The anatomy of forearm free flap phalloplasty for transgender surgery

Abstract

Transgender surgeries are becoming more frequent and visual interpretation of anatomy is essential for both surgeons and patients. Since the forearm free flap phalloplasty was introduced in 1984, it has been known to provide reliable cosmetic and functional results for transitioning men compared with phalloplasty by different flaps. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. The forearm free flap consists of the anterior forearm skin, subcutaneous tissue, fascia containing the radial artery as the perforator and its venae comitantes, cephalic and basilic veins, and lateral and medial antebrachial cutaneous nerves are demonstrated in relation to the surgically derived flap. Song's forearm free flap phalloplasty requires two surgical stages with a three-month interval between the stages: prelamination of a neourethra and construction of a neophallus. The neophallus created by forearm flap phalloplasty is reported to achieve acceptable aesthetical and psychological satisfaction, appropriate size and shape, and satisfying sexual intercourse. Despite increasing experiences in gender confirming surgery with modifications made by many authors, urethral complications including fistula and/or stricture formation are the leading causes of reoperation. The poor esthetic outcome of the forearm donor site and a decrease in rigidity of the neophallus are the main limitations. Illustrations of anatomy help inform surgical choice and understanding of risks and benefits by patients. The anatomy of the free forearm flap phalloplasty supports creation of a neophallus for transsexual anatomy revision. Clin. Anat. 31:145-151, 2018. © 2017 Wiley Periodicals, Inc.

Primary Use of the Deep Inferior Epigastric Pedicle for Free-flap Phalloplasty: Rationale, Technique, and Outcomes

“…Though optimal recipient vessel selection is crucial for any free-flap reconstruction, [18][19][20][21][22][23][24] this topic has been neglected in most phalloplasty reports, 25 which only describe the FA and GSV as recipient vessels. 8,10,11,15,[26][27][28][29][30][31] In one of the only available studies discussing alternative recipient vessel choices, 25,39 Danker et al 25 discuss the DIEV's reliability as an adjunct to the GSV for venous outflow, with improvement of outcomes after adding the DIEV. From our literature search, no reports have described phalloplasty outcomes using the DIEV as the primary source of venous drainage.…”

“…Another important advantage of using the DIEA instead of the FA as the recipient artery is the DIEA pedicle’s reliably adequate length, resulting in rare need for interposed veins grafts, which are often needed to bridge distance between the flap’s pedicle and the FA. 30 Such grafts can contribute to complications such as neointimal hyperplasia, and anastomotic pseudoaneurysm or blowout from high-pressure flow. Although such issues are not commonly reported, our group has cared for a patient referred for postphalloplasty symptomatic femoral pseudoaneurysm and high-pressure flow through an arterialized vein, which presented as symptomatic groin pain and visible pulsations over the pseudoaneurysm.…”

The evolution of transgender surgery

“…One patient's surgery was complicated by the development of a fistula, however. These researchers popularized the ‘tube‐within‐a‐tube’ radial forearm free flap (RFFF) which is often considered the current gold standard procedure, providing reliable functional and cosmetic results (Kim et al ). The two‐step staging approach to this procedure, that is, phalloplasty followed by urethroplasty, has captured great attention.…”

“…The difficulty of the urethroplasty after phalloplasty procedure is notably by cause of the poor blood supply of the neourethra (Santucci, ). However, this technique reduces the number of urological complications, offers better wound healing, and improves the appearance of the neophallus (Garcia et al ; Kim et al ). Notwithstanding, modifications to the basic one‐stage technique is commonly used to reduce the risk of complications (Kim et al ; Kim et al ).…”

Phalloplasty – Sensate radial forearm free flap for creation of neourethra and neophallus in gender affirmation surgery: A case report

“…With a growing number of requests for gender affirmation surgery, it is imperative to understand the intricacies of the same. The aim of phalloplasty is to construct an aesthetically acceptable neophallus, ability to void urine while standing, tactile and erogenous sensation and rigidity sufficient for sexual activity [4]. The RFFF is considered a good option as it can achieve these goals.…”