As plastic surgery has evolved over the years, Phalloplasty the procedure has come a long way to where it is today. Complicated ridden multistage tube pedicles which were popular earlier are now replaced by forearm flaps with the advent of microsurgery. It is now also quite possible to reconstruct aesthetically pleasing glans as well which meets both aesthetic & functional desires of patients. However, there still are complications encountered in the reconstructive effort which includes urethral stricture, urethral fistula, flap failure & stiffener related problems.
Why Undergo Phalloplasty Surgery
It is one of the most enduring dreams in medicine so as to possibly replicate or replace human organs which have been lost to disease or trauma. Phallus, which is symbolic of manhood, has however received far less attention than the breast, heart, liver or kidney, possibly just because one can survive without a penis. Another reason which is possible is that function of this organ almost appears to be magical by the way it is able to respond to changes in emotion & environment. Moreover, unlike many other organs, cadaveric transplantation seems to be desecrating. With plastic surgery trying to replace like with like, real phalloplasty would only appear to be a dream. Nevertheless, this, in any case, does not undermine the importance of efforts to reconstruct as perfect a phallus as is possible with materials that are available; perfection being not just in form but in function as well.
Indications for Phalloplasty Surgery
Though most phalloplasty cases predominantly consist of gender reassignment cases, indications for this plastic procedure are not limited to this group of patients anyway. Some main indications to opt for phalloplasty procedure are listed below.
- Penile Hypoplasia or Micropenis
- Congenital Absence, Hypoplasia or Malformation
- Epispadias / Ectopia Vesicae Complex
- Avulsion Injuries
- Mutilating Trauma
- Road Traffic Accidents
- Heavy Moving Machinery Accidents
- Blast Injuries
- Improvised Explosive Device Injuries
- Mine-Blast Injuries
- Criminal Mutilations
- Self Inflicted Penile Amputations
- Sexual Partners-Inflicted Injuries
- Drug Addicts
- Mentally Incapacitated Patients
- Ambiguous Genitalia
- Female to Male Transsexuals
- Gender Identity Disorder
- BXO – Balanitis Xeroderma Obliterans
- Necrotizing Fasciitis
- Penile Loss following Tumor Extirpation
- Circumcision-Related Injuries
Goals of Phalloplasty Surgery
- Phalloplasty should be a single-stage procedure which can also be reproduced.
- It should involve a competent neo-urethra so as to allow patients for voiding while standing.
- It should also ideally return both erogenous & tactile sensibility.
- It should have enough bulk to tolerate insertion of the stiffener.
- Results should be aesthetically acceptable to patients.
- Phalloplasty procedure should cause minimal scarring.
- There should be no functional loss in the donor area.
Patient’s perception of normal form & function is extremely relevant. Patients are generally looking for a scrotum, glans, rigidity & an aesthetically appealing appearance while being nude or wearing a tight swim suit.
Phalloplasty Surgery Techniques
Many different techniques have been utilized over the years so as to reconstruct the penis in order to achieve the goals mentioned above. With advancements in plastic surgery, especially with the advent of microvascular surgery, the bar for expected goals has constantly been rising. Various methods utilized for phalloplasty surgery are mentioned below.
- Random Pattern Flaps – These are tubed abdominal flaps which are used for de novo fabrication of penis. It usually undergoes multiple stages before formally being fashioned into a phallus. Although used for many years, random pattern flaps are associated with a prolonged stay in hospitals & high rates of flap failure. Additionally, aesthetic & functional results are also sub-optimal. Since most complications of this technique are related to urethroplasty, several surgeons have attempted to perform phalloplasty & urethroplasty by using abdominal skin flap & bladder / buccal mucosa graft. Even though complications are fairly common to this technique, it, however, creates a phallus of reasonable shape & size.
- Pedicled Flaps
- Groin Flap – Groin flap was first introduced for penile reconstruction in 1978. However, necrosis of distal part of the flap and/or other complications were found to occur in many cases. However, this procedure does not comply with modern goals of phalloplasty but may still play a role in cases where other complex options are not at all possible. Various modifications to groin flaps have also been tried. In order to add rigidity to neophallus, a composite flap including lateral groin skin flap & iliac crest bone in the entire length is reported to have been tried, based on superficial circumflex pedicle & use of both superficial & deep iliac vessel in order to ensure bone in flap & well-vascularised extended skin.
- Anterolateral Thigh Flap – Also known as ALTF, anterolateral thigh flap is a sensate flap for phalloplasty. Lateral cutaneous femoral nerve stump is sutured to dorsal clitoris branch from pudendal nerve in this procedure for flap sensation. Two-point discrimination of about 2.5 cm has been demonstrated after six months following surgery. Single stage phalloplasty utilizing ALTF technique employing tube in tube design for urethroplasty has also been performed in patients. Partial or complete penile loss reconstruction with pedicled ALTF has also been successfully performed as phalloplasty treatments. However, in all cases, urethra was designed through a tube within a tubular fashion. Moreover, all flaps have been found to survive completely. Urethral continuity was effectively restored in a single stage with a small percentage of fistula rate in more than half the cases.
- Island Tensor Fascia Lata Flap – Utility of Island TFL Flap has been aptly demonstrated mostly in female-to-male transsexual phalloplasty with good success rates & is presently recommended as a safe sensate flap procedure which leaves less conspicuous donor scars.
- Free Flaps
- Radial Forearm Free Flap – This has become a primary option for phalloplasty surgery for most reconstructive operations around the world since the introduction of Chinese Flap design using RFFF in 1984. RFFF is presently considered as gold standard for phalloplasty when compared to other flaps. Ulnar hairless part of the forearm is commonly used to reconstruct the urethra in RFFF technique. Urethral part of the flap can also be distally extended in a tongue shape for glans as proximally to give an adequate neo-urethral length for anastomosis. Phallourethroplasty is generally performed by rolling flap in the tube-within-tube pattern. The advantage of RFFF is the potential it holds for customizing flap to individual requirement, especially so in male patients who have suffered avulsion injuries. However, main problems associated with RFFF include a high number of initial urinary fistulas, forearm hair causing urethral obstruction, the need for stiffener or prosthesis, limitation in size of available forearm skin & residual scar on forearm donor site. Some phalloplasty surgeons also feel that there is a loss of phallic girth resulting from tissue atrophy rendering phallic contour which is cosmetically unsatisfactory to patients.
- Donor Site of RFFF – Although this is an extremely reliable technique employed for the creation of a normal looking penis & scrotum, full functionality is however achieved through a minimum of two procedures. Patients are able to void while standing & in maximum cases are also able to experience sexual satisfaction. Long-term follow-up studies have revealed good results both in term of flap survival & satisfaction among patients. However, even when most patients have reported psychological & physical satisfactions, they should be clearly informed that RFFF procedure can seldom be completed in a single stage & is having high rates of complications including about 25 percent for flap associated complications & about 64 percent complications relating to urethroplasty.
- Modifications of RFFF – Various modifications of RFFF are also available. Prefabricated flap with tube graft is a technique which is less complicated & has resulted in lower rates of fistula. It is reported that RFFF phalloplasty with urethral prefabrication has not witnessed any urethral stricture or fistula. Although RFFF design incorporating urethra in the centre of flap improves vascularity of the segment, it takes away the advantage of hairless ulnar skin which is typically used for urethroplasty used in the Chinese flap design apart from generating a propensity to develop meatal stenosis. Another design variation of RFFF incorporates a centrally located neourethra which is in continuity with the neo glans. This also ideally eliminates the circumferential metal suture line & meatal stenosis problems without sacrificing on phallic length.
- Osteocutaneous Radial Forearm Free Flap – This technique was originally introduced in order to give the advantage of RFFF phalloplasty without the need for any additional stiffeners. This method has reported 40 – 50 percent urethral fistula rates & about 20 percent urethral stricture problems. A significant amount of donor forearm morbidity has been reported in about 9 percent of the cases & which include radius fracture. However, no penile fracture have been reported & more than 70 percent of the cases report excellent stiffener function during intercourse which was provided by radial segment including the flap. Osteocutaneous radial forearm flap is a two-stage operation & has also been described as a prefabricated sensate flap. Ulnar forearm free flap has been described by experts as an alternative to RFFF so as to obtain more of non-hair bearing skin & thereby reducing problems associated with hair growth in neourethra.
- Lateral Arm Free Flap – This technique gives an advantage of a relatively inconspicuous donor site which also does not compromise the size of the neophallus. In consonance with the concept used in two-staged RFFF phalloplasty, this method involves a prefabricated neourethra within lateral arm & has been described to permit coexistence of erectile prosthesis alongside fully vascular urethra. However, LAFF patients require at least 5 procedures on average in order to complete phalloplasty. Results moreover are complication free for most cases beyond the first year following operation. Neophalluses have also been found to effectively attain erogenous & tactile sensibility while inflatable prosthesis allows penetration during a sexual intercourse.
- Osteocutaneous Free Fibula – This method was first described for phalloplasty in the year 1993. Main advantages of gastrocutaneous free fibula lie in rigidity without any need of additional stiffener & a long vascular pedicle allowing end-to-side anastomosis of the flap to femoral artery along with a donor site location which can be covered with socks. Long-term follow-up of this phalloplasty technique has also shown good results where the fibula has proved to be viable even after displaying 9 years of reconstruction neural integrity confirmed on sensate flaps & most patients reporting pleasurable sexual intercourse & orgasm. However, experience with urethral prelamination of gastrocutaneous free fibula has not been very promising with high flap failure rates & urethral complications.
- Anterolateral Thigh Free Flap – ALTEF technique has been described as successful with consistency in shape of the neophallus & high percentage of patient satisfaction. Moreover, the flap can be sensate & an erectile prosthesis can also be easily implanted.
- Latissimus Dorsi Free Flap – LDFF is another phalloplasty procedure which has successfully used in both children & adults for constructing good-sized no phalluses. The size of phallus constructed through this method generally is 14 – 18 cm long in adults & 13 – 16 cm in children. The circumference of neophallus achieved using this flap usually ranges between 11 – 15 cm in adults & 10 – 12 cm in children. This is a very reliable phalloplasty technique in terms of flap survival. It is also possible to close donor sites primarily in LDFF in most cases & scars are located in a hidden location. Urethroplasty is generally performed at a later stage in LDFF using buccal mucosa. Even though an inflatable penile prosthesis can be used in LDFF, there is a peculiar advantage of re-innervated LDFF where thoracodorsal nerve anastomosed to ilioinguinal nerve provides the ability to achieve what is called a ‘paradox erection’ for sexual activity when the patient voluntarily contracts the muscle & thereby avoids any use of stiffeners.
- Free Scapular Flap – This technique for penile reconstruction was first described in 2003. All free scapular flap surgeries have been found to remain viable postoperatively over a 5 year follow-up period. No cases of urethral fistula, stenosis or prosthesis infection or extrusion were reported. Free Scapular Flap phalloplasty surgery is recommended as an ideal technique which achieves satisfactory appearance & function for penile reconstruction due to the reliable blood supply, an adequate amount of tissue & acceptable donor site morbidity.
Prior attempts at phalloplasty were only directed towards the reconstruction of the form of male genital organ & urethral reconstruction was subsequently added as a secondary goal. Since the construction of neourethra has frequently led to strictures & fistulas, some surgeons have even abandoned progressive attempts. Understanding of patient’s requirements however improved & urethroplasty was finally included as a primary goal of phalloplasty. Different techniques have subsequently been described for reconstruction of the urethra. Prefabrication, prelamination, tube-in-tube or even separate flaps have been successfully used for reconstruction of the pendulous urethra. Local vaginal or labial flaps, separate flaps, free skin or mucosal grafts & extra long urethral component of phalloplasty flap have been described for reconstruction of fixed urethra. However, improved outcome has been achieved by use of prelamination techniques, but they are found to increase the number of stages required to complete the phalloplasty procedure.
Reconstruction of glans penis has now become an important portion of phalloplasty patient’s wishes for a normal & aesthetic looking penis. This is a procedure which involves raising a circumferential de epithelializing skin flap at level with the proposed coronal ridge which is subsequently rolled up while the free edge of the flap is sutured to its own base in order to form a ridge. Following this, the raw area is covered with graft. Split-thickness skin graft is able to produce a normal-looking coronal sulcus than what a full-thickness skin graft could. While providing the best results, this technique has been regarded as an ideal method for coronal ridge & sulcus construction.
Risks & Complications of Phalloplasty Surgery
Regarded as one of the most complex reconstruction procedures which plastic surgeons are called upon to perform, total phalloplasty involves replicating form & function of a phallus which is truly unique. Along with this fact, sub-optimal material availability & emotional overlay which is associated with phallus reconstruction, this task assumes a Herculean responsibility for plastic surgeons. Therefore, it is no wonder that phallus reconstruction is fraught with a plethora of complications. Although survival of the flap & appearance is primarily the first requisite to successful phallus reconstruction, it is also the function which is both urinary & sexual, which will eventually determine success or failure.
- Realistic Expectations from Phalloplasty Reconstruction – It is important that patients should be counseled & made to understand what they should expect & what not to expect from phalloplasty surgery results. In cases where phalloplasty fails, most of the time it is the patient’s local tissues which are more scarred than before, & thereby limiting the scope any worthwhile attempts in future. Moreover, alternative procedures are simply lifeboats which can never deliver similar results as was expected from the first choice of procedure. This point also needs to be emphasized & discussed with the patient prior to the surgeon agreeing to perform phalloplasty reconstruction procedure.
- Flap Failure – Survival rates of free flap have gradually increased to 98 percent while pedicled flaps rarely show any total flap loss. However, flap survival is of paramount importance as the even partial loss is found to lead to urethral fistulae, exposure of implant, infection & thrombosis of pedicle which eventually leads to total flap loss. Latissimus dorsi flap, lateral arm & radial forearm have reported highest rates of survival amongst the most commonly performed free flap procedures. Partial & total flap failure rates are most commonly seen in Osteocutaneous free fibula phalloplasty procedure as compared to other flaps. ALTF phalloplasty has impressive survival rates amongst pedicled flaps with an added advantage of hidden donor site while obviating the need for microsurgical setup.
- Urethral Fistula – Suprapubic abdominal flaps display a high rate of a fistula which is almost 55 percent while RFFF phalloplasty procedure has reported fistula rates which are ranging between 22 – 68 percent. These fistulae are found to be more common where the urethral anastomosis is located proximally. However, reduced rates of fistulae are when local flaps are used for urethroplasty in gender reassignment cases, in addition to RFFF phalloplasty procedures. These statistical figures also hold true for OCRFFF phalloplasty procedures. Prelaminated OCFF phalloplasty procedures have fistula rates ranging between 15 – 22 percent. Surprisingly, pedicled flaps like ALTF & extended pedicle groin flaps have lowest fistula rates of about 10 percent.
- Urethral Stricture – Phalloplasty procedure with suprapubic abdominal flap have the highest urethral stricture rates of about 64 percent. Prelaminated OCFF or RFFF stricture rates vary between 17 -31 percent with procedures associated with OCFF moving towards the higher range. Urethral stricture rates are much lower in RFFF urethroplasty cases (2.56%) or extended pedicle groin flap phalloplasty cases (4.15%) & which are quite similar to urethral fistula rates. Mean stricture length is generally around 3.5 cm in length. Stricture locations commonly include anastomosis (most commonly), phallic urethra, meatus, fixed part & at multiple sites. Different forms of urethroplasty which are normally used as a treatment of urethral strictures following phallic reconstructions include two-stage urethroplasty, pedicled flap urethroplasty, free graft urethroplasty, excision & primary anastomosis, Heineken-Mikulicz principle, meatotomy & perineotomy following urethral reconstruction. The endoscopic incision is also the recommended technique for shorter or less than 3 cm urethral strictures. Rates of stricture recurrence following various treatments are about 61.9 percent.
- Stiffener Related Complications – Combining a completely patent neourethra while trying to achieve sufficiently rigid neophallus which would allow sexual intercourse is a daunting task. Rigidity in neophallus can be achieved by transplanting autologous tissue to be used as stiffeners, or by using external stiffeners or by implanting inflatable or semi-rigid prosthesis. Autologous tissue generally includes cartilage & rib grafts which are sometimes embarrassing by permanently keeping the phallus in a semi-rigid state are also additionally at times complicated by fracture, resorption & even infection & extrusion. Moreover, the prosthesis is also associated with high rates of infection & extrusion. Nearly 30 percent of neophalluses which are inserted with implants are found to develop implant related complications in form of infection or failure of device & which eventually call for high rates of implant removal.
Avoidance of Major Complications
However, phalloplasty procedure has no clear cut indications & a homogenous population of patients. Even decision for using a particular flap cannot be based upon rates of flap survival & functional outcomes alone. Indication for gender reassignment or for loss can also influence flap selection as visible forearm donor site can stigmatize individuals who are transgender. Plastic surgeons starting out with such challenging reconstructions are advised to train with experts before picking up a particular technique. Radial forearm which portrays a reliable anatomy, long pedicle with good caliber of vessels & pliable sensate skin should primarily be considered as the first choice of treatment for most indications. This has been the gold standard for phalloplasty procedures & various other modifications along with this can prove very useful in particular situations. Flap survival rates are also very high with this technique except for the hair-bearing nature fistulae & strictures which are quite common. Moreover, visibility of donor site is also a serious drawback. Other options which find considerable usage is pedicled ALTF which provides a large amount of skin. Moreover, donor site is also well hidden & total flap loss is unlikely since it is a pedicled flap. This is usually thick but can also be successfully thinned by application of liposuction. Sensory recovery in this phalloplasty technique is, however, poorer when compared to radial forearm flap.
- Avoiding High Rates of Urethral Fistulae & Strictures – Persistent high rates of urethral strictures & fistulae are related to a number of factors. Firstly, it may be the urethral segment of the flap which may be lying away from pedicle & therefore may be less vascularised. Secondly, it may the length of the urethral segment which is limited due to overall dimensions of flap & may thus be inadequate for a tension-free urethral anastomosis. Finally, like most flaps are from hair-bearing parts of the body, hair growth within urethra can obstruct urinary flow & result in complications. Reducing these complications will depend to a large extent upon the technique which the surgeon will use. Even when it is improper to generalize, two-stage procedures are found to have lower rates of complications than single-stage phalloplasty procedures. However, in select cases, prelamination with full thickness graft will significantly reduce the rate of phallus reconstruction complications.
Concluding a Successful Phalloplasty Operation
Development of techniques for phalloplasty has effectively paralleled the evolution of plastic surgery, both in terms of popularity & practicability. Tubed pedicled flaps were sensibly followed by RFFF as the standard technique for phalloplasty. Moreover, an osteocutaneous variant of forearm flap & OCFF held several promises including an all-for-one & one-for-all function provided in a single flap. Prefabrications & prelaminations were subsequently introduced in order to reduce rates of urethral complications. Roll of stiffener prostheses was also introduced to assist erection during sexual intercourse. However, the fact is that RFFF method has by far withstood the test of time & is still offering a single-stage technique for total penile reconstruction.
Final Outcome of Single-Stage Radial Forearm Free Flap Phalloplasty
Uncontested space of several conventional free flaps has been effectively challenged in penile implant surgery with the advent of perforator flaps. Similarly, the introduction of ALTF in sensate pedicled format has all of a sudden started replacing RFFF as the best choice of phallus reconstruction. The main advantage of this new-found technique is that the donor site is well hidden within everyday clothing along with no necessity for microvascular expertise required from the surgeon. Earlier, since no sensibility in phallus was expected to be considered, no stiffeners were used in pedicled flaps as these were regarded to be techniques featuring few indications for phalloplasty. However, things have changed & innervated pedicled ALTF has proved to be a workable proposition & has also proved to effectively solve the problem of stiffener retention.
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