Phalloplasty using the free radial forearm flap

Our experience of phalloplasty using the radial forearm flap in five transsexual cases is reported. The results are disappointing due to the high incidence of complications. We had partial success in two cases, both complicated by a fistula, and complete failure in three cases due to vascular thrombosis.     

Sensory reconstruction in sensate radial forearm flap transfer

The authors treated 14 patients (13 men and one woman), using a sensate radial forearm flap. Their ages at operation ranged from 27 to 67 years (mean: 52 years). Preoperative conditions were amputations in 10 cases, degloving injury in three, and crush injury in one. Reconstructive sites involved the thumb in nine cases, the mitten-like hand in two, the index finger in one, the ring and small finger in one, and the palm in one. In all cases, the radial forearm flap, including the lateral antebrachial cutaneous nerve, was harvested. Sensory evaluation was performed using the moving two-point discrimination test (m-2PD). Sensation in the mid-palmar area of 50 forearms was examined in 25 healthy adult volunteers as a control group. Follow-up periods ranged from 12 to 87 months (mean: 39.6 months). The mean m-2PD of the 14 sensory flaps was 13.2 mm, and the mean of 50 forearms in the control group was 18.08 mm. A statistically significant difference was demonstrated between the sensory flaps and the 50 forearms of the control group. The mean m-2PD was much more sensitive in the innervated radial forearm flaps than in the donor forearm. The results suggested that sensory return in the innervated flaps is influenced not by the donor nerve in the flaps, but by the recipient digital nerve.     

Phalloplasty with free (septocutaneous) fibular flap sine fibula

PURPOSE: The free prefabricated fibular flap has been used as a good alternative to the free radial forearm flap in female-to-male sex reassignment surgery. We describe a new technique of harvesting the flap without sacrificing the fibula. The neophallus is thinner, more elegant, less rigid and able to contain a hydraulic penile prosthesis. MATERIALS AND METHODS: Five biologically female patients underwent reassignment surgery using this technique. Average patient age was 30 years (range 24 to 37) and average followup was 25 months. All patients underwent total hysterectomy, salpingo-oophorectomies, vaginectomy and urethral prelamination 6 months before flap surgery. The lateral calf cutaneous island was raised on the peroneal artery septocutaneous perforators without disrupting the continuity of the fibula. Urethro-urethral anastomosis was done 3 months later. RESULTS: All patients sustained good results with no flap loss. Voiding from a standing position was achieved and the neophallus was esthetically acceptable. Donor morbidity was minimal with no disturbance to ambulation compared to the conventional method, in which the fibula is sacrificed. CONCLUSIONS: The free fibular flap without the fibula is a challenging refinement of neophallus construction that confers benefits to recipient and donor sites. It is a welcomed addition to the armamentarium for neophalloplasty.     

Usefulness of free sensate osteofasciocutaneous forearm and fibula flaps for neophallus construction

Female-to-male transsexuals have been treated by the authors since the 1970's, using different operative methods. Since 1981, these patients have received neophallus construction with free sensate osteofasciocutaneous forearm flaps and, since 1993, with free sensate osteofasciocutaneous fibula flaps. In order to evaluate the usefulness of these flaps, the authors performed, in 24 patients (12 with forearm and 12 with fibula flaps), the following examinations: clinical and radiologic evaluations of the neophallus and its donor site, as well as patient questionnaires. In all patients, subjective findings and clinical examinations showed no significant variations in neophallus size and form. Patients with fibula flaps had better sexual intercourse, although their neophallus sensibility was minor, when compared to the forearm flap patients. Donor-site morbidity was moderate in both groups. On radiologic examination, robust, calcified bone structure, and no fracture of the neophallus bone and its donor site, as well as no instability of the ankle joint (in the fibula flap patients) were found. These findings further support the use of these free sensate osteofasciocutaneous flaps for neophallus construction. In the authors' opinion, it is the patient who must decide which method should be used for neophallus construction.     

前臂游离皮瓣在保存舌功能的半舌再造术中的应用

目的 探讨前臂游离皮瓣在保存舌功能的半舌再造术中的I临床应用.方法 2002年7月至2006年11月,对40例原发灶为舌侧缘且未超过中线的舌癌患者,于舌癌联合根治术同期行吻合血管的前臂游离皮瓣移植修复半舌缺损,部分病例将前臂外侧皮神经与舌神经断端吻合,制备成感觉皮瓣.结果 40例患者伤口均一期愈合,前臂游离皮瓣完全成活.术后随访6个月至4年6个月,平均2年6个月,供、受区均无严重并发症.再造舌外形好,运动协调.吞咽、语音功能接近正常,感觉功能也有不同程度的恢复,临床疗效满意.结论 对于舌癌联合根治术造成的半舌缺损,应用前臂游离皮瓣修复的临床效果满意.重建后的舌功能恢复较为理想.     

The free fascial forearm flap

The unpleasant appearance of the donor site after harvesting a forearm flap limits its use in many centers. In this paper, the author records his experience with a modification of the standard fasciocutaneous forearm flap. Such modification involves the utilization of the fascial component of the flap sparing the skin of the forearm, which is closed as a longitudinal line. This fascial forearm flap (FFF) was used as a free flap in eight cases. All the flaps survived well, and the donor site appearance was excellent. The fascial forearm flap advantages and limitations are discussed with recommendations for further utilization of other fascial flaps.     

The free ulnar forearm flap

Many flaps have been described based on the septocutaneous perforators; these have many advantages for the coverage of soft tissue defects. The ulnar forearm flap described by Lovie is a septocutaneous flap based on the septocutaneous perforators of the ulnar artery. We report the use of this flap in 2 patients who required soft tissue coverage. The ulnar forearm flap has the advantages of thin and pliable skin, constant and large pedicle, and the technical possibility of combination with the muscles, sensory or motor nerve, and ulna. Comparing it with the radial forearm flap, there is no possibility of exposure of flexor tendons, which usually results in the good take of skin grafts. After skin grafting, the donor scar is unnoticeable because of its position on the forearm. This flap is for the coverage of thin defects that require mobility, such as in the extremities or the intraoral region. It also could be used for the coverage of hand or arm defects as a distally or proximally based island flap, respectively.     

Pretransfer expansion of a sensate lateral arm free flap

Tissue expansion as a reconstructive technique has gained widespread popularity in the field of plastic and reconstructive surgery since Radovan reported his original work in Boston in 1976. Reconstruction by free muscle or composite flaps transferred by microsurgery has preceded the use of tissue expansion. However, a combination of both modalities of reconstruction to fulfill particular reconstructive needs has not yet been reported. This article reports a case of a sensate lateral arm free flap that was expanded prior to its transfer to resurface a 12 X 18 cm defect of the ankle and foot in a child, with primary closure of the donor site. The initial successful resurfacing was followed by recovery of sensation in the entire flap over a period of six months, and the static two-point discrimination measured 9 to 11 mm, which was close to that of the corresponding area of the opposite arm. The child has resumed his sports activities with no problems over a one-year follow-up.     

Combination of a total free forearm flap and a sensate local flap for preservation of the shoulder girdle in massive, nonreplantable upper extremity injuries

BACKGROUND: After massive upper extremity injuries, prosthetic use might be complicated by the formation of pressure ulcerations. Especially the coverage with insensate free flaps may predispose the patient for developing chronic ulcerations when using an upper extremity prosthesis. This complication may be reduced when sensate local flaps are used to cover bony prominences. METHODS: A new operative technique is described. RESULTS: Immediate sensate soft tissue coverage improves prosthetic fitting. Successful manipulation of the prosthesis can be quickly achieved with a decreased risk for pressure ulceration. CONCLUSION: This challenging procedure helps to achieve durable and sensate coverage of bony prominences. The use of local sensate tissue to cover bony prominences reduces the risk for pressure ulceration when wearing a prosthesis. Areas where prosthetic use causes only low pressure and shearing forces are adequately covered with free flaps. Immediate sensibility of local flaps allows prosthetic fitting and use as soon as wound healing has occurred. Return to work is thus expedited.     

前臂游离皮瓣移植阴茎再造术式的发展与演变

前臂皮瓣游离移植阴茎再造经典术式由张涤生、高学书等于1984年首先报道，至今仍被国内外广泛采用，并被称为中国方法(Chinese method)。该术式的主要优点如下：①皮瓣供血血管恒定、粗大、蒂长、易与受区血管吻合；②皮瓣面积大、皮下组织薄、易切取与塑形；③再造之阴茎外形较好、可有感觉；④手术可Ⅰ期完成。该术式的皮瓣设计与操作方法如图1所示(见中插4)，其适应证、并发症、优缺点等已写进中外有关教科书，此不赘述。     

Eye socket reconstruction with free radial forearm flap

Deformity of the orbital region and contraction of the eye socket were encountered in 3 patients who in their infancy underwent exenteration of the orbit and postoperative irradiation for the treatment of retinoblastoma. These major problems were attributed to the less-vascularized cicatricial conjunctiva left in place. To solve these disadvantages, a microvascular technique using a free radial forearm flap was adopted. A large permanent eye socket was achieved and depression deformity of the orbital region was corrected in a one-stage operation. This is, to our knowledge, the first report on the use of a free vascularized skin flap for "malignant contracture" of an anophthalmic eye socket. The excellent cosmetic results of this method are demonstrated.     

Radial forearm free flap for soft palate reconstruction

Defects of the soft palate resulting from head and neck oncologic surgery traditionally have been rehabilitated using a prosthetic obturator. In general, the results of soft palate obturation have been satisfactory, with most patients achieving velopharyngeal competence during speech and swallowing. However, soft palate obturators have several disadvantages. Device stability and retention are impaired in patients who are edentulous. In addition, prosthetic obturators cover large areas of sensate mucosa in the hard palate, maxillary alveolus, and oropharynx, contributing significantly to the loss of sensory feedback from the oral cavity and oropharynx. Considerable evidence suggests that sensory impairment within the oral cavity and pharynx results in impaired mastication, deglutition, and articulation. A minority of patients find palatal obturators to be unsatisfactory, secondary to either inconvenience or device discomfort.     

The ulnar artery forearm free flap

The ulnar artery forearm flap is a reliable, versatile and convenient fasciocutaneous flap. Based on the ulnar artery distal to the common interosseous branch it may include muscle (FCU) tendon (PL) and bone (ulna). The arterial and venous anatomy allow a flow-through capability and a reversal of flow which permits its use as a distally pedicled island flap. Many of its properties are shared with the radial flap, but the ulnar flap has further advantages. The donor site is virtually hairless, easily closed even when bone is taken, and is less obvious as it lies on the proximal ulnar aspect of the forearm. The ulnar artery is not reconstituted and in 11 cases there has been no clinical evidence of any circulatory, sensory or motor impairment of the hand. The flap is especially useful in intra-oral reconstruction and has been valuable in the lower leg where it may restore deficient distal circulation.     

Dual free flap transfer using forearm flap for mandibular reconstruction.

To reconstruct a composite mandibular defect, we have simultaneously transferred a vascularized bone graft or osteocutaneous flap together with a forearm flap. The radial forearm flap, being thin, pliable, and having a long vascular stalk, served as mucosal lining and/or an interpositional flap acting as a vascular bridge. Between 1982 and 1989, we used this procedure in 17 patients with a mandibular defect or deformity which developed following treatment of oral cancer. Our clinical experience has demonstrated that this dual free tissue transfer has many advantages. It is useful for obtaining a good alveolar ridge in patients with a composite mandibular defect. It is applicable in cases where only a single pair of recipient vessels are present and may be useful when the recipient vessels are positioned some distance from the defect.     

One stage reconstruction of penis with free forearm flap

One stage reconstruction of the penis using free tissue transfer was performed on a 43-year-old man who had total penectomy for carcinoma of the penis. A free forearm tissue flap was used to reconstruct urethra and for external skin coverage and Jonas silver penile prosthesis was used as a stent. Nutrient vessels (one artery and two veins) were anastomosed with a lateral circumflex femoral artery and two branches of the saphenous veins respectively and the nerve of flap was anastomosed with the pudendal nerve. We believe that this method is functionally and cosmetrically acceptable for reconstructing the penis, although unfortunately extrusion of the prosthesis ensued 63 days after the operation in our case.