the Radial Forearm Phalloplasty Donor Site: Do Dermal Matrices Improve Donor Site Morbidity? PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6114. [PMID: 39228422 PMCID: PMC11368217 DOI: 10.1097/gox.0000000000006114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 07/01/2024] [Indexed: 09/05/2024]
Abstract
Background The radial forearm free flap is frequently chosen for phalloplasty; however, flap size required for phalloplasty is associated with a large scar burden and functional concerns. We sought to investigate donor site functionality, aesthetics, and volume deficits in a cohort of individuals who underwent radial forearm phalloplasty (RFP) with donor site skin grafting alone or dermal substitute and subsequent skin grafting. Methods Donor site functionality was assessed using the quick Disabilities of Arm, Shoulder, and Hand (qDASH). Patient- and clinician-reported aesthetics were assessed using the Patient and Observer Scar Assessment Scale (POSAS). An Artec Leo three-dimensional scanner was used to measure volumetric differences from the donor site forearm and contralateral forearm. Results Fifteen patients who underwent RFP agreed to participate. No statistically significant differences were identified between different donor site closure methods regarding qDASH, patient-reported POSAS, or total volumetric deficits. A blinded clinician reported that POSAS approached significance at 4.7 for biodegradable temporizing matrix (BTM), 4.2 for Integra, and 3.0 for split-thickness skin graft (P = 0.05). No statistically significant differences were identified regarding distal, middle, or proximal volume deficits; however, a trend was observed regarding total volumetric deficits with BTM experiencing the lowest deficit (10.3 cm3) and skin graft experiencing the highest deficit (21.5 cm3, P = 0.82). Conclusions The addition of dermal matrix (BTM or Integra) to the treatment algorithm for RFP did not show statistically significant improvement in donor site volume deficits, patient-reported scar appearance (POSAS), or functionality (qDASH).
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Affiliation(s)
- Jessica L. Marquez
- From the Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Brandon Nuckles
- From the Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Telisha Tausinga
- From the Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Brittany Foley
- From the Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Dallin Sudbury
- Department of Orthopedics, The University of Utah Hospital, Salt Lake City, Utah
| | - Stephanie Sueoka
- Department of Orthopedics, The University of Utah Hospital, Salt Lake City, Utah
| | - Chong Zang
- Division of Epidemiology, Department of Internal Medicine, The University of Utah Hospital, Salt Lake City, Utah
| | - Priya Lewis
- From the Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Isak Goodwin
- From the Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
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2
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Lee WG, Christopher AN, Ralph DJ. Commentary: Bioengineered dermal matrix reduces donor site morbidity in total phallic construction with RAFFF. Int J Impot Res 2024:10.1038/s41443-024-00953-z. [PMID: 38997583 DOI: 10.1038/s41443-024-00953-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 06/13/2024] [Accepted: 07/03/2024] [Indexed: 07/14/2024]
Affiliation(s)
- W G Lee
- University College London Hospitals NHS Foundation Trust, London, UK.
- St Peter's Andrology, London, UK.
- Division of Surgery and Interventional Sciences, University College London, London, UK.
| | - A N Christopher
- University College London Hospitals NHS Foundation Trust, London, UK
- St Peter's Andrology, London, UK
| | - D J Ralph
- University College London Hospitals NHS Foundation Trust, London, UK
- St Peter's Andrology, London, UK
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3
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Zhang C, Pandya S, Alessandri Bonetti M, Costantino A, Egro FM. Comparison of split thickness skin graft versus full thickness skin graft for radial forearm flap donor site closure: A systematic review and Meta-analysis. Am J Otolaryngol 2024; 45:104156. [PMID: 38142610 DOI: 10.1016/j.amjoto.2023.104156] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/04/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND The radial forearm flap (RFF) is one of the most commonly used flaps in reconstructive surgery. Split-thickness skin grafting (STSG) has traditionally been used for closure of the forearm. However, full-thickness skin grafting (FTSG) has gained in popularity to achieve more satisfactory results. The aim of the study is to identify the best RFF donor site closure technique by comparing the functional and aesthetic outcomes of STSG and FTSG. METHODS PubMed and EMBASE databases were queried. Only studies comparing complications rate, functional and aesthetic outcomes between STSG and FTSG were included. The primary outcome was graft failure rate. Secondary outcomes included the aesthetic result and functionality of the forearm/wrist. RESULTS A total of 13 studies were included in this review, accounting for a total of 712 patients with mean age of 60.7 years. Overall, 348 patients underwent FTSG and 377 underwent STSG. The mean follow-up was 14.7 months. The rate of graft failure in FTSG was significantly higher compared to STSG (OR: 2.79, 95 % CI 1.38-5.65, p = 0.004). There was no significant difference in rate of tendon exposure (OR: 0.83, p = 0.65) and infection (OR: 1.37, p = 0.42). Regarding the aesthetic outcome, no significant difference between FTSG and STSG based on observer (SMD = -0.37, p = 0.17) and patient (SMD = -0.016, p = 0.93) assessment, respectively. Overall postoperative functional assessment showed a not severely impaired hand and arm function in both groups. Subjective evaluation of pain was similar between groups. CONCLUSION FTSG is associated with higher risk of graft failure than STSG in RFF donor site closure, without significant improvement in aesthetic results.
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Affiliation(s)
- Casey Zhang
- University of Pittsburgh Medical Center, Department of Plastic Surgery, Pittsburgh, PA, USA
| | - Sumaarg Pandya
- University of Pittsburgh Medical Center, Department of Plastic Surgery, Pittsburgh, PA, USA
| | | | - Andrea Costantino
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090 Pieve Emanuele, MI, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, MI, Italy
| | - Francesco M Egro
- University of Pittsburgh Medical Center, Department of Plastic Surgery, Pittsburgh, PA, USA.
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4
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Ferrin PC, Aryanpour Z, Peters BR. The Primacy of the Radial Forearm in Gender-Affirming Phalloplasty: Shifting Focus Away From A Search for Alternatives Toward Reduction of Donor Site Morbidity. Ann Plast Surg 2024; 92:259-260. [PMID: 38170980 DOI: 10.1097/sap.0000000000003747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Affiliation(s)
- Peter C Ferrin
- From the Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Zain Aryanpour
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Blair R Peters
- Division of Plastic and Reconstructive Surgery, Oregon Health and Science University, Portland, OR
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5
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Moors JJE, Xu Z, Xie K, Rashad A, Egger J, Röhrig R, Hölzle F, Puladi B. Full-thickness skin graft versus split-thickness skin graft for radial forearm free flap donor site closure: protocol for a systematic review and meta-analysis. Syst Rev 2024; 13:74. [PMID: 38409059 PMCID: PMC10895847 DOI: 10.1186/s13643-024-02471-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 01/27/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND The radial forearm free flap (RFFF) serves as a workhorse for a variety of reconstructions. Although there are a variety of surgical techniques for donor site closure after RFFF raising, the most common techniques are closure using a split-thickness skin graft (STSG) or a full-thickness skin graft (FTSG). The closure can result in wound complications and function and aesthetic compromise of the forearm and hand. The aim of the planned systematic review and meta-analysis is to compare the wound-related, function-related and aesthetics-related outcome associated with full-thickness skin grafts (FTSG) and split-thickness skin grafts (STSG) in radial forearm free flap (RFFF) donor site closure. METHODS A systematic review and meta-analysis will be conducted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines will be followed. Electronic databases and platforms (PubMed, Embase, Scopus, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure (CNKI)) and clinical trial registries (ClinicalTrials.gov, the German Clinical Trials Register, the ISRCTN registry, the International Clinical Trials Registry Platform) will be searched using predefined search terms until 15 January 2024. A rerun of the search will be carried out within 12 months before publication of the review. Eligible studies should report on the occurrence of donor site complications after raising an RFFF and closure of the defect. Included closure techniques are techniques that use full-thickness skin grafts and split-thickness skin grafts. Excluded techniques for closure are primary wound closure without the use of skin graft. Outcomes are considered wound-, functional-, and aesthetics-related. Studies that will be included are randomized controlled trials (RCTs) and prospective and retrospective comparative cohort studies. Case-control studies, studies without a control group, animal studies and cadaveric studies will be excluded. Screening will be performed in a blinded fashion by two reviewers per study. A third reviewer resolves discrepancies. The risk of bias in the original studies will be assessed using the ROBINS-I and RoB 2 tools. Data synthesis will be done using Review Manager (RevMan) 5.4.1. If appropriate, a meta-analysis will be conducted. Between-study variability will be assessed using the I2 index. If necessary, R will be used. The quality of evidence for outcomes will eventually be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. DISCUSSION This study's findings may help us understand both closure techniques' complication rates and may have important implications for developing future guidelines for RFFF donor site management. If available data is limited and several questions remain unanswered, additional comparative studies will be needed. SYSTEMATIC REVIEW REGISTRATION The protocol was developed in line with the PRISMA-P extension for protocols and was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 17 September 2023 (registration number CRD42023351903).
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Affiliation(s)
- Jasper J E Moors
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen, 52074, Germany
- Institute of Medical Informatics, University Hospital RWTH Aachen, 52074, Aachen, Germany
| | - Zhibin Xu
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Kunpeng Xie
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen, 52074, Germany
- Institute of Medical Informatics, University Hospital RWTH Aachen, 52074, Aachen, Germany
| | - Ashkan Rashad
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Jan Egger
- Cancer Research Center Cologne Essen (CCCE), West German Cancer Center Essen (WTZ), 45122, Essen, Germany
- Institute of Artificial Intelligence in Medicine, Essen University Hospital, 45131, Essen, Germany
| | - Rainer Röhrig
- Institute of Medical Informatics, University Hospital RWTH Aachen, 52074, Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Behrus Puladi
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen, 52074, Germany.
- Institute of Medical Informatics, University Hospital RWTH Aachen, 52074, Aachen, Germany.
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6
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Küenzlen L, Wallmichrath JC, Küntscher MV, Rothenberger J, Laback C, Schaefer DJ, Schaff J, Bozkurt A, Djedovic G, Langer S, Hirsch T, Rieger U. [Choice of flaps for phalloplasty: what is the contemporary standard? Consensus Statement of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels]. HANDCHIR MIKROCHIR P 2023; 55:427-436. [PMID: 37783212 DOI: 10.1055/a-2134-5891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
The ever-expanding number of transmen as well as their surgeons share an increasing interest in the construction of a neophallus. While the indication for surgery and the positive effect of a phalloplasty on the quality of life, mental health and sexual function has already been thoroughly analysed, there is a lack of data comparing and evaluating the surgical steps. During the consensus conference on the "choice of flaps for phalloplasty" at the annual meeting of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels, the current literature was discussed and a consensus on the surgical technique of a phalloplasty was reached. This manuscript publishes jointly developed recommendations on the following topics: choice of flaps for phalloplasty, preoperative diagnostic tests before phalloplasty, urethral construction in the radial forearm flap and anterior lateral thigh flap, preformation of the urethra at the forearm or thigh, venous drainage of the radial forearm flap, innervation of the phallus, staged phalloplasty, coronaplasty and managing the donor site of a radial forearm flap.
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Affiliation(s)
- Lara Küenzlen
- Klinik für Plastische und Ästhetische Chirurgie, Wiederherstellungs- und Handchirurgie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | | | - Markus V Küntscher
- Plastische Chirurgie, Privatpraxis für Plastische & Ästhetische Chirurgie, Hohen Neuendorf, Germany
| | - Jens Rothenberger
- Klinik für Plastische und Ästhetische Chirurgie, Wiederherstellungs- und Handchirurgie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Christian Laback
- Klinische Abteilung für plastische, ästhetische und rekonstruktive Chirurgie, Medizinische Universität Graz, Graz, Austria
| | | | | | - Ahmet Bozkurt
- Klinik für Plastische, Ästhetische und Handchirurgie , HELIOS Universitatsklinikum Wuppertal, Wuppertal, Germany
| | - Gabriel Djedovic
- Abteilung für Plastische, Ästhetische und Rekonstruktive Chirurgie, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Stefan Langer
- Sektion Plastische, Ästhetische und Spezielle Handchirurgie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Tobias Hirsch
- Klinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Fachklinik Hornheide eV, Munster, Germany
- Abteilung für Plastische Chirurgie, Klinik für Unfall-, Hand- und Wiederherstellungschirugie, Universitätsklinikum Münster, Munster, Germany
| | - Ulrich Rieger
- Klinik für Plastische und Ästhetische Chirurgie, Wiederherstellungs- und Handchirurgie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
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7
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Falcone M, Preto M, Ciclamini D, Peretti F, Scarabosio A, Blecher G, Cirigliano L, Ferro I, Plamadeala N, Scavone M, Timpano M, Gontero P. Bioengineered dermal matrix (Integra®) reduces donor site morbidity in total phallic construction with radial artery forearm free-flap. Int J Impot Res 2023:10.1038/s41443-023-00775-5. [PMID: 37848642 DOI: 10.1038/s41443-023-00775-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 09/25/2023] [Accepted: 10/02/2023] [Indexed: 10/19/2023]
Abstract
Total phallic construction with radial artery forearm free-flap (RAFFF) is widely regarded as the gold standard approach for phalloplasty. However, donor-site morbidity remains a significant concern, which is typically managed by using a full-thickness skin graft (FTSG) on the forearm. Split thickness skin grafts (STSG) have been proposed as an alternative, along with the use of an acellular dermal matrix substitute. A retrospective comparative analysis was performed to assess the differences in operative, functional and cosmetic outcomes between FTSG (Group A) and the combination of acellular dermal matrix with STSG (Group B). A retrospective cohort study was conducted on all patients who underwent total phallic construction with RAFFF, between 2016 and 2021. Post-operative surgical and functional outcomes were evaluated using validated tools. A total of 34 patients were included in the study, with 18 patients (52.9%) in Group A and 16 patients (47.1%) in Group B. Group B demonstrated a significant advantage in terms of healing time (24 days vs. 30 days, p = 0.003) and complete graft take (93.8% vs. 27.8%, p = 0.001). Group B also had significantly shorter operative times (310 min vs. 447 min, p = 0.001) and a reduced median hospital stay (8 days vs. 10 days, p = 0.001). Satisfaction with cosmesis was significantly higher in Group B (93.8% vs. 66.7%, p = 0.048).
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Affiliation(s)
- Marco Falcone
- Department of Urology, "A.O.U. Città della Salute e della Scienza", Turin, Italy
| | - Mirko Preto
- Department of Urology, "A.O.U. Città della Salute e della Scienza", Turin, Italy.
| | - Davide Ciclamini
- Department of Orthopaedics and Traumatology, Hand and Microsurgery Unit, Orthopaedic Trauma Center CTO-"A.O.U. Città della Salute e della Scienza", Turin, Italy
| | - Federica Peretti
- Department of Urology, "A.O.U. Città della Salute e della Scienza", Turin, Italy
| | - Anna Scarabosio
- Department of Urology, "A.O.U. Città della Salute e della Scienza", Turin, Italy
| | - Gideon Blecher
- Department of Surgery, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
- Department of Urology, The Alfred Hospital, Melbourne, VIC, Australia
- Monash Health, Bentleigh East, VIC, Australia
| | - Lorenzo Cirigliano
- Department of Urology, "A.O.U. Città della Salute e della Scienza", Turin, Italy
| | - Ilaria Ferro
- Department of Urology, "A.O.U. Città della Salute e della Scienza", Turin, Italy
| | - Natalia Plamadeala
- Department of Urology, "A.O.U. Città della Salute e della Scienza", Turin, Italy
| | - Martina Scavone
- Department of Urology, "A.O.U. Città della Salute e della Scienza", Turin, Italy
| | - Massimiliano Timpano
- Department of Urology, "A.O.U. Città della Salute e della Scienza", Turin, Italy
| | - Paolo Gontero
- Department of Urology, "A.O.U. Città della Salute e della Scienza", Turin, Italy
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8
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Yoshimatsu H, Karakawa R, Fuse Y, Yano T. Tube-in-Tube Phalloplasty with Tailor-made Bilateral Superficial Circumflex Iliac Artery Perforator Flaps Using Preoperative High-resolution Ultrasound. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5280. [PMID: 37744775 PMCID: PMC10513362 DOI: 10.1097/gox.0000000000005280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/02/2023] [Indexed: 09/26/2023]
Abstract
In phalloplasty, the radial forearm free flap is the most commonly used flap, followed by the anterolateral thigh flap. Superficial circumflex iliac artery perforator (SCIP) flaps have been used in phalloplasty, but bulkiness and unstable perfusion have precluded their common use. In this report, we present a case in which tube-in-tube phalloplasty was performed using bilateral SCIP flaps assisted by preoperative high-resolution ultrasonography. A 67-year-old man underwent resection of his penis for treatment of carcinoma. A year later, phalloplasty using bilateral SCIP flaps was planned. After mapping out the superficial circumflex iliac artery and the superficial circumflex iliac vein to their terminal portions using preoperative high-resolution ultrasonography, a 12 cm × 8 cm rectangular flap was designed on the right groin for reconstruction of the phallus, and a 10 cm × 4 cm rectangular flap was designed on the left groin for reconstruction of the urethra. Both flaps were harvested above the superficial fascia, and the thickness of both flaps was 4 mm. The Foley catheter was removed three weeks after the operation, and the patient began urinating in the standing position. No fistula or urethral stenosis had occurred as of 12 months after the reconstruction, and the patient was satisfied with the cosmesis. The use of preoperative high-resolution ultrasonography played a decisive role in ensuring the perfusion of the flap, resulting in prevention of postoperative complications such as fistula and/or urethral stenosis caused by malperfusion of the flap.
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Affiliation(s)
- Hidehiko Yoshimatsu
- From the Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ryo Karakawa
- From the Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yuma Fuse
- From the Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomoyuki Yano
- From the Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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9
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Marque M, Chartier R, Donette I, Assaf N, Dast S, Sinna R. [The tube in tube thoracodorsal perforator flap phalloplasty]. ANN CHIR PLAST ESTH 2023; 68:378-384. [PMID: 36801117 DOI: 10.1016/j.anplas.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 02/18/2023]
Abstract
This article deals with a clinical case of a tube in a tube TDAP phalloplasty in a 38 years old trans-man. While penis reconstruction surgery aroused an efflorescence of different operative techniques, the resulting female to male surgery sees these procedures boil down to two or three flaps. If we usually discuss before surgery about the way to lengthen the urinary tract, as the way to implant later for intercourse; the choice of the donor site remains too systematized. Surgeons commonly focus on the reconstructed site prior to the donor site. In this case, laxity in the back and reliability of direct closure make us harvest the thoracodorsal perforator flap. Dissection of perforators saves muscular function and direct closure afford an aesthetic result less visible than a graft on the forearm. The thin flap we harvest allows tube in tube phalloplasty so that phallus and urethra are being built in the same time. One case has been reported in the literature of thoracodorsal perforator flap phalloplasty with grafted urethra, but no case of tube within a tube TDAP phalloplasty.
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Affiliation(s)
- M Marque
- Service de chirurgie plastique reconstructrice et esthétique, CHU d'Amiens Picardie, Rond-point Pr Cabrol, 80054 Amiens cedex 1, France
| | - R Chartier
- Service de chirurgie plastique reconstructrice et esthétique, CHU d'Amiens Picardie, Rond-point Pr Cabrol, 80054 Amiens cedex 1, France
| | - I Donette
- Service de chirurgie plastique reconstructrice et esthétique, CHU d'Amiens Picardie, Rond-point Pr Cabrol, 80054 Amiens cedex 1, France
| | - N Assaf
- Service de chirurgie plastique reconstructrice et esthétique, CHU d'Amiens Picardie, Rond-point Pr Cabrol, 80054 Amiens cedex 1, France
| | - S Dast
- Service de chirurgie plastique reconstructrice et esthétique, CHU d'Amiens Picardie, Rond-point Pr Cabrol, 80054 Amiens cedex 1, France
| | - R Sinna
- Service de chirurgie plastique reconstructrice et esthétique, CHU d'Amiens Picardie, Rond-point Pr Cabrol, 80054 Amiens cedex 1, France.
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10
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Benjamin T, Zebolsky AL, Haddad AF, Ochoa E, Plonowska-Hirschfeld KA, Park AM, Seth R, Knott PD. Anterolateral Thigh Free Flap Versus Thigh Split Thickness Skin Graft: Comparison of Morbidity in the First 30 Days. Facial Plast Surg Aesthet Med 2023; 25:108-112. [PMID: 36201233 DOI: 10.1089/fpsam.2022.0155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Background: An anterior thigh split thickness skin graft (AT-STSG) is frequently needed to close the radial forearm free flap (RFFF) donor site, conferring morbidity to two extremities. The anterolateral thigh (ALT) free flap is virtually always closed primarily. Objective: To compare donor site pain, sensation, motor function, and cosmesis associated with the AT-STSG and the ALT. Methods: Patients undergoing an ALT or an RFFF with AT-STSG were enrolled in a prospective observational cohort study. Pain, tingling, numbness, lower extremity function, and subjective donor site cosmetic satisfaction were measured at 1 week and 1 month postoperation using validated instruments. Results: Forty-eight patients were included, with a mean age of 64.2 years (female 31.2%). There were no differences in age or medical comorbidities between the two groups. The average donor defect was 50 and 180 cm2 for the AT-STSG and ALT cohorts, respectively. At 1 week and 1 month postoperatively, we did not detect a difference in donor site pain, pruritus, numbness or tingling, lower extremity function, or subjective cosmetic satisfaction between the two cohorts. Conclusion: ALT primary donor site morbidity, including pain, sensory function, motor function, and cosmesis, is equivalent to RFFF secondary donor site morbidity at 1 week and 1 month postoperatively.
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Affiliation(s)
- Tania Benjamin
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Aaron L Zebolsky
- Homer Stryker M.D. School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | - Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Edgar Ochoa
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Karolina A Plonowska-Hirschfeld
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Andrea M Park
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Rahul Seth
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - P Daniel Knott
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
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11
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Burger A, Kiehlmann M, Gruenherz L, Gousopoulos E, Sohn M, Lindenblatt N, Giovanoli P, Rieger UM. Donor Site Defect Coverage of the Forearm with Dermal Substitute After Harvesting Radial Forearm Free Flap for Phalloplasty: Is MatriDerm® Worth the Effort? Indian J Surg 2023. [DOI: 10.1007/s12262-023-03705-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
AbstractAn aesthetically and functionally pleasing phalloplasty is most commonly performed by a free radial forearm flap. However, the problem with donor site morbidity on the forearm remains unsolved. The aim of this study was to evaluate if the use of a dermal template such as MatriDerm® on the donor site significantly decreases the incidence of complications based on the Clavien–Dindo classification, such as wound healing disorders and reoperation rate, and if it could shortens the duration of hospital stay. A case series analysis was conducted at our institution. A total of 21 patients divided into two groups undergoing the phallic construction after the Gottlieb and Levine design in a single center underwent the donor site defect coverage either by MatriDerm® and split-thickness skin graft from the thigh or by full-thickness skin graft from the groin area. The use of MatriDerm® and split-thickness skin graft showed to have a statistically significant impact on the rate of complications (p = 0.008). Complications that were treated conservatively as well as that require surgical revision were significantly lower in the MatriDerm® group than in the full-thickness skin graft group (p = 0.002). Complications occurred not only at the forearm but also at the groin, where the full-thickness skin graft was harvested. The large dimension of the free radial forearm flap used for phalloplasty resulted in a significant donor site morbidity, leading to wound healing disorders, reoperations, and extended length of hospital stay. Therefore, we consider the use of dermal templates such as MatriDerm® as worth the additional effort and costs in this patient collective.
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Shin SW, Kim H, Nam W, Kim HJ, Cha IH, Koh YW, Kim D. Robot-assisted radial forearm free flap harvesting: a propensity score-matched case-control study. J Robot Surg 2023:10.1007/s11701-023-01539-5. [PMID: 36740631 DOI: 10.1007/s11701-023-01539-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 01/20/2023] [Indexed: 02/07/2023]
Abstract
Although some surgeons prefer anterolateral thigh and latissimus dorsi flap for soft tissue reconstruction in the head and neck area because it minimizes donor site complications, the radial forearm flap remains the workhorse for soft tissue reconstruction due to its reliability. To reduce donor site morbidity, the authors developed a novel technique for radial forearm flap harvesting using a robotic device. 42 radial forearm free flap reconstruction cases were studied, consisting of 31 conventional and 11 robot-assisted cases. 1:1 propensity score matching was done according to age, sex, previous and postoperative radiation therapy history and method used for vein anastomosis. There was no significant difference in flap outcome, which was 100% vitality in the robot-assisted group and 90.9% vitality in the conventional group. The robot-assisted group showed significantly longer mean harvesting time than did the conventional group, being 107.2 min and 67.0 min, respectively. Robot-assisted radial forearm flap harvesting can reduce donor site complications by minimizing incision. When more surgical experience is gained under appropriate case selection, we expect our robot-assisted method will yield a harvesting time similar to that of the conventional method and thus become more reliable and feasible.
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Affiliation(s)
- Seung-Woo Shin
- Department of Oral and Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul, Korea
| | - Hyounmin Kim
- Department of Oral and Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul, Korea
| | - Woong Nam
- Department of Oral and Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul, Korea
| | - Hyung Jun Kim
- Department of Oral and Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul, Korea
| | - In-Ho Cha
- Department of Oral and Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul, Korea
| | - Yoon Woo Koh
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
| | - Dongwook Kim
- Department of Oral and Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul, Korea.
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Lee WG, Christopher AN, Ralph DJ. Gender Affirmation Surgery, Transmasculine. Urol Clin North Am 2022; 49:453-465. [DOI: 10.1016/j.ucl.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Abstract
Genital gender affirming surgery is an effective treatment for gender dysphoria in transgender individuals. Optimization of medical and mental health conditions, including coordination with a patient's entire care team, is essential. Feminizing procedures include vaginoplasty (creation of female genitalia with a vaginal canal) and vulvoplasty (creation of female genitalia with a short or absent vaginal canal). Masculinizing procedures include metoidioplasty (construction of male genitals via local tissue rearrangement) and phalloplasty (creation of a phallus from extra-genital tissue). We aim to provide an overview of genital gender affirming surgery for providers who are interested in learning more about genital gender affirming surgery.
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Affiliation(s)
- Virginia Y Li
- Department of Urology, 82579Kaiser Permanente Los Angeles, Los Angeles, CA, USA
| | - Alysen Demzik
- Department of Urology, 2331UNC School of Medicine, Chapel Hill, NC, USA
| | - Liem Snyder
- Department of Urology, 2331UNC School of Medicine, Chapel Hill, NC, USA
| | - Adeyemi A Ogunleye
- Department of Surgery, Division of Plastic Surgery, 2331UNC School of Medicine, Chapel Hill, NC, USA
| | - Annmarie Wang
- Department of Urology, 2331UNC School of Medicine, Chapel Hill, NC, USA
| | - Bradley D Figler
- Department of Urology, 2331UNC School of Medicine, Chapel Hill, NC, USA
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Peters BR, Sikora Z, Timmins BH, Berli JU. “Nerve-Morbidity at the Radial Forearm Donor Site Following Gender-Affirming Phalloplasty”. J Plast Reconstr Aesthet Surg 2022; 75:3836-3844. [DOI: 10.1016/j.bjps.2022.06.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 04/17/2022] [Accepted: 06/05/2022] [Indexed: 11/28/2022]
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16
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Wu SH, Shen BH, Perng CK, Wang TH, Shih YC, Ma H, Wu HY. Complications of free-flap procedures for phalloplasty in female-to-male transgender surgery: 25-year experience a single medical center. J Chin Med Assoc 2022; 85:341-345. [PMID: 35259134 DOI: 10.1097/jcma.0000000000000677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND To present the complications of free-flap phalloplasty in three-staged female-to-male transgender surgery. METHODS This retrospective study included patients who underwent a three-staged free-flap phalloplasty for female-to-male transgender surgery between January 1988 and December 2013. Data regarding demographics, operative techniques, and complications were collected and analyzed. RESULTS A total of 101 patients with a mean age of 30.2 years were included. Phalloplasty with traditional free forearm tube-in-tube fasciocutaneous flap was performed in 25 (24.8%) patients, free forearm fasciocutaneous flap with vaginal mucosa for a prefabricated urethra in 30 (29.7%) patients, free radial forearm osteocutaneous flap with vaginal mucosa for a prefabricated urethra in 22 (21.8%) patients, and free fibula osteocutaneous flap with vaginal mucosa for a prefabricated urethra in 24 (23.8%) patients. Complication rates of partial flap loss, urethrocutaneous fistula, urethral stricture, and hair or stone formation were 12.9%, 49.5%, 24.8%, and 5.0%, respectively. Patients receiving fibula osteocutaneous flap phalloplasty had the lowest overall complication rate (33.3%), followed by those with radial forearm osteocutaneous flap (40.9%), forearm fasciocutaneous flap (43.3%), and forearm tube-in-tube fasciocutaneous flap (80.0%). Forearm tube-in-tube fasciocutaneous flap procedure was associated with significantly higher rates of overall complications (p = 0.05), urethrocutaneous fistula (p = 0.005), and hair or stone formation (p = 0.002) compared with the other three types of procedures. Rates of all complications did not significantly differ among fibula osteocutaneous flap, radial forearm osteocutaneous flap, and forearm fasciocutaneous flap procedures. CONCLUSION In free-flap phalloplasty for female-to-male transgender surgery, utilization of free fibula osteocutaneous flap with vaginal mucosa for a prefabricated urethra resulted in the lowest complication rate. Further comparisons among different procedures of phalloplasty are warranted.
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Affiliation(s)
- Szu-Hsien Wu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Bing-Hwei Shen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Cherng-Kang Perng
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Tien-Hsiang Wang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yu-Chung Shih
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Hsu Ma
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Ho-Yu Wu
- Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Özer M, Toulabi SP, Fisher AD, T'Sjoen G, Buncamper ME, Monstrey S, Bizic MR, Djordjevic M, Falcone M, Christopher NA, Simon D, Capitán L, Motmans J. ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery". Sex Med 2022; 10:100471. [PMID: 34971864 PMCID: PMC8847816 DOI: 10.1016/j.esxm.2021.100471] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 10/06/2021] [Accepted: 11/09/2021] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Much has been published on the surgical and functional results following Gender Affirming Surgery ('GAS') in trans individuals. Comprehensive results regarding sexual wellbeing following GAS, however, are generally lacking. AIM To review the impact of various GAS on sexual wellbeing in treatment seeking trans individuals, and provide a comprehensive list of clinical recommendations regarding the various surgical options of GAS on behalf of the European Society for Sexual Medicine. METHODS The Medline, Cochrane Library and Embase databases were reviewed on the results of sexual wellbeing after GAS. MAIN OUTCOMES MEASURE The task force established consensus statements regarding the somatic and general requirements before GAS and of GAS: orchiectomy-only, vaginoplasty, breast augmentation, vocal feminization surgery, facial feminization surgery, mastectomy, removal of the female sexual organs, metaidoioplasty, and phalloplasty. Outcomes pertaining to sexual wellbeing- sexual satisfaction, sexual relationship, sexual response, sexual activity, enacted sexual script, sexuality, sexual function, genital function, quality of sex life and sexual pleasure- are provided for each statement separately. RESULTS The present position paper provides clinicians with statements and recommendations for clinical practice, regarding GAS and their effects on sexual wellbeing in trans individuals. These data, are limited and may not be sufficient to make evidence-based recommendations for every surgical option. Findings regarding sexual wellbeing following GAS were mainly positive. There was no data on sexual wellbeing following orchiectomy-only, vocal feminization surgery, facial feminization surgery or the removal of the female sexual organs. The choice for GAS is dependent on patient preference, anatomy and health status, and the surgeon's skills. Trans individuals may benefit from studies focusing exclusively on the effects of GAS on sexual wellbeing. CONCLUSION The available evidence suggests positive results regarding sexual wellbeing following GAS. We advise more studies that underline the evidence regarding sexual wellbeing following GAS. This position statement may aid both clinicians and patients in decision-making process regarding the choice for GAS. Özer M, Toulabi SP, Fisher AD, et al. ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery". Sex Med 2022;10:100471.
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Affiliation(s)
- Müjde Özer
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Sahaand Poor Toulabi
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Alessandra D Fisher
- Andrology, Women's Endocrinology, Gender Incongruence Unit, Department of Experimental Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - Guy T'Sjoen
- Department of Endocrinology and Center for Sexology and Gender, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Marlon E Buncamper
- Department of Plastic, Reconstructive and Hand Surgery, Ghent University Hospital, Ghent, Belgium
| | - Stan Monstrey
- Department of Plastic, Reconstructive and Hand Surgery, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Marta R Bizic
- Department of Pediatric Urology, University of Belgrade, Belgrade, Serbia
| | | | - Marco Falcone
- Department of Urology, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Nim A Christopher
- Department of Urology, St Peter's Andrology Centre and The Institute of Urology, London, UK
| | - Daniel Simon
- Facialteam Surgical Group, HC Marbella International Hospital, Marbella, Málaga, Spain
| | - Luis Capitán
- Facialteam Surgical Group, HC Marbella International Hospital, Marbella, Málaga, Spain
| | - Joz Motmans
- Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
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Allepot K, Cristofari S, Boucher F. [Scapular flap, an alternative to the radial forearm flap in phalloplasty: Advantages and limitations]. ANN CHIR PLAST ESTH 2021; 67:49-56. [PMID: 34949490 DOI: 10.1016/j.anplas.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/22/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Antebrachial phalloplasty is considered as the standard technique in total penile reconstruction. This technique allows the creation of a phallus and a neourethra in one step at the cost of significant sequelae of the donor site. Thus, this technique has been replaced in some centers by other techniques such as the MSLD flap or the ALT flap. However, in Western populations, these techniques require the addition of a technique dedicated to the urethroplasty. The scapular flap is a technique that is not widely described in the literature and, like the antebrachial flap, allows the creation of a phallus and a urethra in one step according to the "tube within tube" technique. AIM The aim of the study was to detail this technique, to study its vascularization and to adapt the measurements of the flap to a western population. PATIENTS AND METHODS Six cadaveric dissections were performed in the laboratory. Intravascular injection of colored latex allowed easier identification of the vessels of interest and study of the subcutaneous vascular tree. Scapular flaps of variable size were raised to adapt the size to a Western population. RESULTS Six dissections were performed in Caucasian subjects. The scapular circumflex artery was constant and had a mean diameter of 3.5mm (3.3mm-3.8mm). The mean pedicle length was 7.3cm (6.8cm-8.1cm). The size of the flaps was adapted to the subcutaneous tissue and flaps of at least 14×16cm allowed the "tube within tube" technique to be performed. CONCLUSION The scapular flap has the advantage of allowing phalloplasty with urethroplasty to be performed at the same time. The pedicle is constant and of good diameter. In addition, the sequelae of the donor site are minimal. On the other hand, the pedicle used is short and the flap cannot be surgically reinnervated. Nevertheless, the restoration of a protective sensitivity allows the implantation of a penile prosthesis.
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Affiliation(s)
- K Allepot
- Hospices civils de Lyon, Lyon, France.
| | - S Cristofari
- Assistance Publique des Hôpitaux de Paris, Paris, France
| | - F Boucher
- Hospices civils de Lyon, Lyon, France
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Krakowczyk Ł, Opyrchał J, Bula D, Wierzgoń J, Szymczyk C, Maciejewski A. Dynamic Reconstruction of the Lower Lip With Free Functioning Gracilis Muscle Transfer. J Craniofac Surg 2021; 33:1655-1658. [PMID: 34907952 DOI: 10.1097/scs.0000000000008389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 11/04/2021] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT The restoration of large full-thickness lip defects still remains a formidable challenge for the reconstructive surgeons. Traumatic injuries, infections and tumors (primarily squamous cell carcinoma) are the most common source of the lip defects. Lower lips are more important in providing oral competence, unfortunately throughout the life-time they are significantly more exposed to ultraviolet radiation and thus are the most common site for the lip cancers (89%). This type of defect requires a complex reconstruction of an adequate sphincter function, defined vermilion, proper oral lining and sufficient mouth opening. To maintain the oral competence, it is of paramount importance to restore the function of orbicularis oris, which principally composes the body of the lip. Currently, the dynamic reconstructions are gaining considerable interest. They enables not only improvement of appearance but also a restoration of function and preservation of health-related quality of life. The use of the free gracilis muscle transfer to reconstruct the lower lip and its dynamic character in contrast to other, static reconstructions can provide the sufficient movement of the lower lip, which does not depend on function of other mimic muscles as it becomes an independent motor unit with its own neurotization. In our opinion the free functioning gracilis muscle flap, due to its anatomic and functional features as well as low-rate donor-site morbidity is the worth considering option for a lower lip reconstruction.
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Affiliation(s)
- Łukasz Krakowczyk
- Maria Sklodowska-Curie Memorial National Cancer Center, Gliwice, Poland
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Bruin LL, Hundepool CA, Duraku LS, Mureau MAM, Zuidam JM. Higher incidences of neuropathic pain and altered sensation following radial forearm free flap: A systematic review. J Plast Reconstr Aesthet Surg 2021; 75:1-9. [PMID: 34736849 DOI: 10.1016/j.bjps.2021.09.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/28/2021] [Accepted: 09/19/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The radial forearm free flap (RFFF) has been used extensively for complex tissue defect reconstructions; however, the potential for significant donor-site morbidity remains a major drawback. Despite an abundance of literature on donor-site morbidities, no consensus has been reached on exact incidences of sensory morbidities that vary largely between 0% and 46%. Incidences of neuropathic pain in the donor site following RFFF still lack, even though clinical experience shows it often occurs. Therefore, the purpose of this systematic review was to identify the incidence of neuropathic pain and altered sensation in the hand following harvesting of a RFFF. METHODS A systematic search was performed in multiple databases (Embase, Medline, Cochrane, Web of Science, and Google Scholar). Studies from 1990 onwards that reported donor-site morbidities following harvest of the RFFF were included. Analyzed parameters included hand pain, hypoesthesia, cold intolerance, hyperesthesia, neuroma formation, paresthesia, sharp sensation loss, light sensation loss, and defect closure. RESULTS Of the 987 selected studies, 51 eligible articles were selected. The mean level of evidence was 3 (SD 0.6). Twenty articles reported pain as a donor-site morbidity, and the mean incidence of pain reported was 23% (SD 7.8). Hypoesthesia was reported by 37 articles and had a mean incidence of 34% (SD 25). Locations of pain and hypoesthesia included, amongst others, the area of the radial sensory nerve and the skin graft area. The mean incidences of cold intolerance and hyperesthesia were 13% (SD 13) and 16% (SD 15), respectively. CONCLUSION The results of this systematic review suggest that 23% of all patients are dealing with neuropathic pain in the donor-site following harvest of an RFFF. Future studies should therefore focus on the prognostic factors and preventive measures of neuropathic pain to further improve clinical outcomes of this widely used flap.
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Affiliation(s)
- L L Bruin
- The Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - C A Hundepool
- The Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - L S Duraku
- The Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M A M Mureau
- The Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J M Zuidam
- The Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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De Castro R, Iaquinto M, Caldamone AA. Neo-phalloplasty in children and adolescents for acquired penile loss. J Pediatr Urol 2021; 17:566.e1-566.e12. [PMID: 33849793 DOI: 10.1016/j.jpurol.2021.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 03/18/2021] [Accepted: 03/20/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION From 2000 to 2019, the De Castro's neo-phalloplasty was used in 47 patients with congenital and acquired penile loss. PURPOSE Herein, the technical aspects of penile reconstruction and the outcomes in 17 children and adolescents treated for total or sub-total acquired penile loss are reported. MATERIAL AND METHODS The median age at the time of injury was 3 months (range: 2 days-15 years). Twelve patients were born with normal penis but suffered injuries (11) or underwent surgical resection of the penis (1). The remaining 5, affected by bladder exstrophy (2) or cloacal exstrophy (3), had penile loss due to surgical complications. RESULTS The median age at the time of surgery was 5 years (range: 2-20 years). The median length of the procedure was 5 h (range 4-8 h). Skin expander were inserted in preparation of phalloplasty in 9 patients. Corpora-cavernosa remnants were found and incorporated in the neophallus in 12 patients. In 7 patients, urethral remnants were also incorporated into the repair, placing the meatus at the tip of the neophallus. In the remaining patients the urethra was left in the acquired position after penile loss creating a perineal (2), scrotal (3), peno-scrotal (3), or posterior penile (1) urethrostomy. The first patient of this series was the only patient to receive simultaneously phalloplasty and total urethroplasty, with failure of urethral reconstruction. The median follow-up was 2 years (range 1-11 years). The overall complication rate was about 47%. All of the complications were late and required surgical revision. The results were assessed regarding overall functionality (voiding, erection/erogenous areas, masturbation/sexual intercourse) and aesthetic outcome using subjective and objective parameters. Psychological evaluation for both patient and parents was performed in 4 cases. DISCUSSION There are no specific guidelines for treating significant penile injuries in the pediatric population. We do not think secondary severe penile impairments should wait until adult age for repair. In this specific subgroup of patients technical aspects differ from phalloplasty done for congenital aphallia, due to the possible presence of corpora-cavernosa/urethral remnants and the feasibility to perform a "functional phalloplasty" with very encouraging results. CONCLUSION The De Castro's neo-phalloplasty remains one of the few techniques available for total penile reconstruction in pediatric age group. Data demonstrate that this technique for acquired aphallia is feasible and reproducible, however, it is a challenging procedure with a high complication rate and likelihood of revisions.
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Affiliation(s)
- Roberto De Castro
- Department of Urologic and Paediatric Surgery, Burlo Garofolo Children's Hospital, Via dell' Istria 65, 34137, Trieste, Italy.
| | - Marianna Iaquinto
- Department of Urologic and Paediatric Surgery, Burlo Garofolo Children's Hospital, Via dell' Istria 65, 34137, Trieste, Italy.
| | - Anthony A Caldamone
- Division of Pediatric Urology, Hasbro Children's Hospital, Warren Alpert School of Medicine at Brown University, 593 Eddy St, Providence, 02905, Rhode Island, USA.
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Abbate V, Iaconetta G, Sani L, Bonavolontà P, Di Lauro AE, Masone S, Califano L, Orabona GDA. The Use of Dermal Substitutes for Donor Site Closure After Radial Forearm Free Flap Harvesting. J Craniofac Surg 2021; 32:e205-e208. [PMID: 33705075 DOI: 10.1097/scs.0000000000006808] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The aim of our study was to analyze the aesthetic and functional outcome in the radial forearm free flap donor site using a simple split thickness skin grafting (STSG) closure compared with the use of dermal scaffold supporting the STSG closure. METHODS The study analyzed 18 patients, divided in 2 groups based on the donor site closure modality. In STSG group, a simple STSG was used to cover the defect. In the DS + STSG group, the defect was covered by the use of dermal substitute (MatriDerm) supporting the STSG. Groups were compared on the following outcome variable: scar status; hand function; circumferences at most proximal and most distal point of the graft. All patients were followed up 1, 6, and 12 months post-operative. RESULTS Nine patients from STSG group showed a difference in circumference between the operated and contralateral limbs respectively of 2.9 mm proximal and 1.2 mm distal; in the 9 patients of DS + STGS group the difference was respectively of 1.2 mm proximal and 1.3 mm distal. Welch unequal variances t-test demonstrated statistical significance of the values with P < 0.004 (P < 0.5). The average VSS was 1.82 ± 0.2 for STSG group and 1.75 ± 0.2 for DS + STGS group. The DASH score was 21.8% in STSG group and 19.4% in DS + STGS group. CONCLUSION Our study shows that patients treated with Matriderm + STSG obtained a better result both in esthetic and functional outcomes.
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Affiliation(s)
- Vincenzo Abbate
- University of Naples "Federico II," Department of Neurosciences, Reproductive and Odontostomatological Sciences, Maxillofacial Surgery Unit, Naples
| | | | - Lorenzo Sani
- University of Naples "Federico II," Department of Neurosciences, Reproductive and Odontostomatological Sciences, Maxillofacial Surgery Unit, Naples
| | - Paola Bonavolontà
- University of Naples "Federico II," Department of Neurosciences, Reproductive and Odontostomatological Sciences, Maxillofacial Surgery Unit, Naples
| | - Alessandro E Di Lauro
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II;"
| | - Stefania Masone
- University of Naples "Federico II", Department of Clinical Medicine and Surgery, General Surgery Unit, Naples, Italy
| | - Luigi Califano
- University of Naples "Federico II," Department of Neurosciences, Reproductive and Odontostomatological Sciences, Maxillofacial Surgery Unit, Naples
| | - Giovanni D A Orabona
- University of Naples "Federico II," Department of Neurosciences, Reproductive and Odontostomatological Sciences, Maxillofacial Surgery Unit, Naples
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Küenzlen L, Nasim S, Neerven SV, Binder M, Wellenbrock S, Kühn S, Spennato S, Rieger UM, Bozkurt A. Multimodal evaluation of donor site morbidity in transgender individuals after phalloplasty with a free radial forearm flap: a case-control study. J Plast Reconstr Aesthet Surg 2021; 75:25-32. [PMID: 34321186 DOI: 10.1016/j.bjps.2021.05.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 04/25/2021] [Accepted: 05/27/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND In phalloplasty, there is a lack of standardized follow-up examinations of motor function and strength after harvesting oversized radial forearm free flaps (RFFF). METHODS We evaluated the donor site of 20 transmen after phalloplasty, using a multimodal, standardized approach, assessing the following parameters: opposition of the thumb, composite range of motion of the finger joints, grip strength, mobility of the wrist, lesion of the superficial branch of the radial nerve, the dorsal branch of the ulnar nerve, the sensation of pain, and cold intolerance. The contralateral, nonoperated forearm was used as a control. RESULTS No impairment of the mobility of the thumb (Kapandji score median 10, range 5-10) or fingers (all fingers at both sides pulp-to-palm 0 cm, nail-to-table 0 cm) were detected. Grip strength (median 36,3kg, p=0.629) and wrist extension (62.5°vs.70°, p=0.357), flexion (70°vs.70°, p=0.535), pronation (90°vs.90°), supination (90°vs.90°), radial (30°vs.30°, p=0.195), and ulnar deviation (40°vs.50°, p=0.125) did not statistically differ between donor and control hand. Injury of the dorsal branch of the ulnar nerve was uncommon (0% hypoesthesia, 10% positive Tinel's sign). We did not observe any persistent pain of the donor forearm (NRS median 0, range 0-9). We did observe irritation of the superficial branch of the radial nerve (hypoesthesia 40%, neuroma 45%). CONCLUSION The harvest of an oversized RFFF for phalloplasty does not cause any significant difference in motor function or strength between the donor and nonoperated hand. A potential risk of injuring the radial nerve branch is to be avoided. An aesthetic impairment could be addressed in future studies.
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Affiliation(s)
- Lara Küenzlen
- Department of Plastic & Aesthetic, Reconstructive & Hand Surgery, AGAPLESION Markus Hospital Frankfurt, Wilhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany.
| | - Sahra Nasim
- Department of Plastic & Aesthetic, Reconstructive & Hand Surgery, AGAPLESION Markus Hospital Frankfurt, Wilhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany
| | - Sabien van Neerven
- Department of Radiology, Leiden University Medical Centre, Leiden, Netherlands
| | - Moritz Binder
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sascha Wellenbrock
- Department of Plastic, Reconstructive and Aesthetic Surgery, Fachklinik Hornheide, Münster, Germany
| | - Shafreena Kühn
- Department of Plastic & Aesthetic, Reconstructive & Hand Surgery, AGAPLESION Markus Hospital Frankfurt, Wilhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany
| | - Stefano Spennato
- Department of Plastic & Aesthetic, Reconstructive & Hand Surgery, AGAPLESION Markus Hospital Frankfurt, Wilhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany
| | - Ulrich M Rieger
- Department of Plastic & Aesthetic, Reconstructive & Hand Surgery, AGAPLESION Markus Hospital Frankfurt, Wilhelm-Epstein-Straße 4, 60431 Frankfurt/Main, Germany
| | - Ahmet Bozkurt
- Department of Plastic, Hand, Aesthetic and Reconstructive Surgery, Helios University Hospital Wuppertal, Germany
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Falcone M, Preto M, Blecher G, Timpano M, Gontero P. Total phallic construction techniques in transgender men: an updated narrative review. Transl Androl Urol 2021; 10:2583-2595. [PMID: 34295745 PMCID: PMC8261414 DOI: 10.21037/tau-20-1340] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/25/2021] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Marco Falcone
- Department of Neurourology, A.O.U. Città della Salute e della Scienza di Torino - Unità Spinale Unipolare, Turin, Italy.,Department of Urology, A.O.U. Città della Salute e della Scienza di Torino - Molinette Hospital, Turin, Italy
| | - Mirko Preto
- Department of Urology, A.O.U. Città della Salute e della Scienza di Torino - Molinette Hospital, Turin, Italy
| | - Gideon Blecher
- Department of Urology, The Alfred Hospital, Melbourne, Australia.,Monash Health, Bentleigh East, Australia
| | - Massimiliano Timpano
- Department of Urology, A.O.U. Città della Salute e della Scienza di Torino - Molinette Hospital, Turin, Italy
| | - Paolo Gontero
- Department of Urology, A.O.U. Città della Salute e della Scienza di Torino - Molinette Hospital, Turin, Italy
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25
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Terrier M, Morel-Journel N, Carnicelli D, Ruffion A, Terrier JE, Maucort-Boulch D, Paganelli L, Neuville P. Suprapubic phalloplasty in transmen: surgical results and critical review. Int J Impot Res 2021; 33:754-761. [PMID: 33727691 DOI: 10.1038/s41443-021-00426-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 10/07/2020] [Accepted: 03/02/2021] [Indexed: 11/09/2022]
Abstract
This article presents the surgical outcomes of a consecutive series of 71 transmen undergoing pre-expanded suprapubic phalloplasty (SPP) in a specialized center. The median [IQR] duration to finalize this three-stage phalloplasty procedure was 7 months [6-7]. Median [IQR] follow-up was 39.4 months [19.7-81.2]. Among those included, 25 (35.2%) had a urethroplasty, and 40 (56.3%) a penile prosthesis as additional procedures. Complications were the result of disorders of wound healing (dehiscence, infection, partial necrosis) or tissue expander (migration, infection). Sixty patients (84.5%) experienced at least one complication during the phalloplasty procedure, mostly minor complications Clavien < IIIa (81.8%). Among these, 16 (22.5%) underwent at least one reintervention, 2 of whom underwent two reinterventions (18 reinterventions in total for Clavien ≥ IIIa complication). There was no loss of phalloplasty. Among the wide variety of techniques developed for phalloplasty, the suprapubic technique seems to be a valuable option for transmen on the path to genital gender affirming surgery.
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Affiliation(s)
- Manon Terrier
- Department of Urology, Centre hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite Cedex, France.
| | - Nicolas Morel-Journel
- Department of Urology, Centre hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite Cedex, France
| | - Damien Carnicelli
- Department of Urology, Centre hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite Cedex, France
| | - Alain Ruffion
- Department of Urology, Centre hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite Cedex, France
| | - Jean-Etienne Terrier
- Department of Urology, Centre hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite Cedex, France
| | | | - Lena Paganelli
- Department of Urology, Centre hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite Cedex, France
| | - Paul Neuville
- Department of Urology, Centre hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite Cedex, France
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26
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Robinson IS, Blasdel G, Cohen O, Zhao LC, Bluebond-Langner R. Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 2021; 18:800-811. [PMID: 33663938 DOI: 10.1016/j.jsxm.2021.01.183] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/07/2021] [Accepted: 01/25/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Current literature on surgical outcomes after gender affirming genital surgery is limited by small sample sizes from single-center studies. AIM To use a community-based participatory research model to survey a large, heterogeneous cohort of transmasculine patients on phalloplasty and metoidioplasty outcomes. METHODS A peer-informed survey of transmasculine peoples' experience was constructed and administered between January and April 2020. Data collected included demographics, genital surgery history, pre- and postoperative genital sensation and function, and genital self-image. OUTCOMES Of the 1,212 patients completing the survey, 129 patients underwent genital reconstruction surgery. Seventy-nine patients (61 percent) underwent phalloplasty only, 32 patients (25 percent) underwent metoidioplasty only, and 18 patients (14 percent) underwent metoidioplasty followed by phalloplasty. RESULTS Patients reported 281 complications requiring 142 revisions. The most common complications were urethrocutaneous fistula (n = 51, 40 percent), urethral stricture (n = 41, 32 percent), and worsened mental health (n = 25, 19 percent). The average erect neophallus after phalloplasty was 14.1 cm long vs 5.5 cm after metoidioplasty (P < .00001). Metoidioplasty patients report 4.8 out of 5 erogenous sensation, compared to 3.4 out of 5 for phalloplasty patients (P < .00001). Patients who underwent clitoris burial in addition to primary phalloplasty did not report change in erogenous sensation relative to primary phalloplasty patients without clitoris burial (P = .105). The average postoperative patient genital self-image score was 20.29 compared with 13.04 for preoperative patients (P < .00001) and 21.97 for a historical control of cisgender men (P = .0004). CLINICAL IMPLICATIONS These results support anecdotal reports that complication rates following gender affirming genital reconstruction are higher than are commonly reported in the surgical literature. Patients undergoing clitoris burial in addition to primary phalloplasty did not report a change in erogenous sensation relative to those patients not undergoing clitoris burial. Postoperative patients report improved genital self-image relative to their preoperative counterparts, although self-image scores remain lower than cisgender males. STRENGTHS & LIMITATIONS These results are unique in that they are sourced from a large, heterogeneous group of transgender patients spanning 3 continents and dozens of surgical centers. The design of this study, following a community-based participatory research model, emphasizes patient-reported outcomes with focus on results most important to patients. Limitations include the recall and selection bias inherent to online surveys, and the inability to verify clinical data reported through the web-based questionnaire. CONCLUSION Complication rates, including urethral compromise and worsened mental health, remain high for gender affirming penile reconstruction. Robinson IS, Blasdel G, Cohen O, et al. Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 2021;18:800-811.
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Affiliation(s)
- Isabel S Robinson
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA
| | - Gaines Blasdel
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Oriana Cohen
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA
| | - Lee C Zhao
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA.
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Abstract
BACKGROUND Phalloplasty is performed as genital gender-affirming surgery in transmasculine persons. It requires the harvest of sizeable autologous fasciocutaneous flaps, which is associated with donor-site morbidity and extensive scarring. Flap preexpansion has been used to facilitate wound closure and reduce scarring, but the efficacy of flap preexpansion in phalloplasty is unclear. The objective of this study was to assess the safety and effectiveness of preexpansion before phalloplasty. METHODS Transmasculine persons who underwent phalloplasty between December 2006 and July 2014 at our institution were identified and invited to participate. A chart review was performed to obtain patient demographics and expander-related complications. Outcomes regarding the donor-site scar (Patient Observer Scar Assessment Scale, scar size, patient satisfaction) were measured at the outpatient clinic and compared between transmasculine persons treated with and transmasculine persons treated without preexpansion. RESULTS Of 33 transmasculine persons who underwent phalloplasty, 17 underwent preexpansion. Phalloplasty techniques included the use of the radial forearm free flap, the anterolateral thigh flap, or a combination of both. In total, 34 tissue expanders were placed in the forearm (n = 12) and/or thigh (n = 22). Complications occurred in 18 (52.9%) of 34 tissue expanders and in 13 (76.5%) of 17 transmasculine persons. Seven reoperations were performed because of extrusion (n = 2), infection (n = 2), port failure (n = 2), or leakage (n = 1). Sixteen transmasculine persons visited our clinic for scar assessment (8 with and 8 without preexpansion). Primary closure was achieved in 4 (31%) of 13 expanded donor sites. Relative scar size was reduced when the wound could be closed primarily, but overall scar size, quality, and satisfaction did not differ significantly between groups. CONCLUSION Donor-site expansion before phalloplasty was associated with high rates of expander-related complications and expander failure. Primary closure of the donor site was achieved in less than a third of the cases. Primary closure may potentially lead to smaller scars and greater satisfaction; however, we concluded that the potential advantages of preexpansion do not outweigh the high risk of complications and lack of success.
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28
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Falcone M, Preto M, Timpano M, Ciclamini D, Crosio A, Giacalone F, Battiston B, Tos P, Gontero P. The surgical outcomes of radial artery forearm free-flap phalloplasty in transgender men: single-centre experience and systematic review of the current literature. Int J Impot Res 2020; 33:737-745. [PMID: 33603245 DOI: 10.1038/s41443-021-00414-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 01/05/2021] [Accepted: 01/25/2021] [Indexed: 11/09/2022]
Abstract
Radial artery forearm free-flap (RAFFF) phalloplasty is considered by most authors as the gold-standard technique for genital gender-affirming surgery (GGAS). RAFFF surgical complications have rarely been investigated, and the aim of this study and literature review is to analyse and focus on the surgical technique and its postoperative vascular complications. From May 2016 to January 2020, a consecutive series of 25 transgender men who underwent GGAS were enrolled in the present study. Age, BMI and smoking habits were recorded for all patients. Overall, vascular flap complications occurred in 20% of cases. Complete flap loss due to acute arterial thrombosis was recorded in a single case (4%). In 8% of cases, limited ventro-proximal arterial ischaemia was detected, while in the remaining 8% of cases, venous ventral ischaemia was reported. These results were compared with the current literature results. Indeed, from our analysis, the number of flap veins (<2) was the only predictive factor for vascular complications. In conclusion, RAFFF represents a reliable option for total phallic construction, leading to satisfactory results in terms of flap survival. To optimize the surgical outcomes, venous vascular drainage should be recommended.
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Affiliation(s)
- Marco Falcone
- Department of Neurourology, Unità Spinale Unipolare, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy.
- Department of Urology, Molinette Hospital, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy.
| | - Mirko Preto
- Department of Urology, Molinette Hospital, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Massimiliano Timpano
- Department of Urology, Molinette Hospital, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Davide Ciclamini
- Department of Orthopedic, Microsurgery Unit, CTO Hospital, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Alessandro Crosio
- Hand Surgery and Reconstructive Microsurgery Department, CTO, ASST Gaetano Pini, Milan, Italy
| | - Francesco Giacalone
- Department of Orthopedic, Microsurgery Unit, CTO Hospital, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Bruno Battiston
- Department of Orthopedic, Microsurgery Unit, CTO Hospital, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Pierluigi Tos
- Hand Surgery and Reconstructive Microsurgery Department, CTO, ASST Gaetano Pini, Milan, Italy
| | - Paolo Gontero
- Department of Urology, Molinette Hospital, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
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29
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Schloßhauer T, Kueenzlen L, Spennato S, Bozkurt A, Sohn M, Rieger UM. [Microsurgical penile reconstruction in case of intersexuality and after penis carcinoma]. HANDCHIR MIKROCHIR P 2020; 52:297-307. [PMID: 32428939 DOI: 10.1055/a-1017-3629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND The goals of penile reconstruction and phalloplasty include aesthetics as natural as possible and the ability of patients to void while standing and to have sexual intercourse. This article presents two more rare indications and techniques, the phalloplasty using free radial forearm flapin case of intersexuality and after penectomy due to penis carcinoma. PATIENTS AND METHODS In transsexual individuals numerous phalloplasties in Gottlieb and Levine`s technique, by means phalloplasty of free radial forearm-flap of the non-dominant forearm, were performed in our department over the last few years. However, this technique also has its significance for phalloplasty in non-transgender persons.Two patients are considered in detail with regard to indication and surgical technique and were followed up in a multimodal setting.Patient 1 is genetically male, thirty-five years old with a micropenis in the case of pseudohermaphroditism masculine and androgen resistance.Patient 2 is a fifty-one-year old genetically male and as a result of a penis carcinoma his penis had to be amputated at the level of penis root. After absence of recurrence for 1,5 years, the penile reconstruction took place after complete resection of the remaining residual penile stump and corpora cavernosa. Both patients underwent multimodal follow-up 15 months postoperatively with regard to phalloplasty sensors and donor-site restrictions. RESULTS An aesthetic and functional acceptable result could be obtained for both patients. Both patients are able to void while standing. The multimodal follow-up 15 months postoperatively revealed relevant differences in the sensory findings of both patients, which are due to the different anatomy of reinnervation. CONCLUSION In microsurgical experienced departments, the technique of A. radialis phalloplasty can also be used successfully in more rare indications, as shown here, a satisfying result can be achieved in terms of function and aesthetics. The complications shown here do not differ from those using phalloplasty in transgender persons.
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Affiliation(s)
- T Schloßhauer
- AGAPLESION MARKUS KRANKENHAUS, Akademisches Lehrkrankenhaus der Johann Wolfgang Goethe-Universität Frankfurt am Main, Klinik für Plastische, Ästhetische, Wiederherstellungs- und Handchirurgie
| | - L Kueenzlen
- AGAPLESION MARKUS KRANKENHAUS, Akademisches Lehrkrankenhaus der Johann Wolfgang Goethe-Universität Frankfurt am Main, Klinik für Plastische, Ästhetische, Wiederherstellungs- und Handchirurgie
| | - S Spennato
- AGAPLESION MARKUS KRANKENHAUS, Akademisches Lehrkrankenhaus der Johann Wolfgang Goethe-Universität Frankfurt am Main, Klinik für Plastische, Ästhetische, Wiederherstellungs- und Handchirurgie
| | - A Bozkurt
- HELIOS Universitatsklinikum Wuppertal, Klinik für Plastische, Ästhetische und Handchirurgie
| | - M Sohn
- AGAPLESION MARKUS KRANKENHAUS, Akademisches Lehrkrankenhaus der Johann Wolfgang Goethe-Universität Frankfurt am Main, Klinik für Urologie
| | - U M Rieger
- AGAPLESION MARKUS KRANKENHAUS, Akademisches Lehrkrankenhaus der Johann Wolfgang Goethe-Universität Frankfurt am Main, Klinik für Plastische, Ästhetische, Wiederherstellungs- und Handchirurgie
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30
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Küenzlen L, Nasim S, van Neerven S, Kühn S, Burger AE, Sohn M, Rieger UM, Bozkurt A. Multimodal Evaluation of Functional Nerve Regeneration in Transgender Individuals After Phalloplasty With a Free Radial Forearm Flap. J Sex Med 2020; 17:1012-1024. [DOI: 10.1016/j.jsxm.2020.02.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 02/10/2020] [Accepted: 02/12/2020] [Indexed: 10/24/2022]
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31
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Spennato S, Burger AE, Schlosshauer T, Küenzlen L, Rothenberger J, Kühn S, Kiehlmann M, Radacki I, Sohn M, Rieger UM. Microsurgical Phalloplasty in Nontranssexual Patients - Considerations After a Retrospective Single-center Analysis of 23 Cases. Urology 2020; 141:154-161. [PMID: 32283166 DOI: 10.1016/j.urology.2020.03.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/16/2020] [Accepted: 03/22/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the outcome of a single-center series of penile reconstruction using the radial free forearm flap in rare indications. MATERIALS AND METHODS From April 1993 until September 2016, 23 nontranssexual patients underwent phallic reconstruction by the use of a neuromicrovascular free radial forearm flap in our clinic. Patient-specific characteristics, surgical techniques, complications, and outcomes were retrospectively evaluated and interpreted. RESULTS The indications for surgery were: disorders of sex development (34.8%), reconstruction after oncologic surgery (34.8%), automutilation (8.7%), iatrogenic (8.7%), microphallus (8.7%), and 1 case of priapism (4.3%). Two patients (8.7%) had a total flap necrosis and 2 patients (8.7%) had a partial flap necrosis; 3 out of these 4 patients were heavy smokers. Urinary fistulae and strictures were frequent but were successfully managed by urologists in all cases. There was no statistically significant correlation between smoking, comorbidities, number of venous anastomoses, and complications. CONCLUSION In departments experienced in microsurgery, the goals of penile reconstruction could also be achieved in patients with rare indications by the use of the neuromicrovascular free radial forearm flap. Despite the high rate of postoperative complications, penile reconstruction with the free radial forearm flap yields satisfying results. An intensive cooperation between the plastic-reconstructive team and the urological team is a prerequisite to achieve the best surgical result.
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Affiliation(s)
- Stefano Spennato
- Department of Plastic Surgery, AGAPLESION Markus Hospital, Frankfurt, Germany.
| | - Anna E Burger
- Department of Plastic Surgery, University Hospital of Zurich, Zurich, Switzerland
| | | | - Lara Küenzlen
- Department of Plastic Surgery, AGAPLESION Markus Hospital, Frankfurt, Germany
| | - Jens Rothenberger
- Department of Plastic Surgery, AGAPLESION Markus Hospital, Frankfurt, Germany
| | - Shafreena Kühn
- Department of Plastic Surgery, AGAPLESION Markus Hospital, Frankfurt, Germany
| | - Marcus Kiehlmann
- Department of Plastic Surgery, AGAPLESION Markus Hospital, Frankfurt, Germany
| | - Isabel Radacki
- Department of Plastic Surgery, AGAPLESION Markus Hospital, Frankfurt, Germany
| | - Michael Sohn
- Department of Urology, AGAPLESION Markus Hospital, Frankfurt, Germany
| | - Ulrich M Rieger
- Department of Plastic Surgery, AGAPLESION Markus Hospital, Frankfurt, Germany
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32
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Kristinsson S, Johnson M, Ralph D. Review of penile reconstructive techniques. Int J Impot Res 2020; 33:243-250. [PMID: 32152468 DOI: 10.1038/s41443-020-0246-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 01/08/2020] [Accepted: 02/26/2020] [Indexed: 11/09/2022]
Abstract
Reconstructive surgery of the penis holds many unique challenges due to the unique physiological properties of the tissues. Much of the effort involved therefore goes to preserving as much of the native tissue as possible whilst novel and creative methods have been adopted to repair defects and in creation of neophallus. A search of the PubMed database was carried out using the following keywords: 'penile trauma', 'penile cancer', 'lichen sclerosus', 'glansectomy', 'glans resurfacing', 'penile-sparing surgery', 'micropenis', 'aphallia', 'female-to-male sex reassignment surgery', 'scrotal flap' and 'genital lymphoedema'. Results for glans resurfacing in treating cancer showed low local recurrence rates at 0-10% whilst 90% of lichen sclerosus patients reported complete resolutions of pain and pruritis. For repairs of penile shaft skin defects the literature supports the use of full-thickness skin graft and pedicled scrotal flaps. The radial artery-based forearm free flap remains the best option for neophallus creation in terms of function, sensation and cosmesis but unfortunately leaves a disfiguring scar and involves multiple stages. Some novel techniques have been developed to circumvent these issues and are discussed. This article presents an update on the important developments in the field of penile reconstructive surgery.
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Affiliation(s)
- Sverrir Kristinsson
- St. Peter's Andrology Centre and UCLH, 145 Harley Street, London, W1G 6BJ, UK
| | - Mark Johnson
- St. Peter's Andrology Centre and UCLH, 145 Harley Street, London, W1G 6BJ, UK
| | - David Ralph
- St. Peter's Andrology Centre and UCLH, 145 Harley Street, London, W1G 6BJ, UK.
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33
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Falcone M, Timpano M, Oderda M, Cocci A, Morelli G, Preto M, Polito C, Giorgio IR, Gideon B, Gontero P. Suprapubic pedicled phalloplasty in transgender men: a multicentric retrospective cohort analysis. Int J Impot Res 2020; 33:808-814. [PMID: 32034312 DOI: 10.1038/s41443-020-0238-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/19/2020] [Accepted: 01/23/2020] [Indexed: 11/09/2022]
Abstract
A variety of approaches are available to address a genital gender affirming surgery (GGAS) in transgender men. The aim of the present study is to report surgical and functional outcomes after a suprapubic pedicled phalloplasty (SPP). From November 2008 to August 2018, a consecutive series of 34 patients underwent an SPP in two tertiary referral centers. GGAS was conducted as a multistaged procedure, consisting (1) SPP with subsequent radial artery-based forearm free-flap urethroplasty, (2) glans sculpting, urethral anastomosis, and scrotoplasty, and (3) penile prosthesis implantation. The duration of surgery, intra and postoperative complications, and hospital stay were selected as variables for surgical outcomes. Functional outcomes were extrapolated from a four-item questionnaire.A partial necrosis of phallus was detected in two cases (5.8 %). Two cases of seroma formation with wound dehiscence (5.8%) were detected. Overall, 89% of patients declared to be fully satisfied of the SPP, 83% would recommend the procedure to someone else, and 89% would undergo the same procedure again. Overall, 66% of patients could achieve an orgasm during sexual penetrative intercourses. The retrospective design, the lack of randomization and validated questionnaire for outcomes reporting, and the limited follow-up represent the main drawbacks of our study. Our evidences suggest that SPP represents as an acceptable option for GGAS.
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Affiliation(s)
- Marco Falcone
- Urology department, Città della Salute e della Scienza-Molinette Hospital, University of Turin, Turin, Italy.
| | - Massimiliano Timpano
- Urology department, Città della Salute e della Scienza-Molinette Hospital, University of Turin, Turin, Italy
| | - Marco Oderda
- Urology department, Città della Salute e della Scienza-Molinette Hospital, University of Turin, Turin, Italy
| | - Andrea Cocci
- Urology department, Careggi Hospital, University of Florence, Florence, Italy
| | | | - Mirko Preto
- Urology department, Città della Salute e della Scienza-Molinette Hospital, University of Turin, Turin, Italy
| | | | | | - Blecher Gideon
- Urology Department, University of Melbourne, Melbourne, VIC, Australia
| | - Paolo Gontero
- Urology department, Città della Salute e della Scienza-Molinette Hospital, University of Turin, Turin, Italy
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Donor Site Morbidity in Phalloplasty Reconstructions: Outcomes of the Radial Forearm Free Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2442. [PMID: 31942400 PMCID: PMC6908408 DOI: 10.1097/gox.0000000000002442] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 07/15/2019] [Indexed: 11/26/2022]
Abstract
The radial artery forearm free flap (RFFF) is the workhorse technique for phallus reconstruction. The RFFF provides good cosmesis and potential sensory recovery. However, the donor site is large in comparison to other applications of the RFFF which may increase the potential for donor site morbidity, such as nerve injury, delayed wound healing, and decreased hand strength. This study systematically reviewed the current literature to assess the donor site morbidity associated with RFFF phalloplasty (RFFFP).
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Kjölhede A, Cornelius F, Huss F, Kratz G. Metoidioplasty and groin flap phalloplasty as two surgical methods for the creation of a neophallus in female-to-male gender-confirming surgery: A retrospective study comprising 123 operated patients. JPRAS Open 2019; 22:1-8. [PMID: 32158891 PMCID: PMC7061636 DOI: 10.1016/j.jpra.2019.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/04/2019] [Indexed: 11/30/2022] Open
Abstract
Background In gender-confirming surgery of the female-to-male gender dysphoric patient, there is currently no ideal method for the creation of a neophallus. Historically, in our clinic, groin flap phalloplasty (GFP) has been the dominating method, but during the last 20 years, it has gradually been replaced with metoidioplasty (MP). The aim of this study was to investigate whether this change of method has influenced factors such as the frequency of complications and the number of operations needed to complete the reconstruction of the neophallus. Methods This is a retrospective, single-centre, study comprising 123 consecutive female-to-male patients receiving a neophallus by GFP or MP between 2002 and 2015 at Linköping University Hospital, Sweden. Results One-hundred twenty-three patients underwent 126 primary surgical procedures (39 GFPs and 87 MPs) with the intention of reconstructing a neophallus. The mean number of procedures required in the GFP group was 5.2 ± 2.7 compared with that of 2.4 ± 1.7 in the MP group (p < 0.001). In the GFP group, 18/39 (46.2%) had a documented complication compared with 30/87 (34.5%) in the MP group; however, the difference was not statistically significant (p = 0.21). Conclusions The present study shows that the shift in method from GFP to MP has resulted in a decreased number of complications as well as a decrease in total surgical occasions. Both methods were found to be associated with relatively high frequencies of complications, however, mostly minor.
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Affiliation(s)
- A Kjölhede
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Surgery, Linköping University Hospital, Linköping, Sweden
| | - F Cornelius
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - F Huss
- Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden.,Department of Surgical Sciences, Plastic Surgery, Uppsala University, Uppsala, Sweden
| | - G Kratz
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Plastic Surgery, Linköping University Hospital, Linköping, Sweden
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Aggarwal A, Singh H, Mahendru S, Brajesh V, Singh S, Ghag N, Khazanchi RK. Minimising the donor area morbidity of radial forearm phalloplasty using prefabricated thigh flap: A new technique. Indian J Plast Surg 2019; 50:91-95. [PMID: 28615818 PMCID: PMC5469244 DOI: 10.4103/ijps.ijps_158_16] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Phalloplasty is indicated in various conditions of penile loss or absence. There are numerous techniques for phalloplasty including the pedicle and free flaps with the ultimate goal of micturition in standing position, attaining adequate size, aesthesis and sensations for sexual intercourse. Radial forearm phalloplasty is the gold standard flap to achieve above results but gives a very bad scar on the forearm. We present a technique of using prefabricated thigh flap to reduce the morbidity of donor area. The descending branch of lateral circumflex femoral pedicle was placed in a subcutaneous plane over tissue expander. After attaining an adequate size of flap with tissue expansion, it was delayed 3 weeks before phalloplasty. Prefabricated flap was thin and of large size replicating the radial forearm flap used for phalloplasty. Whole forearm defect was covered with the thigh flap, and the thigh could be closed primarily. This new technique of using prefabricated thigh flap has significantly reduced the donor site morbidity both aesthetically and functionally without the use of skin grafting in the whole procedure.
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Affiliation(s)
- Aditya Aggarwal
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medanta - The Medicity, Sector 38, Gurgaon, Haryana, India
| | - Hardeep Singh
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medanta - The Medicity, Sector 38, Gurgaon, Haryana, India
| | - Sanjay Mahendru
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medanta - The Medicity, Sector 38, Gurgaon, Haryana, India
| | - Vimalendu Brajesh
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medanta - The Medicity, Sector 38, Gurgaon, Haryana, India
| | - Sukhdeep Singh
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medanta - The Medicity, Sector 38, Gurgaon, Haryana, India
| | - Nitin Ghag
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medanta - The Medicity, Sector 38, Gurgaon, Haryana, India
| | - Rakesh Kumar Khazanchi
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medanta - The Medicity, Sector 38, Gurgaon, Haryana, India
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Namba Y, Watanabe T, Kimata Y. Flap Combination Phalloplasty in Female-to-Male Transsexuals. J Sex Med 2019; 16:934-941. [PMID: 30894300 DOI: 10.1016/j.jsxm.2019.02.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/12/2019] [Accepted: 02/14/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Although phalloplasty with a free radial forearm (RF) flap is the gold standard for sex reassignment surgery in female-to-male transsexuals, it can result in unsightly scars, lymphedema, and numbness of the hand. AIM To introduce the concept of flap combination phalloplasty and its clinical application. METHODS This is a retrospective chart review study of patients undergoing phalloplasty using various multiple flaps. Demographic data, surgical data, and outcomes were recorded. OUTCOMES Of the 15 cases, 5 were urethral fistulas; 4 were venous thrombosis; 2 were urethral calculus; and 1 was a partial flap loss. RESULTS 15 patients were included (age range 25-43 years, median 34 years). An RF flap and a deep inferior epigastric artery perforator flap combination were most frequently used. The median operative time for flap combination phalloplasty was 10.5 hours (range 6.5-12.5 hours). There was no total flap necrosis, but there was 1 case of partial flap loss. There were urethral fistulas in 5, venous thrombosis in 4, and urethral calculus in 2 cases. CLINICAL IMPLICATIONS Flap combination phalloplasty will become the third option when both the RF flap and the anterolateral thigh pedicle flap are not useful. STRENGTH & LIMITATIONS Flap combination phalloplasty is a complex operative procedure with a prolonged operative time, but it can provide more flap selection and reduce the morbidity at each donor site. Choosing from many different options can be beneficial to patients. CONCLUSION Flap combination phalloplasty has a similar complication rate to other procedures and has advantages in terms of flexibility and less donor site morbidity; it may thus be an option when either the RF flap or the anterolateral thigh pedicle flap cannot be used. Namba Y, Watanabe T, Kimata Y. Flap Combination Phalloplasty in Female-to-Male Transsexuals. J Sex Med 2019;16:934-941.
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Affiliation(s)
- Yuzaburo Namba
- Gender Center, Okayama University Hospital, Okayama, Japan.
| | - Toshiyuki Watanabe
- Department of Plastic and Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshihiro Kimata
- Department of Plastic and Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Longo B, Sorotos M, Laporta R, Santanelli di Pompeo F. Aesthetic improvements of radial forearm flap donor site by autologous fat transplantation. J Plast Surg Hand Surg 2018; 53:51-55. [PMID: 30442054 DOI: 10.1080/2000656x.2018.1537977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Despite its reliability, radial forearm (RF) flap is still affected by high donor site morbidity with poor cosmetic and functional outcomes after coverage with skin grafts. Having fat grafting demonstrated promising and effective filling and rejuvenating properties, we considered and tested it as a valuable alternative to dermal substitutes for the aesthetic improvement of RF flap donor site. Thirty-three patients with previous RF free flap reconstruction and poor donor site outcomes after full-thickness skin grafting to RF region were evaluated for secondary fat injection to improve outcomes. Objective and subjective assessments of results with standardized ultrasonographic soft tissue thickness measurements, cutaneous sensibility tests with the pressure-specified sensory device and scar assessment scale (POSAS) have been performed. Bivariate statistical analyses were performed comparing outcomes with contralateral healthy forearm. All cases showed significant improvement in soft tissue thickness (p< 0.031), cutaneous sensibility and scar appearance, with improved patient's and observers' scar assessment scores (<0.001). In conclusion, fat transplantation is an effective procedure that provided us with an adjunctive autologous layer in-between skin graft and underlying fascia, as well as a rejuvenating effect on skin and scars.
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Affiliation(s)
- Benedetto Longo
- a Plastic Surgery Unit , Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome , Rome , Italy
| | - Michail Sorotos
- a Plastic Surgery Unit , Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome , Rome , Italy
| | - Rosaria Laporta
- a Plastic Surgery Unit , Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome , Rome , Italy
| | - Fabio Santanelli di Pompeo
- a Plastic Surgery Unit , Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome , Rome , Italy
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Outcomes after Phalloplasty: Do Transgender Patients and Multiple Urethral Procedures Carry a Higher Rate of Complication? Plast Reconstr Surg 2018; 141:220e-229e. [PMID: 29019859 DOI: 10.1097/prs.0000000000004061] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Phalloplasty is associated with improved quality-of-life in those with penile defects, and in female-to-male transgender (transmale) patients seeking gender-confirming surgery. However, aggregate complication and outcome data are sparse. This study compares phalloplasty outcomes between transmale and cismale patients and between those with primary versus staged urethroplasty. METHODS A comprehensive literature search of PubMed, MEDLINE, and Google Scholar databases was conducted for studies relating to phalloplasty. Data on techniques, complications, outcomes, and patient demographics were collected. Analysis using the random-effects model with subgroup analyses was performed. RESULTS A total of 50 studies (1351 patients) were included: 19 studies (869 patients) for transmale patients and 31 studies (482 patients) for cismale patients. The urethral complication rate in the transmale group was 39.4 percent (95 percent CI, 30.6 to 48.9 percent; p = 0.028) compared to 24.8 percent (95 percent CI, 16.5 to 35.4 percent; p < 0.001) in the cismale group. The overall flap complication rates for transmale and cismale patients were 10.8 percent (95 percent CI, 7.0 to 16.2 percent; p < 0.001) and 8.1 percent (95 percent CI, 5.5 to 11.7 percent; p < 0.001), respectively. Twenty-three studies (723 patients) used primary urethroplasty and 13 studies (210 patients) performed staged urethroplasty procedures. Flap complication rates of primary and staged urethroplasty were 8.6 percent (95 percent CI, 5.3 to 13.8 percent; p < 0.001) and 16.7 percent (95 percent CI, 10.7 to 24.9 percent; p < 0.001), respectively. Primary urethroplasty had superior outcomes of voiding while standing, sexual function, and patient satisfaction compared with staged urethroplasty. CONCLUSIONS Cismale patients undergoing phalloplasty had lower urethral and flap complication rates compared with transmale patients. Staged urethroplasty had more flap complications, and worse outcomes and patient satisfaction compared with primary urethroplasty.
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Aesthetic Refinements after Radial Free Flap Phalloplasty: Optimizing the Donor Site and the Phallus. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1611. [PMID: 29632786 PMCID: PMC5889466 DOI: 10.1097/gox.0000000000001611] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 09/01/2017] [Indexed: 11/26/2022]
Abstract
Background: Phalloplasty with radial forearm flap is the gold standard for female-to-male sex reassignment surgery. However, it leaves a stigmatizing forearm scar, and as the new phallus is created with the forearm’s skin and fat, it does not look like that of a biological man. The aesthetic appearance of the donor site and the neophallus can be optimized after phalloplasty. In this study, we review refinement techniques (RTs) performed after radial forearm flap phalloplasty. Methods: We present a historical cohort of patients who underwent the following RTs: forearm fat grafting and localized laser in the forearm’s scars, and micropigmentation of the neophallus. Patient’s aesthetic satisfaction was evaluated using the Patient and Observer Scar Assessment Scale for the forearm’s refinements and the Male Genital Self-Image Scale for the neophallus. Results: Between January 2014 and January 2016, 8 patients underwent forearm fat grafting with localized laser, and 7 patients micropigmentation of the neophallus after radial flap phalloplasties. All Patient and Observer Scar Assessment Scale parameters showed a statistically significant reduction between preoperative and postoperative values. Male Genital Self-Image Scale survey showed that all patients felt positively about their genitals after micropigmentation. Patients who underwent refinement procedures were highly satisfied with the aesthetic outcome and felt more confident. They also claim that they would choose to have the refinement procedure done again. Conclusions: The proposed RTs are minimally invasive interventions to complement and enhance female-to-male sex reassignment surgery with very few complications and excellent aesthetic results of both the forearm scars and the constructed phallus.
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Karamitros GA, Kitsos NA, Sapountzis S. Systematic Review of Quality of Patient Information on Phalloplasty in the Internet. Aesthetic Plast Surg 2017; 41:1426-1434. [PMID: 28698939 DOI: 10.1007/s00266-017-0937-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 06/24/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND An increasing number of patients, considering aesthetic surgery, use Internet health information as their first source of information. However, the quality of information available in the Internet on phalloplasty is currently unknown. This study aimed to assess the quality of patient information on phalloplasty available in the Internet. METHODS The assessment of the Web sites was based on the modified Ensuring Quality Information for Patients (EQIP) instrument (36 items). Three hundred Web sites were identified by the most popular Web search engines. RESULTS Ninety Web sites were assessed after, duplicates, irrelevant sources and Web sites in other languages rather than English were excluded. Only 16 (18%) Web sites addressed >21 items, and scores tended to be higher for Web sites developed by academic centers and the industry than for Web sites developed by private practicing surgeons. The EQIP score achieved by Web sites ranged between 4 and 29 of the total 36 points, with a median value of 17.5 points (interquartile range, 13-21). The top 5 Web sites with the highest scores were identified. CONCLUSIONS The quality of patient information on phalloplasty in the Internet is substandard, and the existing Web sites present inadequate information. There is a dire need to improve the quality of Internet phalloplasty resources for potential patients who might consider this procedure. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Beilan JA, Manimala NJ, Slongo J, Loeb A, Spiess PE, Carrion RE. Surgical Reconstruction After Penile Cancer Surgery. CURRENT SEXUAL HEALTH REPORTS 2017. [DOI: 10.1007/s11930-017-0134-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Watfa W, di Summa PG, Meuli J, Raffoul W, Bauquis O. MatriDerm Decreases Donor Site Morbidity After Radial Forearm Free Flap Harvest in Transgender Surgery. J Sex Med 2017; 14:1277-1284. [PMID: 28843466 DOI: 10.1016/j.jsxm.2017.08.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 07/27/2017] [Accepted: 08/01/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND Phalloplasty with the radial forearm free flap is associated with a large donor site defect. AIM To compare two methods of donor site closure for functional and cosmetic long-term results: full-thickness skin grafting vs split-thickness skin grafting with MatriDerm. METHODS Thirty-seven transgender patients had a neophallus created from a radial forearm free flap, and all were operated on by the same senior surgeon. Eight patients had their donor site defect closed by total skin grafting and 29 patients, operated on after 2009, received a split-thickness skin graft with MatriDerm closure. All 37 patients were evaluated by questionnaire and by careful clinical examination. Pressure perception was assessed with the Semmes-Weinstein monofilament test. Sensory recovery, skin quality, and cosmetic result also were compared. The contralateral arm was used as the control. OUTCOMES Pressure perception values showed better sensory return in the MatriDerm group. Split-thickness skin grafting with MatriDerm achieved superior results in skin sensibility, superficial radial nerve recovery, and cosmetic aspect. RESULTS Our findings support the hypothesis that MatriDerm can be used to preserve sensory function and decrease morbidity of the donor site. CLINICAL IMPLICATIONS The use of a dermal substitute decreases the morbidity of the forearm free flap donor site. STRENGTHS AND LIMITATIONS The strength of this study is its retrospective nature conducted of a prospectively maintained database of 37 consecutive radial forearm free flaps with superimposable dimensions and location performed by the same surgeon, thus limiting biases. A limitation is its small sample (particularly for the control group). CONCLUSION Our experience showed that the combination of a split-thickness skin graft with MatriDerm substantially decreases postoperative complications at the donor site defect on the forearm of transgender patients. Watfa W, di Summa PG, Meuli J, et al. MatriDerm Decreases Donor Site Morbidity After Radial Forearm Free Flap Harvest in Transgender Surgery. J Sex Med 2017;14:1277-1284.
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Affiliation(s)
- William Watfa
- Department of Plastic, Reconstructive and Hand Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
| | - Pietro G di Summa
- Department of Plastic, Reconstructive and Hand Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Joaquim Meuli
- Department of Plastic, Reconstructive and Hand Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Wassim Raffoul
- Department of Plastic, Reconstructive and Hand Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Olivier Bauquis
- Department of Plastic, Reconstructive and Hand Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
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fMRI after Phalloplasty with Nerve Anastomosis in a Trans-Man Patient. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1353. [PMID: 28740768 PMCID: PMC5505829 DOI: 10.1097/gox.0000000000001353] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 04/17/2017] [Indexed: 12/23/2022]
Abstract
We report on a case of a trans-man patient, who underwent penile reconstruction with the use of a radial forearm flap, urethroplasty, vaginectomy and scrotoplasty, insertion of testicle implants, and penile erection implants, similar to previously described methods. One of the requirements for an ideal phalloplasty is the preservation of erogenous sensitivity, which is often demanded by the patients for fulfilling their sexual well-being. For the first time known to us, we use a functional magnetic resonance imaging following radial forearm flap phalloplasty with nerve anastomosis to assess the cortical activation after clitoral stimulation. The patient was poked with a plastic pen on the neophallus and the groin. Regular block design with T1 and BOLD-T2* images were used. The results contradict the classic Penfield and Rasmussen homunculus, that is, the activations in the primary somatosensory cortex (S1) were bilateral with a left-sided dominance in the lateral parts of the medial postcentral gyrus (same region as the groin), and no activations were observed in the mesial parts of the postcentral gyrus. We also reported bilateral activations with a left-sided dominance in the secondary somatosensory cortex (S2) and near Broca's area at the sylvian fissure just posterior to ramus ascendens. Our findings are similar to previous studies reporting on imaging related to genital sensitivity.
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Jacobsson J, Andréasson M, Kölby L, Elander A, Selvaggi G. Patients’ Priorities Regarding Female-to-Male Gender Affirmation Surgery of the Genitalia—A Pilot Study of 47 Patients in Sweden. J Sex Med 2017; 14:857-864. [DOI: 10.1016/j.jsxm.2017.04.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 03/31/2017] [Accepted: 04/03/2017] [Indexed: 12/01/2022]
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Abstract
BACKGROUND Acquired or congenital absence of the penis can lead to severe physical limitations and psychological outcomes. Phallic reconstruction can restore various functional aspects of the penis and reduce psychosocial sequelae. Moreover, some female-to-male transsexuals desire creation of a phallus as part of their gender transition. Because of the complexity of phalloplasty, there is not an ideal technique for every patient. This review sets out to identify and critically appraise the current literature on phalloplasty techniques and outcomes. METHODS A comprehensive literature search of the MEDLINE, PubMed, and Google Scholar databases was conducted for studies published through July of 2015 with multiple search terms related to phalloplasty. Data on techniques, outcomes, complications, and patient satisfaction were collected. RESULTS A total of 248 articles were selected and reviewed from the 790 identified. Articles covered a variety of techniques on phalloplasty. Three thousand two hundred thirty-eight patients underwent phalloplasty, with a total of 1753 complications reported, although many articles did not explicitly comment on complications. One hundred four patients underwent penile replantation and two underwent penile transplantation. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction. CONCLUSIONS Phalloplasty techniques are evolving to include a number of different flaps, and most techniques have high reported satisfaction rates. Penile replantation and transplantation are also options for amputation or loss of phallus. Further studies are required to better compare different techniques to more robustly establish best practices. However, based on these studies, it appears that phalloplasty is highly efficacious and beneficial to patients.
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Boucher F, Brosset S, Mojallal AA, Braye F, Chateau J, Morel Journel N. [Phalloplasty: Microsurgical options and management algorithm]. ANN CHIR PLAST ESTH 2017; 62:617-624. [PMID: 28456428 DOI: 10.1016/j.anplas.2017.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 03/27/2017] [Indexed: 11/18/2022]
Abstract
The free radial forearm flap is considered as the gold standard in penile reconstruction for good functional and aesthetic results. The scar on donor site could be considered as pathognomonic of their situation by transsexual patients. The development of microsurgical flaps provides new therapeutic options. This options are discussed and a therapeutic algorithm is presented. The main techniques used are the pedicled anterolateral thigh perforator flap and free muscle sparing latissimus dorsi flap. Principal criteria are listed, the choice of patient and the local anatomical conditions are the most important. Antebrachial flap stay the first choice. In case of non-feasibility of this flap, phalloplasty with pedicle ALT flap or free MSLD flap will be proposed. Urethral reconstruction will be done by a narrow free forearm flap or by a delayed thin skin graft or buccal mucosa graft. Microsurgical phalloplasty options are not limited to the forearm flap. Satisfactory results can be obtained using alternative procedure. The use of a therapeutic algorithm allows to choose the most optimal solution for each patient.
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Affiliation(s)
- F Boucher
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital de la Croix-Rousse, hospices Civils de Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France.
| | - S Brosset
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital de la Croix-Rousse, hospices Civils de Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - A A Mojallal
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital de la Croix-Rousse, hospices Civils de Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - F Braye
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital de la Croix-Rousse, hospices Civils de Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - J Chateau
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital de la Croix-Rousse, hospices Civils de Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - N Morel Journel
- Service d'urologie, centre hospitalier Lyon Sud, hospices civils de Lyon, Lyon, France
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An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient. Plast Reconstr Surg 2017; 139:728-737. [DOI: 10.1097/prs.0000000000003062] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bickell M, Beilan J, Wallen J, Wiegand L, Carrion R. Advances in Surgical Reconstructive Techniques in the Management of Penile, Urethral, and Scrotal Cancer. Urol Clin North Am 2017; 43:545-559. [PMID: 27717440 DOI: 10.1016/j.ucl.2016.06.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This article reviews the most up-to-date surgical treatment options for the reconstructive management of patients with penile, urethral, and scrotal cancer. Each organ system is examined individually. Techniques and discussion for penile cancer reconstruction include Mohs surgery, glans resurfacing, partial and total glansectomy, and phalloplasty. Included in the penile cancer reconstruction section is the use of penile prosthesis in phalloplasty patients after penectomy, tissue engineering in phallic regeneration, and penile transplantation. Reconstruction following treatment of primary urethral carcinoma and current techniques for scrotal cancer reconstruction using split-thickness skin grafts and flaps are described.
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Affiliation(s)
- Michael Bickell
- Department of Urology, University of South Florida, Tampa, FL, USA
| | - Jonathan Beilan
- Department of Urology, University of South Florida, Tampa, FL, USA
| | - Jared Wallen
- Department of Urology, University of South Florida, Tampa, FL, USA
| | - Lucas Wiegand
- Department of Urology, University of South Florida, Tampa, FL, USA
| | - Rafael Carrion
- Department of Urology, University of South Florida, Tampa, FL, USA.
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