Surgical techniques of phalloplasty in transgender patients: a systematic review

Abstract

Gender confirmation surgery has a crucial role among transgender individuals. Phalloplasty is a procedure that uses flaps for phallic shaft creation. Flaps can be classified in free flaps or pedicle flaps and can be obtained from different donor sites such as forearm, thigh, abdomen, groin, and leg, and upper back.We conducted a systematic review about surgical flaps for phallic shaft creation in transgender patients.A systematic review was conducted on PubMed/MEDLINE, Cochrane Clinical Answers, and Cochrane Central Register of Controlled Trials databases without timeframe limitations. Exclusion criteria included articles that reported phalloplasty on patients other than transgender, as well as other surgical techniques such as urethroplasty, vaginectomy, hysterectomy and studies focused on psychosocial outcomes. Two hundred twenty-eight potential articles were identified in the initial search. Forty-one studies fulfilled the inclusion and exclusion criteria. Surgical flaps for phallic shaft creation in transgender patients were reported on 1,391 cases. Microsurgical flaps were the most common (24 of 33). The flap technique most frequently described was radial forearm flap (15 of 33) followed by Anterolateral thigh flap (7 of 33), Latissimus dorsi flap (5 of 33), abdominal flap (4 of 33), fibular flap (3 of 33), and groin flaps (3 of 33). The literature on surgical flaps for phallic shaft creation in transgender patients reflected how challenging the reconstruction of the phallus is. In summary, there is no universal choice of flap that could be applied to every patient. Therefore, the surgical approach must be chosen considering surgeon experience, physical examination, and patient desire. We hope this review supports future studies on surgical flaps for phallic shaft creation in transgender patients.

Thinking outside the box: Alternative techniques for gender affirming phalloplasty

“…What is evident is the frequency at which the RFFF is utilized in phalloplasty, followed by the ALT pedicled flap. [4][5][6]9 Given the lack of outcomes data, determining the most efficient, safe, and reliable means is an unattainable task. What the existing literature does imply is the need for a tailored, patient centered approach in which the surgeon and patient consider all factors involved in making this decisiontissue available based on anatomic features and habitus, the desired size of the phallus, ability to conceal the donor site, and most importantly, the willingness to accept the complications associated with all techniques.…”

“…Based on the literature that exists, it is impossible to draw a conclusion stating complete superiority of one technique over another. What is evident is the frequency at which the RFFF is utilized in phalloplasty, followed by the ALT pedicled flap 4–6,9 . Given the lack of outcomes data, determining the most efficient, safe, and reliable means is an unattainable task.…”

“…1 Arguably, the most performed or widely accepted technique is that of radial forearm free flap (RFFF). 1,[4][5][6] In this technique, the soft tissue is transferred from the forearm along with its vascular supply (radial artery, vena comitantes, cephalic vein) and neural components (lateral and medial antebrachial cutaneous nerves). With the inclusion of these components, a sensate phallus and urethra can be constructed.…”

„Wahl der Lappenplastik zur Phalloplastik – was ist zeitgemäßer Standard“ – Konsensus-Bericht der deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße

“…Die Radialislappenplastik ist gegenwärtig die am häufigsten verwendete Lappenplastik zur Phalloplastik [15,18,19]. Ihre vergleichsweise geringe Dicke und Formbarkeit sowie die gute Innervation sind wichtige Vorteile, der auffällige Hebedefekt der große Nachteil [20][21][22][23][24].…”

30 Years of Experience in Musculocutaneous Latissimus Dorsi Flap Phalloplasty with Reinnervation: Optimal Principles

“…10,11 Recently, the phalloplasty method using the latissimus dorsi flap (LDF) has attracted interest as evidenced by frequent publications and presentations by colleagues from various countries. 12,13 However, the radial forearm free flap and anterolateral thigh flap methods were dominant. The authorship of this method of phalloplasty using an LDF in these publications is not definitely cited and is mainly attributed to Perovic.…”