The anatomy of abdominal flap phalloplasty for transgender surgery

Abstract

Abdominal flap phalloplasty is surgical construction of a neophallus using a pedicled abdominal flap for patients transitioning female to male, for males whose penis is congenitally absent, or lost from trauma. It is an option for trans men whose goals do not require urethroplasty or vaginectomy but would like a phallus suitable for male gender appearance. A prosthesis can be placed for penetrative sexual capability. Surgical text descriptions were enhanced by creation of new anatomic illustrations. Anatomy of donor site and surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. Significant structures of the donor site of the abdominal flap include the superficial external pudendal artery and ilioinguinal nerve that provide the blood supply and sensory innervation to the base of the flap, respectively. As a pedicled phalloplasty procedure, microsurgical anastomosis is not needed. Patients can expect to have tactile sensation but not innate rigidity. The dorsal nerve of clitoris (and sometimes the clitoris itself) is preserved to provide erogenous sensation. Abdominal flap phalloplasty makes it possible to maintain the natural blood supply and innervation to the neophallus. The neophallus created by abdominal flap phalloplasty has the advantage of homogeneous skin color and texture from contiguous skin. Grafting leaves a less stigmatizing horizontal scar running from one side of the pelvis to the other along the lower abdomen. The anatomy of the abdominal flap phalloplasty supports creation of a neophallus for transsexual anatomy revision. Clin. Anat. 31:181-186, 2018. © 2017 Wiley Periodicals, Inc.

Thinking outside the box: Alternative techniques for gender affirming phalloplasty

“…Through the vascular supply of the superficial epigastric system and the superficial external pudendal artery, the tissue of the lower abdomen extending to the labia majora is perfused. This same tissue is innervated superiorly by the ilioinguinal nerve and inferiorly to the level of the clitoris by the pudendal nerve which terminates as the dorsal nerve of the clitoris 20 . Performed in either the supine or modified lithotomy position, the flap is marked from the base of the clitoris superiorly along the anterior abdominal wall inferior to the umbilicus.…”

Partial flap loss in transgender phalloplasty using the anterolateral thigh or forearm - a systematic literature review

“…(B) Specific to RFFFP: (1) Failure to include the critical and sparse proximal radial artery perforators during flap harvest and only relying only on distal perforators [ Figure 4]. (2) Positioning of the flap design that fails to place the radial artery as close to the center of the flap as possible.…”

“…(C) Specific to ALT phalloplasty: (1) Failure to include or the absence of distal perforators. (2) Inability to position the flap distal enough on the thigh allowing adequate pedicle length for transposition while still including an adequate number of perforators to support the volume of tissue harvested. 3Excessive intra-operative thinning or excessive size of flap harvested with tissue take beyond the perfusion capacity of the perfasomes.…”

“…Phalloplasty as a surgical treatment for gender dysphoria was pioneered by Sir Harold Gillies and has been performed since 1946 [1] . Early techniques pre-dated the current era of mainstream microsurgery and relied on adjacent tissue transfer in the form of loco-regional pedicled flaps, typically tubed abdominal flaps [2] . As microsurgical techniques evolved and perforator flap dissection became clinically routine, tissue from more distant locations became available for the construction of a neophallus [3][4][5] .…”

Piloting a Genital Affirmation Surgical Priorities Scale for Trans Masculine Patients

“…The second, phalloplasty, uses a flap to create a phallus, most commonly a radial forearm free flap. 4–7 Urethral lengthening, which can be done as part of either phalloplasty or metoidioplasty, is also an important part of genital affirmation for many men. Extending the urethra to the tip of the neophallus gives patients the ability to urinate while standing.…”