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We present a salvage procedure to reconstruct the neo-urethra after partial flap necrosis occurring in free radial forearm flap (RFF) phalloplasty for sex reassignment surgery. Two cases of tube-in-tube phalloplasty using a free sensate RFF are described in which partial flap necrosis occurred involving the complete length of the neo-urethra and a strip of the outer lining of the neo-phallus. Neo-urethra-reconstruction was performed with a second RFF from the contralateral side providing well-vascularized tissue. No flap-related complications were observed. Twelve months postoperatively, both patients were able to void while standing. A satisfactory aesthetic appearance of the neo-phallus could be preserved with an excellent tactile and erogenous sensitivity. Using this technique, we successfully salvaged the neo-urethra and reconstructed the outer lining of the neo-phallus © 2013 Wiley Periodicals, Inc. Microsurgery 34:58–63, 2013.
The free sensate radial forearm flap (RFF) is widely considered the standard technique for phalloplasty in female-to-male sex reassignment surgery. Different case series have confirmed its feasibility, reliability, and good aesthetic and functional results.[1-4] Major goals, namely the ability to urinate while standing and an appealing aesthetic appearance with protective and erogenous sensitivity, may be reached in a one-stage procedure. The implantation of an erectile prosthesis for sexual intercourse is usually performed after protective sensitivity of the neo-phallus is regained 6–12 months postoperatively.
Possible complications comprise early and late anastomotic revisions due to venous, arterial, or combined thromboses, partial or total flap loss, and urological complications such as fistulas and strictures, which frequently require multiple urological revisions.[2, 6-9]
Multiple designs for the RFF have been described, with the Chang- and the Gottlieb-designs being the most frequently used for tube-in-tube phalloplasty.[10, 11] Modifications, such as prelamination of the urethra using split-thickness skin grafts (STSG), full-thickness skin grafts (FTSG), or vaginal mucosa grafts have been performed.[8, 9, 12]
We describe two cases of partial flap necrosis after free RFF-phalloplasty (Chang-design), which led to a full-length necrosis of the neo-urethra. For neo-urethra-reconstruction, we performed a second free RFF from the contralateral side in a modified Chang-design. Furthermore, we reviewed the literature for complications after RFF-phalloplasty.
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Partial flap necrosis is reported to occur in 7–11% of phalloplasty cases.[1-3] The largest series published by Doornaert et al. showed a rate of 7.2% (23 out of 316 cases) with a higher incidence in smokers, patients who insisted on large-sized neo-phalluses, and after anastomotic revision. In 15 out of these 23 patients (63%), debridement and secondary closure or skin grafting was necessary. Partial flap necrosis frequently affects the radial and ulnar flap borders, which are both directly involved in the formation of the neo-urethra in the Chang-design. This may lead to a necrotic or exposed neo-urethra and consequently to urethral dysfunction. Possible contributing factors to partial flap necrosis in a tube-in-tube setting are the flap width and the need for double bending of the flap. Additionally, postoperative flap-swelling may cause venous congestion. In the presented cases, additional risk factors which may have contributed to the occurrence of the partial flap necrosis are a heavy smoking history in both cases, as well as an osteogenesis imperfecta and arterial hypertension in the second case. In the first case, the simultaneously performed vaginectomy led to an increased operation time and blood loss, which might have further increased the risks. This led us to modify our approach by performing vaginectomy together with hysterectomy and adnexectomy. The partial flap necrosis resulted in a complete loss of the neo-urethra and a partial loss of the outer lining of the neo-phallus on the ventral side. A second free RFF in a modified, shortened Chang-design provided well-vascularized tissue for reconstruction of both elements. Instead of a second free flap for immediate neo-urethra-reconstruction, a tubed skin graft could be used, although the risk for urethral strictures due to graft contracture may be increased compared to vascularized tissue. Moreover, the decreased circumference due to partial loss of the outer lining and the loss of flap volume is not addressed. If no immediate neo-urethra-reconstruction is considered, a primary urethrostomy has to be performed. To our knowledge, no data concerning the specific problem of total loss of the neo-urethra and its treatment after RFF-phalloplasty in sex reassignment surgery is available in the literature. Harrison initially described the usage of the free RFF for urethral reconstruction in hypospadia. Dabernig et al. presented a series of nine patients who underwent urethral reconstruction and in some cases simultaneous glans penis reconstruction with a tubed RFF: three patients after subcutaneous penectomy for penile cancer and six patients after failure of primary urethra-construction in phalloplasty for sex reassignment surgery. Of these six phalloplasties, three were bilateral groin flaps and three abdominal flaps. The indication was recurrent strictures after multiple corrective procedures. All patients had satisfactory skin envelope of the neo-phallus. Two patients suffered strictures at the site of urethral anastomosis, requiring revision procedures with local flaps. At 6 months, all patients were able to urinate while standing. In order to prevent partial flap necrosis in RFF-phalloplasty, alternatives to the Chang-design may be considered. As a modification to the Chang-design, in which the neo-urethra is constructed with the ulnar part of the flap, the Gottlieb-design may be chosen, in which the neo-urethra is constructed with the central part of the flap. The flap width and the need for double-bending of the flap, however, are not altered. Additionally, most patients do not accept an additional scar on the dorsal, most visible part of the neo-phallus. Another possibility to reduce the necessary flap width and double-bending consists of neo-urethra-prelamination with STSG, FTSG, or vaginal mucosa.[3, 8, 9, 12] The partial flap necrosis rate of prelaminated neo-urethra varies in most case series. A significantly lower rate in partial flap necrosis, however, does not clearly appear in the literature review. Küntscher and Hartmann reported no occurrence in 15 cases of RFF phalloplasties with prelaminated urethra (FTSG). In contrast, Schaff and Papadopulos presented a large case series of phalloplasties with prelaminated urethra (vaginal mucosa or STSG) with a partial flap necrosis-rate of 16% (5 out of 31 cases) in free fibular flaps and 16.6% (1 out of 6 cases) in free RFF. Fang et al. compared the traditional tube-in-tube flap and the free RFF with a prelaminated urethra (vaginal mucosa). Partial flap necrosis occurred in 6 out of 28 patients (21%) in the traditional flap group, while none was found in the 28 patients of the prelaminated group. In a recent study, Song et al. reported on 3 partial flap necrosis (15.8%) of their 19 free osteocutaneous RFF with prelaminated urethra (FTSG).
The literature review of urological complication shows a high incidence of strictures and fistulas. The benefits of urethra prelamination have not been clearly demonstrated. Fang et al. reported strictures in 14% (4 out of 28 cases) and urethrocutaneous fistulas in 79% (22 out of 28 cases) of patients after the classic tube-in-tube design. With prelaminated urethra, strictures occurred in 11% (3 out of 28 cases) and urethrocutaneous fistulas in 57% (16 out of 28 cases). All the fistulas occurred at the junction between the pars fixa and the pars pendulans of the neo-urethra and no fistulas were observed in vaginal mucosa prefabricated penile neo-urethra. With the classic tube-in-tube free RFF, Doornaert et al. reported on urological complications in 40% of their patients (127 out of 316 cases). Fistulas were detected in 25% (80 out of 316 cases), strictures in 6% (20 out of 316 cases), and a combination of both in 8.5% (27 out of 316 cases). Spontaneous healing occurred in 66% (53 out of 80 cases) of the fistulas, while 42.5% (54 out of 127 cases) of the patients with urological problems needed further surgical procedures to obtain urethral function. Küntscher and Hartmann found an incidence of 53% out 15 cases for fistulas at the urethra-anastomosis in their series of free RFF with a FTSG-prelaminated urethra. Using a FTSG for prelamination of a osteocutaneous-free RFF in 19 phalloplasties, Song et al. observed one fistula (5.3%), five strictures (26.3%) and a combination of both in nine cases (47.4%) when suturing the urethral anastomosis in a multilayer fashion including perineal muscle flaps to bolster the anastomosis. In a series of 31 free sensate osteofasciocutaneous fibula flaps and 6 RFF with prelaminated urethras, Schaff and Papadopulos presented 32.4% out of 37 cases involving urethral strictures and 16.2% (6 out of 37 cases) involving fistulas. Five out of the six fistulas originated at the connection site of the lengthened urethra to the prelaminated urethra. In both our cases, urological complications occurred leading to open urethroplasties. Twelve months postoperatively, both patients were able to urinate through a competent neo-urethra while standing. We do not think that the occurrence of urological complications is related to the salvage-procedure but rather reflects the generally high incidence in phalloplasties.
Donor-site morbidity after the RFF harvesting is considered a major drawback. Incomplete graft-take after donor site coverage with STSG or FTSG, functional impairment, prolonged swelling of the hand and sustained paresthesia in the hand, and neuroma formation have all been described.[15-17] Moreover, the scar on the forearm is frequently perceived as a stigma for transsexuals. In the presented cases, no donor-site complications or morbidities were encountered. The bilateral scars were not perceived as a major problem by either patient.
Summarizing, in two cases of complete loss of the neo-urethra after total phalloplasty using a free sensate RFF in the Chang-design, we successfully salvaged the neo-urethra and reconstructed the outer lining of the neo-phallus using a second RFF. Twelve months postoperatively, both patients were able to urinate while standing. The aesthetic appearances were rated excellent and good, respectively. Sensitivity was not impaired, as both patients reported an excellent tactile and erogenous sensitivity. In our experience, the presented technique is a valuable alternative to primary urethrostomy in such cases.
It is clear that additional techniques for eliminating or at least mitigating partial flap necrosis as a major drawback of the standard tube-in-tube phalloplasty are needed. We propose the primary usage of a flap-in-flap technique, e.g. the combination of a free or pedicled sensate anterolateral thigh flap for neo-phallic construction and a free RFF or a pedicled groin flap for neo-urethral construction. Since only few reports on flap-in-flap approaches are presently available,[18, 19] the feasibility and safety of such a technique needs further assessment.