A true one-stage nonmicrosurgical technique for total phallic reconstruction

Anterolateral Thigh Phalloplasty With Staged Skin Graft Urethroplasty: Technique and Outcomes

OBJECTIVE

1) To describe the authors' technique of anterolateral thigh (ALT) phalloplasty with staged skin graft urethroplasty and 2) to report the surgical outcomes and complications of this technique in a preliminary patient cohort.

METHODS

Following IRB (Institutional Review Board) approval, retrospective chart review identified all patients undergoing primary three-stage ALT phalloplasty by the senior authors. Stage I involves single tube, pedicled ALT transfer. Stage II involves vaginectomy, pars fixa urethroplasty, scrotoplasty, and opening the ALT ventrally and construction of a urethral plate with split-thickness skin graft. Stage III involves tubularization of the urethral plate to create the penile urethra. Data collected included patient demographics, intraoperative details, postoperative courses, and complications.

RESULTS

Twenty-four patients were identified. Twenty-two patients (91.7%) underwent ALT phalloplasty prior to vaginectomy. All patients underwent staged split-thickness skin grafting for the penile urethra reconstruction. Twenty-one patients (87.5%) achieved standing micturition at the time of data collection. Eleven patients (44.0%) experienced at least 1 urologic complication requiring additional operative intervention, most commonly urethrocutaneous fistulae (8 patients, 33.3%), and urethral strictures (5 patients, 20.8%).

CONCLUSION

ALT phalloplasty with split-thickness skin grafting for urethral lengthening is an alternative technique to achieve standing micturition with an acceptable complication rate in gender-affirming phalloplasty.

Scrotal flap phalloplasty as temporary neophallus in infants and children with penile agenesis: Multi-institutional experience and long-term follow-up

INTRODUCTION

Aphallia is a rare congenital disorder pertaining to genotypic males. Early surgical creation of a neophallus is recommended to reinforce the child's male gender-identity, favoring proper psychosexual development. Modern microsurgical techniques used to create a neophallus in adults are not recommended in children due to the invasiveness and complexity of the procedures, along with high complication rates. Scrotal flap phalloplasty is a simple and reproducible technique to create a temporary neophallus in prepubertal boys with aphallia.

OBJECTIVE

We present a multi-institutional experience, ten years after the initial description of the scrotal flap phalloplasty (SFP) technique, in which a flap from the well-developed scrotum is used to build a temporary neophallus, without obvious scars in patients with aphallia.

STUDY DESIGN

The records of surgical neophalloplasty for aphallia patients from 4 centers between 2011 and 2021 were reviewed. All patients had at least one year follow-up to assess for short and long-term complications. Age at initial operation, associated anomalies, and other related surgical procedures were analyzed.

RESULTS

The post-operative aesthetic result in all patients was satisfactory and has been maintained in the long-term follow-up, with all patients presenting a cylindrical structure resembling an uncircumcised penis, without evidence of significant contraction or loss of length. (Summary Figure) DISCUSSION: Non-microsurgical neophalloplasty techniques in patients with penile agenesis are temporary procedures that help to establish the body image and preserve the psychosexual development of the patient with aphallia. These techniques do not involve tissue transplant from a distant region, and are simpler to perform, with less scarring at the donor sites. Due to significant donor scars and considerable morbidity and complexity associated with the definitive phalloplasty techniques, we created a simple, reproducible and straightforward procedure to serve as a temporary neophallus in young boys with aphallia. As affected patients usually have a well-formed scrotum with normal and orthotopic testicles, it is the ideal donor site for a temporary neo-phallus in childhood. Furthermore, other donor sites are preserved for a definitive phalloplasty. There are limitations to this study, as quality of life could not be assessed and psychological or gender-identity investigations have not been carried out. None of these children have reached puberty, and hence decision and outcomes of definitive neophallus reconstruction has not been considered to date.

CONCLUSION

Scrotal flap phalloplasty is a minimally invasive, simple and reproducible technique used to create a temporary neophallus in boys with aphallia, while waiting for definitive reconstructive surgery after puberty.

The pedicled gracilis muscle combined with the fascia lata: a preliminary clinical study of a new biomimetic dynamic phalloplasty method

BACKGROUND

Phalloplasty is a challenging procedure in the field of repair and reconstruction. Traditional skin flap methods with prostheses or autologous tissue implantation are still common; however, with this method the reconstructed phallus is static and has a high risk of complications.

AIM

We aimed to use novel methods for phalloplasty to mimic the normal structure of the phallus while maintaining the patient's ability to obtain sufficient hardness and subjective controllability.

METHODS

The neophallus comprised the bilateral pedicled neurovascular gracilis muscle, which provided neophallus volitional control; the pedicled fascia lata, which mimicked the tunica albuginea; the pedicled anterolateral thigh flap, which was used to reconstruct the neourethra and neoglans; and the thin split-thickness skin grafted on the surface of the fascia lata. The urethral anastomosis was performed simultaneously. The appearance and function of the neophallus, as well as patient satisfaction, were evaluated postoperatively.

OUTCOMES

The biomimetic dynamic phalloplasty using the bilateral pedicled gracilis muscle combined with the fascia lata was successfully performed in 4 patients.

RESULTS

During follow-up at 10-21 months after the procedure, all 4 patients could complete sexual intercourse and were satisfied with the appearance and self-controllability of the neophallus. The size of the neophallus stabilized within 6 months. The tactile, deep touch sensation, and pain sensations of the neophallus partially recovered. All of the patients could stand to urinate.

CLINICAL IMPLICATIONS

We used the gracilis muscle combined with the fascia lata to mimic the basic structure of the corpus cavernosum and tunica albuginea and successfully reconstructed the biomimetic dynamic neophallus.

STRENGTHS AND LIMITATIONS

This is to our knowledge the first report of biomimetic dynamic phalloplasty using the bilateral pedicled gracilis muscle combined with the fascia lata to mimic the complex structure of the phallus and enable the achievement of erection. However, due to the small number of patients included in this study, the data have no statistical significance. More cases are needed to obtain conclusive data and examine the long-term clinical effects of this procedure.

CONCLUSION

Using novel methods for phalloplasty, we successfully maintained the patient's ability to obtain sufficient hardness and subjective controllability without the use of implants, and the preliminary clinical results are encouraging.

At The Forefront of Penile Surgical Reconstruction: A Bibliometric Study of the 100 Most-Cited Articles

PURPOSE

The citation count of a scientific article is considered as the recognition it received from this field. The purpose of this bibliometric analysis was to identify the top 100 most-cited scientific articles in penile surgical reconstruction.

METHODS

The Web of Science database was used to extract the top 100 most-cited articles. Individual articles were reviewed to identify the authorship, published journal, journal impact factor (IF), primary disease, article type, institution and country of origin, and year of publication.

RESULTS

The top 100 most-cited articles were published between 1947 and 2013. The number of citations ranged from 23 to 233. Journal of Urology contributed the most articles (n = 36). Articles with a high level of evidence like prospective analysis (n = 5), systematic review and meta-analysis (n = 2), and guideline (n = 1) were all published after 2000. The average citation per year of articles published in high-IF journals was significantly higher than that of other articles (p = 0.0129). There was a positive linear correlation between citation count per year and publication year (r² = 0.26, p < 0.001). Among the top 100 articles, 74 articles were interlinked via citation of each other. The major topic of co-citation network was the application of flaps in penile reconstruction.

CONCLUSIONS

The analysis of top 100 most-cited articles facilitates the comprehensive recognition of current focus in the field of penile surgical reconstruction, which is the exploration of flaps and development of new techniques in penile reconstruction. In the future, more attention should be paid to evidence-based medicine to provide high-level evidence for research.

LEVEL OF EVIDENCE III

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 .

[Microsurgical penile reconstruction in case of intersexuality and after penis carcinoma]

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.

Urethral Reconstruction in Anterolateral Thigh Flap Phalloplasty: A 93-Case Experience

BACKGROUND

Urethral reconstruction in anterolateral thigh flap phalloplasty cannot always be accomplished with one flap, and the ideal technique has not been established yet. In this article, the authors' experience with urethral reconstruction in 93 anterolateral thigh flap phalloplasties is reported.

METHODS

Ninety-three anterolateral thigh phalloplasties performed over 13 years at a single center were retrospectively reviewed to evaluate outcomes of the different urethral reconstruction techniques used: anterolateral thigh alone without urethral reconstruction (n = 7), tube-in-tube anterolateral thigh flap (n = 5), prelaminated anterolateral thigh flap with a skin graft (n = 8), anterolateral thigh flap combined with a free radial forearm flap (n = 29), anterolateral thigh flap combined with a pedicled superficial circumflex iliac artery perforator flap (n = 38), and anterolateral thigh flap combined with a skin flap from a previous phalloplasty (n = 6). Seventy-nine phalloplasties were performed for female-to-male sex reassignment surgery. The others were performed in male patients with severe penile insufficiency.

RESULTS

Urethral complication rates (fistulas and strictures) were as follows: tube-in-tube anterolateral thigh flap, 20 percent; prelaminated anterolateral thigh flap, 87.5 percent; free radial forearm flap urethra, 37.9 percent; superficial circumflex iliac artery perforator urethral reconstruction, 26.3 percent; and skin flap from previous phalloplasty, 16.7 percent.

CONCLUSIONS

When tube-in-tube urethra reconstruction is not possible (94.2 percent of cases), a skin flap such as the superficial circumflex iliac artery perforator flap or the radial forearm flap is used for urethral reconstruction in anterolateral thigh phalloplasties. Flap prelamination is a second choice that gives high stricture rates. If a penis is present, its skin should be used for urethral reconstruction and covered with an anterolateral thigh flap. With these techniques, 91.86 percent of patients are eventually able to void while standing.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Masculinizing Genital Gender Confirmation Surgery

INTRODUCTION

This article is the third in a 3-part series focused on the comprehensive treatment of gender dysphoria. Multidisciplinary gender dysphoria care may involve a combination of counseling, social gender transition, hormone therapy, and gender confirmation surgery (GCS) to maximize physical characteristics congruent with a patient's gender identity. Nonoperative management of gender dysphoria was covered in part 1. The focus of part 2 was feminizing GCS. In part 3, surgical considerations for masculinizing GCS are summarized, including a review of different phalloplasty techniques. This installment also includes information about adjunctive procedures, therapies, and products used by transgender men and women to express their gender identity.

AIM

To provide an overview of both genital and nongenital masculinizing gender confirmation procedures. To review phalloplasty techniques, preoperative considerations, complications, and outcomes. To summarize ancillary services and procedures available to transgender patients to facilitate their gender presentation.

METHODS

A review of relevant literature through May 2017 was performed via PubMed.

MAIN OUTCOME MEASURES

To summarize ancillary products and services used by transgender patients and to review surgical considerations for masculinizing genitoplasty.

RESULTS

A variety of nonsurgical ancillary services exist for transgender patients to aid their transition. A variety of phalloplasty procedures have been developed for transgender men who seek genital GCS. Most surgeons prefer radial forearm phalloplasty, including the authors whose surgical technique is described. Each phalloplasty approach is associated with its own benefits, drawbacks, and complications.

CONCLUSION

A variety of ancillary services and procedures that help transgender men and women communicate their gender identity in society is available and is an important adjunct to medical or surgical treatment of gender dysphoria. Pre-operative, intra-operative, and post-operative considerations of masculinizing genital gender confirmation procedures were reviewed. Hadj-Moussa M, Agarwal S, Ohl DA, et al. Masculinizing Genital Gender Confirmation Surgery. Sex Med Rev 2019;7:141-155.

The Pedicled Anterolateral Thigh Phalloplasty

The anterolateral thigh (ALT) flap is a viable and reliable option for phalloplasty. The primary advantages of the ALT flap remain an inconspicuous donor site and flexibility in phallus length. The disadvantages of the ALT flap are a higher incidence of both flap and urethral complications compared with a radial forearm phalloplasty. Although the ALT phalloplasty can achieve the primary goals of standing micturition, penetrative intercourse, and an aesthetic phallus, multiple stages and revisions are often necessary. Careful patient selection is paramount in attaining acceptable results with the ALT phalloplasty technique.

Dynamic Penile Corpora Cavernosa Reconstruction Using Bilateral Innervated Gracilis Muscles: A Preclinical Investigation

Introduction

Prosthesis-assisted penile reconstruction has been performed extensively to restore a cosmetically acceptable phallus. However, a large number of patients will undergo revision surgery for various prosthesis-related complications.

Aim

To develop a 1-stage prosthesis-free dynamic cavernosa reconstruction method using bilateral innervated gracilis muscles and to investigate the feasibility and reliability of the surgical design.

Methods

10 fresh cadavers were dissected to assess the availability of bilateral gracilis muscles for functional cavernosa rebuilding. 11 mongrel female dogs were involved in the penile reconstruction surgery. The neophallus consisted of bilateral gracilis muscles as the neo-cavernosa, a right gracilis skin flap as the neourethra, and a lower abdominal flap with an anterior rectus sheath as the skin envelope and neo-tunica albuginea. The function and structure of the neo-phalli were assessed 7 months postoperatively.

Main Outcome Measures

The neurovascular pedicle length of the gracilis muscles and the volume of the gracilis venter musculi were measured in the cadaveric investigation. The average dimensions of the canine neo-phalli at rest and during electrostimulated erection were obtained and the muscular fatigue-resistant curve was drawn. Histologic evaluations also were performed.

Results

The neurovascular pedicle length and volume of the gracilis muscles were sufficient to yield a nearly normal appearance of the neo-cavernosa in the cadaveric and animal studies. The muscular fatigue-resistant curve demonstrated adequate length, stiffness, and duration of erection of the neo-phalli to accomplish normal coitus. Histologic evaluations showed an intact neourethra and nearly normal muscle structure in the inner layer of the canine neo-cavernosa, except for significantly increased amount of collagen fibers and type I/III collagen ratio in the outer layer of the neo-cavernosa. The percentage of type II (fatigue-prone) muscle fibers did not change significantly.

Conclusion

Our preclinical investigation proves that corpora cavernosa reconstruction using bilateral innervated gracilis muscles is technically feasible and functionally efficacious.

Yin Z, Liu L, Xue B, et al. Dynamic Penile Corpora Cavernosa Reconstruction Using Bilateral Innervated Gracilis Muscles: A Preclinical Investigation. Sex Med 2018;6:162–170.

Phalloplasty: A Review of Techniques and Outcomes

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.

Advances in Surgical Reconstructive Techniques in the Management of Penile, Urethral, and Scrotal Cancer

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.

Neophalloplasty in boys with aphallia: A systematic review

OBJECTIVE

Aphallia is a rare penile congenital abnormality. The aim of this systematic review was to assess all available literature on neophalloplasty in infancy with an interest in technical alternatives and clinical outcome.

MATERIALS AND METHODS

We performed a Pubmed search using the terms: neophalloplasty, neophallus, and phalloplasty, and selected articles that presented technical alternatives for penile construction in cases of penile dysgenesis, especially aphallia in children and/or adolescents.

RESULTS

A total of 319 articles were identified in the initial search. Among the different techniques presented in 19 papers collected, we categorized reconstructive procedures into two groups: microsurgical and non-microsurgical techniques. Among the microsurgical techniques, procedures such as the osteocutaneous fibular flap (n = 18), the myocutaneous latissimus dorsi flap (n = 24), and the radial forearm free flap (n = 293) were reported. Among the non-microsurgical techniques, we found a wider range of technical options (6 in total). Most were based on groin, abdominal, and scrotal flaps. Long-term reports on the functionability of the neophallus and psychological aspects of the patients are lacking.

CONCLUSION

In assessing recent literature, it seems rational that neophalloplasty should be regarded as the preferred strategy for boys born with aphallia, in opposition to female gender assignment.

Penile reconstruction in the male

We describe and review the most recent techniques of male genital reconstruction, identifying relevant material with an unstructured PubMed-based search of previous reports, using the keywords ‘reconstruction’, ‘glans’, ‘shaft’, ‘lymphoedema’, ‘skin graft’, ‘scrotoplasty’, ‘urethroplasty’, and ‘penile prosthesis’. This search produced 22 reports that were analysed in this review. Split-thickness skin grafts are ideal for glans reconstruction, while full-thickness skin grafts should be used to cover defects on the shaft penis, as they tend to heal with less contracture. The radial artery-based free-flap phalloplasty is the technique of total phallic reconstruction associated with the highest satisfaction rates. Further research is required to identify an ideal reconstructive technique that would guarantee superior cosmetic and functional results, minimising donor site morbidity.

Penile reconstruction

During the most recent years, a variety of new techniques of penile reconstruction have been described in the literature. This paper focuses on the most recent advances in male genital reconstruction after trauma, excision of benign and malignant disease, in gender reassignment surgery and aphallia with emphasis on surgical technique, cosmetic and functional outcome.

Pedicled deep inferior epigastric perforator flap for total phallic reconstruction

Total phallic reconstruction remains a great challenge in reconstructive surgery. The search for a suitable donor site is never ending. Based on the experiences in using free deep inferior epigastric perforator flap for breast reconstruction, the authors describe a new usage of the deep inferior epigastric perforator flap for phallic reconstruction. In this procedure, the neourethra is centrally located. The rigidity is provided with the 12th rib. The donor site can directly be closed. Over the past 4 years, this surgical procedure has been used successfully for total phallic reconstruction in 2 patients. Four years of follow-up has revealed that an aesthetically acceptable functional neopenis was achieved. The scar of the donor site is inconspicuous and is easily concealed by underwear. Moreover, this new procedure is a nonmicrosurgical technique. Although more clinical experience is needed, this flap can be chosen as an alternative option in phallic reconstruction.

Phalloplasty in complete aphallia and ambiguous genitalia

The most common indications for phalloplasty in children include aphallia, micropenis/severe penile inadequacy, ambiguous genitalia, phallic inadequacy associated with epispadias/bladder exstrophy and female to male gender reassignment in adolescents. There are many surgical options for phalloplasty; both local pedicled tissue as well as free tissue transfer. The advantages of local tissue include a more concealed donor site, less complex operation and potentially faster recovery. However, pedicled options are generally less sensate, making placement of a penile prosthesis more risky and many children with bladder exstrophy have been previously operated upon making the blood supply for local pedicled flaps less reliable. This Here the authors discuss free tissue transfer, including the radial forearm, the anterolateral thigh, the scapula and latissimus, and the fibula free flaps, as well as local rotational flaps from the abdomen, groin, and thigh. The goal of reconstruction should be an aesthetic and functional (ability to penetrate) phallus, which provides tactile and erogenous sensation, and the ability to urinate standing. Ideally, the operation should be completed in one to two operations with minimal donor site morbidity. There are advantages and disadvantages of each of flap and thus the choice of donor site should be a combination of the patient's preference and surgeon's ability to produce a consistent result.

Penile reconstruction

A variety of surgical options exists for penile reconstruction. The key to success of therapy is holistic management of the patient, with attention to the psychological aspects of treatment. In this article, we review reconstructive modalities for various types of penile defects inclusive of partial and total defects as well as the buried penis, and also describe recent basic science advances, which may promise new options for penile reconstruction.

Autologous nerve implantation into denervated monkey skin promotes regeneration of Meissner's corpuscle

Background

The aim of this study was to observe the effects of autologous nerve implantation into the denervated finger flap on the regression and regeneration of sensory nerve endings and Meissner’s corpuscles.

Material/Methods

Bilateral nerves of fingers were separated: one was removed and the other was implanted into the denervated finger in the implantation group. In the non-implantation group, both nerves were removed. The ventral skin of fingers was collected for immunohistochemistry and electron microscopy 3, 6, 9 and 12 months after surgery.

Results

The nerve endings in the Meissner’s corpuscles began to degenerate 3 months after denervation. The elementary structure of Meissner’s corpuscles was not significantly altered. Nerve fibers were present around the Meissner’s corpuscles, accompanied by growing into its inward. The axons in the denervated nerve disappeared and the Meissner’s corpuscles began to atrophy at month 6. More regenerated nerve fibers were observed after nerve implantation, including intensive and thick fibers, accompanied by reinnervation of Meissner’s corpuscles. More nerve fibers and a higher proportion of myelinated nerve fibers were noted at month 9 in the implantation group, and the reinnervation was present in the majority of Meissner’s corpuscles. Naive myelinated nerve fibers appeared at the caudal end of Meissner’s corpuscles. The nerve fibers in the Meissner’s corpuscles increased to the normal level at 12 months after nerve implantation.

Conclusions

The implanted nerve regenerated a large amount of free nerve endings, which helped to regenerate simple Meissner’s corpuscles via governing previously degenerated corpuscles.

The versatility of the anterolateral thigh flap

In the last two decades, the anterolateral thigh flap has emerged as one of the most popular reconstructive options for multiple body sites. Based on a perforator flap harvest concept, the flap encompasses the advantages of versatility, pliability, and potential for composite tissue replacement. Although numerous anatomical variations exist, these are well-described, and flap safety remains uncompromised if certain anatomical boundaries are respected. Careful preoperative planning and identification of perforators remain the cornerstone of successful flap harvest. Once perforators are identified, variations in skin paddle design allow for multiple skin paddle configurations, central or eccentric orientations, and custom-made flaps tailored to fit almost any defect. A suprafascial dissection allows for "ultra-thin" flaps ideal for folding, tubing, or packing purposes. The versatility of the lateral circumflex femoral artery branches can be exploited to include muscle, iliac bone, tendon, fascia, or nerve in extended designs. The anterolateral thigh flap is currently the frontline choice for head and neck reconstruction, including intraoral, mandibular-maxillary, tongue, and facial defects, and is gaining popularity in abdominal and pelvis reconstruction. It can also be used as a pedicled flap in phallus or perineum reconstruction. More recently, the flap has proved to be extremely useful in skin resurfacing and even functional reconstruction in traumatic wounds. This review summarizes the anatomy, planning, flap harvest, donor morbidity, and clinical applications of the anterolateral thigh flap. An algorithm is proposed that facilitates a clear, problem-based approach for the use of this versatile reconstructive option.

The prefabricated pedicled anterolateral thigh flap for reconstruction of a full-thickness defect of the urethra

The ideal reconstructive method for a urethral defect should provide durable, stable coverage, a patent tube passage for voiding and ejaculation, and a natural aesthetic contour, while simultaneously minimising morbidity of both the recipient and donor sites. Since the first report of the anterolateral thigh flap in 1984, this has become one of the most commonly used flaps for the reconstruction of various soft tissue defects. In this report we present our experience with a prefabricated anterolateral thigh flap used for a full-thickness defect of the urethra. The flap was used in a 40-year-old male patient with a defect located on the proximal penile region, including full-thickness urethra and ventral penile skin measuring 2.5x4 cm after delay and prefabrication. To the best of our knowledge this is the only report in the literature to date of an anterolateral thigh flap being used for a urethra defect. The authors conclude that with its evident structural and cosmetic advantages, the anterolateral thigh flap can be considered an excellent and ideal flap option for selected defects of the urethra.

Innervated island pedicled anterolateral thigh flap for neo-phallic reconstruction in female-to-male transsexuals

Many techniques have been described to create an aesthetic and functional neo-phallus after penile amputation or in female-to-male transsexuals. Microsurgical free-flap phalloplasty seems to be the preferred method of penile reconstruction. For many years the radial forearm free flap has been considered the best procedure, but other flaps have been attempted to minimize donor site morbidity and optimize outcome. Pedicled flaps are considered to be reliable and to decrease the risk of total failure. Recently, a one-stage non-microsurgical technique was described for phallic reconstruction in a young male patient. We report successful total phallic reconstruction in a female-to-male transsexual patient using an island pedicled anterolateral thigh (ALT) flap. Urethral reconstruction was left as a possible further procedure due to patient's preference. A malleable soft silicone penile prosthesis was inserted within the flap and the lateral cutaneous femoral nerve stump was sutured to the dorsal clitoris branch from the pudendal nerve for flap sensation. After 6 months, the patient demonstrated successful aesthetic and functional reconstruction referring to satisfactory sexual activity. To our knowledge, this is the first report of an innervated island pedicled ALT flap used for female-to-male penile reconstruction in a transsexual patient. The pedicled ALT flap may be a reliable option to avoid visible scarring at the donor site on exposed parts of the body, and reduce the risk of total flap failure from microsurgical procedures for reconstruction of a neo-phallus in this increasing population of patients.