Use of forearm free‐flap phalloplasty in bladder exstrophy adults

OBJECTIVE

To assess the long‐term outcome and cosmetic results of forearm free‐flap phalloplasty for correcting micropenis associated with bladder exstrophy in men.

PATIENTS AND METHODS

From 1992 to 2000, six men with bladder exstrophy and unsatisfactory penile appearance underwent phalloplasty at our institution. The mean (range) follow‐up was 113 (62–153) months. The surgical procedure consisted of a modified radial free‐flap phalloplasty and prosthesis implantation. One‐stage urethroplasty was electively performed according to the patient’s voiding pattern. Early and late complications were recorded and quality of life after phalloplasty was assessed.

RESULTS

The mean (range) age was 21.2 (17–26) years and flap survival was 100%. Two incontinent patients underwent immediate perineal urethrostomy. One sepsis occurred, requiring the removal of the penile prosthesis and a cutaneous continent urinary diversion; this patient was the only one to complain about the outcome. Two anastomotic urethral strictures were conservatively treated by endoscopic urethrotomy and only one patient underwent subsequent urethral self‐dilatations. Five patients were very satisfied with the cosmesis of the neophallus and three patients reported having regular sexual intercourse.

CONCLUSIONS

Although short, this series indicates the low incidence of early complications and the excellent long‐term satisfaction with forearm free‐flap phalloplasty in bladder exstrophy. Phalloplasty has potential indications when adult exstrophy patients are dissatisfied with the cosmetic appearance of their external genitalia or have unsatisfactory sexual intercourse.     

Urethral reconstruction using the radial forearm free flap: experience in oncologic cases and gender reassignment

OBJECTIVES: Urethra reconstruction in men remains a complex problem, particularly in patients who have had previous amputation for penile tumour or who have undergone gender reassignment. Many reconstructive techniques currently in use recreate the urethra but are prone to recurrent stricture formation and fail to achieve micturition with a good stream when standing. The authors propose using the radial forearm fasciocutaneous free flap as a single-stage technique of male urethral reconstruction. METHODS: During 1999-2004, nine patients underwent microsurgical reconstruction of the male urethra using the radial forearm fasciocutaneous free flap. Three patients underwent urethral reconstruction following previous subcutaneous penectomy for penile cancer. Another six patients had urethral reconstruction performed after failure of primary urethra construction as part of their gender reassignment surgery. RESULTS: The average age at the time of surgery was 35.1 yr (range: 22-55 yr) and average follow-up time was 41.8 mo (range: 13-55 mo). Flap reconstruction was successful in all cases, with no instances of free flap failure; however, two patients developed significant stenosis requiring revision, and no patients had postoperative fistula formation. Therefore, the success rate for urethral reconstruction after the first operation was seven of nine. Two patients with stenosis were treated operatively to release strictures with local flaps. Uroflowmetry demonstrated that these patients had satisfactory flow rates. CONCLUSION: Patient satisfaction and objective studies have demonstrated that urethral reconstruction with the use of radial forearm free flap is a good reconstructive procedure particularly when the patients need an extensive and long urethral reconstruction.     

Modifications of the radial forearm flap phalloplasty for female-to-male gender reassignment

The radial forearm flap remains the preferred technique for phalloplasty. From 1999 to 2009, 19 patients with primary female transsexualism underwent gender reassignment surgery at our center. The radial forearm flap phalloplasty is modified as a two-stage procedure, with prelamination of the neourethra on the donor forearm before microsurgical transfer 3 months later. At 5-year follow-up, patients were asked to complete a survey on the functional, aesthetic, and psychological results postsurgery. The radial forearm flap reliably provided sufficient bulk with stiffness for the neophallus with acceptable aesthetic appearance. We further describe technical modifications to reduce the rate of urethral strictures and fistulas. None of the patients regretted undergoing gender transformation. Patients are satisfied with the surgical result and generally prepared to accept its potential costs, in view of the significant psychological and legal benefits.     

Urethroplasty in female-to-male transsexuals

OBJECTIVE: Female-to-male transformation includes total phallic reconstruction. Construction of a neourethra is necessary to achieve the goal of voiding while standing; however urethral fistula and stricture formation occur in a significant percentage of patients. METHODS: 25 patients with primary female transsexualism underwent phalloplasty with a free radial forearm flap, vaginectomy and urethroplasty in a one-stage procedure. In 16 of these patients the fixed part of the neourethra ("bulbar urethra") was constructed from a vaginal flap. In 9 patients flaps of the labia minora (5 patients) or the "urethral plate" (4 patients) were used. RESULTS: In 14 (58%) patients fistulas and/or strictures in the newly constructed urethra occurred. 11 (69%) of 16 patients in whom the "bulbar urethra" was constructed from a vaginal flap experienced fistulas and/or stricture formation. Fistulas and/or strictures occurred in 3 of 5 patients with labia minora flaps and none of 4 patients with the urethral plate procedure. Repair of fistula and strictures was performed by primary closure of fistulas, staged urethroplasty with local pedicle flaps or distant tissue grafts using buccal mucosa (2-6 procedures). CONCLUSION: One-stage total phalloplasty and urethroplasty is associated with a significant rate of fistulas and strictures. However, these complications can be corrected by the techniques used in modern urethral surgery.     

易性病阴茎再造术中尿道口吻合的改良术式介绍

目的介绍易性病患者(女转男)阴茎再造术中尿道吻合的改良术式,观察其临床效果。方法回顾性分析2016年12月至2020年12月海军军医大学第二附属医院行阴茎和尿道再造手术的易性病(女转男)病例资料。在以阴道黏膜预置的下腹部皮瓣或股前外侧皮瓣行阴茎和尿道再造的手术中,将二期法改为三期法,即二期手术时在预置尿道口的近会阴端预留2 cm宽的皮瓣桥,将预制尿道口与阴阜处预留的尿道口通过皮瓣桥缝合,即两个尿道口之间以此2 cm皮瓣隔开而不做吻合,6个月后再行三期尿道吻接手术。对患者阴茎再造术后尿道功能进行随访,主要观察是否有尿瘘、能否站立排尿,以及尿道通畅情况。结果共纳入6例易性病(女转男)患者,年龄29~40岁,手术过程顺利,其中4例采用右侧股前外侧皮瓣再造阴茎,2例采用左下腹部皮瓣。6例中有1例患者术后1周阴茎远端皮瓣有少部分坏死,游离植皮术后愈合。术后随访10~30个月,所有患者均未发生尿瘘,都能站立排尿,尿道未发生狭窄、完全通畅。结论下腹部皮瓣或股前外侧皮瓣预置尿道、阴茎再造术中,三期改良尿道吻合的技术可以降低易性病(女转男)患者术后尿瘘和尿道狭窄的发生率。     

Radical bulbar dissection to correct severe chordee and proximal hypospadias

PURPOSE: We describe a technique of proximal hypospadias correction that involves freeing the proximal normal bulbar urethra from perineal attachments to lengthen the ventral penis and decrease chordee. MATERIALS AND METHODS: Correction was performed in 9 patients with a mean age of 11.5 months who had proximal hypospadias and severe chordee that was perineal in 2, mid scrotal in 6 and penoscrotal in 1. After the penis was degloved the bulbar urethra was detethered to or beyond the perineal body without lifting the urethra from the corpora cavernosa. Any remaining penile chordee was corrected and the urethral plate was transected only when chordee persisted. When the urethral plate was intact and the penis straight, tubularized incised plate urethroplasty was done to correct hypospadias in 1 stage. Otherwise 2-stage repair was performed. RESULTS: Using this maneuver penile straightening was achieved in 2 of the 9 patients, resulting in a glanular urethral or penoscrotal meatus. Dorsal plication sutures required in 4 cases resulted in a mid shaft and penoscrotal meatus in 1 and 3, respectively. Residual chordee in the remaining 3 patients necessitated division of the urethral plate and 2-stage repair despite aggressive mobilization of the proximal urethra. Simultaneous tubularized incised plate urethroplasty was then performed in the 4 penoscrotal and 1 mid shaft meatus. All 6 patients who underwent a successful 1-stage procedure have excellent cosmetic results, while 1 required meatotomy. No fistula or chordee was present at a mean of 13.8 months of followup (range 3.9 to 27.1). CONCLUSIONS: This safe, rapid technique may compensate for significant penile tethering and chordee in a subpopulation of patients with proximal hypospadias, such as 6 of the 9 in our study. It also allows successful tubularized incised plate urethroplasty to be done simultaneously.     

Avulsion injuries of the male external genitalia: classification and reconstruction with the customised radial forearm free flap.

Between 1995 and 2003, 36 men underwent penile reconstruction for avulsion injuries with radial forearm free flap. Classification was according to location of the native urethra at presentation. In type I injury the meatus was at the corporal stump. In type II injury there was loss of corpora with preservation of the crura leaving the meatus near the pubic symphysis. In type III injuries there was a perineal urethrostomy. In type IV injuries urinary diversion via a supra-pubic catheter was required. In some instances, the flap was designed obliquely over the forearm rather than vertically to gain length. Secondly, we fashioned additional 8-11 cm length of the urethral portion of the flap (with separate draining vein) to tap into the perineal urethrostomy. Seven patients had type I injuries, 15 patients had type II injuries, 10 patients had type III injuries and four patients had type IV injuries. All 22 patients with type I/II injuries and 7/10 patients with type III injuries underwent phalloplasty in a single stage. Three patients with type III injuries had two-stage reconstructions while all four patients with type IV injuries underwent reconstruction in three stages. There was one flap loss, eight developed fistula and six patients developed late stricture. Overall patient satisfaction with the reconstruction was very high.     

Outcome of urethral reconstructive surgery in a series of 74 women

PURPOSE: We evaluated the results of vaginal flap reconstructive surgery of the female urethra. MATERIALS AND METHODS: A series of 74 consecutive women who presented with urethral pathology requiring surgical reconstruction were assessed for anatomical and functional outcome. Followup was 1 to 15 years (median 1.5). Outcome assessment included success or failure of the anatomical repair based on physical examination as well as voiding habits and continence assessed by voiding diary, questionnaire and patient self-assessment. RESULTS: A total of 74 procedures were performed, including 72 vaginal flap repairs (56 with a concomitant pubovaginal sling). Five vaginal flap repairs were performed with a concomitant modified Pereyra procedure and 1 was done with Kelly plication. A patient in whom vaginal flap repair was planned underwent a Tanagho anterior bladder flap procedure, 1 underwent extensive lysis of urethral and periurethral scarring with primary urethral repair and 12 underwent vaginal flap repair without an incontinence procedure. A total of 72 women with an average age +/- SD of 54 +/- 13 years were followed a median of 1.5 years after vaginal flap reconstruction and 2 were lost to followup. Of the 62 patients with preoperative incontinence 54 (87%) considered themselves cured or improved. Successful anatomical repair by single procedure vaginal flap repair was achieved in all except 5 patients (93%). CONCLUSIONS: Single stage vaginal flap reconstruction with concurrent pubovaginal sling and Martius flap graft has a high degree of anatomical and functional success for treating a difficult surgical problem.     

Urethral extensibility applied to reconstructive surgery

PURPOSE: The human male urethra has great capacity to extend under traction. This extensibility is the principle of some surgical techniques used to overcome urethral defects and for penile lengthening. However, to our knowledge safe limits of urethral extensibility in reconstructive surgery have not been yet established by a morphological study. To this end we measured fresh human cadaveric urethras with and without traction. MATERIALS AND METHODS: We analyzed the macroscopically normal, fresh cadaveric urethra from 25 men 6 months to 73 years old at death (mean age 30.6). Penile length and length of the total, penile, bulbar and membranous urethra were measured. Length under maximal constant traction and the maximal stretched length without penile curvature at artificial erection were determined. Extensibility is expressed as the percent of the variation in initial length at rest and maximal constant traction length. Maximal stretched length without penile curvature at artificial erection is expressed as a percent of maximal constant traction length. RESULTS: Total urethral extensibility was higher than penile extensibility (p <0.001). Urethral extensibility decreased with aging (r = -0.806, p <0.001). Mean extensibility of the whole male urethra was 66.2% +/- 7.2% and differences among urethral segments were not significant (p = 0.283). Mean maximal stretched length without penile curvature at artificial erection was 75.2% +/- 3.8% and it did not change with age. CONCLUSIONS: Knowledge of the safe anatomical limit of urethral extensibility applied to reconstructive surgery may avoid complications and the necessity for more complex techniques. This limit should be approximately 75% of the maximal constant traction length or a gap-to-normal urethra ratio of 1:4. However, age related variations should be considered.     

A new phalloplasty technique: the free anterolateral thigh flap phalloplasty.

After a 10-year experience with phalloplasty in female to male gender reassignment surgery and with more than one hundred cases treated, we have introduced a new technique for creation of the neo-phallus. Between 1993 and 2002, phalloplasties were performed in our department using the free radial forearm flap or the pre-expanded suprapubic flap (modified Pryor technique). The study of long-term results and complications of these cases, as well as patient requests for a new donor site, induced us to look for an alternative flap for phalloplasty. The versatility and the low donor site morbidity of anterolateral thigh flap persuaded us to use it for phalloplasty. Since March 2003, six phalloplasties with free anterolateral thigh (ALT) flap have been performed. The results have been encouraging. The shape and the consistency of the neo-phallus are suitable, the flap can be sensate and an erectile prosthesis can easily be implanted. Penile urethral reconstruction is possible in the same operative stage. Patient satisfaction is high. The anatomy and harvesting techniques of ALT flap have already been exhaustively described by several authors and only the operative technique of phalloplasty with free ALT flap, donor site management, preliminary results and complications are reported in this paper.     

De Castro technique used to create neophallus: a case of aphallia

We report on a rare case of aphallia in an X, Y-born male treated at our institution. The child underwent phalloplasty at 5 years of age using the De Castro phalloplasty technique and an abdominal skin flap. Although moderate distal necrosis was seen, the overall immediate and 12-month postoperative results were highly encouraging for our patient. Thus, this technique should be seen as a temporizing reconstructive option for patients with aphallia. Long-term follow-up is necessary to determine whether the neophallic size augments with axial growth and the need for additional intervention to facilitate onset of sexual activity.     

Total vaginectomy and urethral lengthening at time of neourethral prelamination in transgender men

Introduction and hypothesis

For transgender men (TGM), gender-affirmation surgery (GAS) is often the final stage of their gender transition. GAS involves creating a neophallus, typically using tissue remote from the genital region, such as radial forearm free-flap phalloplasty. Essential to this process is vaginectomy. Complexity of vaginal fascial attachments, atrophy due to testosterone use, and need to preserve integrity of the vaginal epithelium for tissue rearrangement add to the intricacy of the procedure during GAS. We designed the technique presented here to minimize complications and contribute to overall success of the phalloplasty procedure.

Methods

After obtaining approval from the Institutional Review Board, our transgender (TG) database at the University of Miami Hospital was reviewed to identify cases with vaginectomy and urethral elongation performed at the time of radial forearm free-flap phalloplasty prelamination. Surgical technique for posterior vaginectomy and anterior vaginal wall-flap harvest with subsequent urethral lengthening is detailed.

Results

Six patients underwent total vaginectomy and urethral elongation at the time of radial forearm free-flap phalloplasty prelamination. Mean estimated blood loss (EBL) was 290 ± 199.4 ml for the vaginectomy and urethral elongation, and no one required transfusion. There were no intraoperative complications (cystotomy, ureteral obstruction, enterotomy, proctotomy, or neurological injury). One patient had a urologic complication (urethral stricture) in the neobulbar urethra.

Conclusions

Total vaginectomy and urethral lengthening procedures at the time of GAS are relatively safe procedures, and using the described technique provides excellent tissue for urethral prelamination and a low complication rate in both the short and long term.

     

Combined buccal mucosa graft and local flap for urethral reconstruction in various forms of hyposapdias

PURPOSE: Hypospadias is one of the most common congenital deformities in the male urogenital system. Although there are more than 250 techniques for treating hypospadias, it is often difficult to repair severe hypospadias using conventional methods. MATERIALS AND METHODS: We combined a buccal mucosa graft with a local onlay flap for urethral reconstruction in cases of severe hypospadias or a failed previous operation. A total of 162 patients with hypospadias (glandular 11, penile 40, penoscrotal 49, scrotal 34 and perineal 28) were treated between July 2000 and November 2003. For patients whose urethral meatus was perineal 2 treatment steps were taken. First, we used the aforementioned method to construct the penile urethra, and then we constructed the scrotal and perineal urethra with a local flap. RESULTS: Of the 134 nonperineal cases 127 were managed successfully in 1 stage, and 26 of 28 perineal cases were managed successfully in 2 stages. Most patients had a satisfactory penile appearance. A urethral fistula resulted in 8 cases, of which 4 closed spontaneously within 1 month postoperatively. Meatal stenosis occurred in 1 case. CONCLUSIONS: This technique is simple, safe and reliable, especially in cases of failed previous operation or for salvage hypospadias repair with deficient local tissue.     

Urethroplasty for refractory anterior urethral stricture.

PURPOSE: We present our results managing anterior urethral strictures previously treated with urethroplasty and/or urethrotomy. MATERIALS AND METHODS: During a 32-month period 69 males 10 to 76 years old (mean age 36) underwent treatment for anterior urethral stricture, including 32 (46%) and 26 (38%) previously treated with urethroplasty and urethrotomy, respectively. In 11 patients (16%) no previous procedures had been done. Anastomotic and dorsal patch urethroplasty was performed for bulbar stricture in 13 and 14 cases, respectively, while in 4 a penile skin flap was placed for penile stricture and in 38 a 2-stage procedure was done with urethral substitution using buccal mucosa or post-auricular skin grafts. Patients were followed with ascending urethrography at 3 weeks, and 12 and 18 months as well as with uroflowmetry. Symptoms were assessed for 6 months to 4 years. RESULTS: Only 1 stricture recurred in patients treated with anastomotic or patch urethroplasty, or a skin flap. Of the patients scheduled for a 2-stage procedure stage 1 revision was required due to graft scarring or stenosis at the urethrostomy site in 21% and stage 2 revision was required in 23%. Other complications in this series included fistula in 3% of cases, wound infection in 3% and post-void dribbling in 12%. CONCLUSIONS: Overall early results are good in our urethroplasty series in patients with a previously instrumented urethra. Patients should be advised of the possible need for multiple revisions of planned staged procedures. The increased rate of revision in these staged procedures compared with the excellent outcome of 1-stage procedures appears to be inherent in this operation in patients with multiple previous procedures rather than due to surgeon experience.     

Second free radial forearm flap for urethral reconstruction after partial flap necrosis of tube‐in‐tube phalloplasty with radial forearm flap: A report of two cases

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.     

Dorsal or ventral placement of the preputial/penile skin onlay flap for anterior urethral strictures:does it make a difference?

OBJECTIVE: To report our experience in managing complex anterior urethral strictures with a dorsally/dorsolaterally placed penile/preputial vascularized flap, and to discuss the advantages of this procedure over a traditional ventrally placed flap. PATIENTS AND METHODS: Between 1995 and 1999, 40 patients (mean age 40.5 years) with recurrent strictures of the pendulous and/or bulbar urethra were treated with longitudinal penile/circumpenile flap substitution urethroplasty. Nineteen patients underwent dorsal placement of the flap as an onlay (DO), whereas 21 patients had a ventral onlay (VO). Five patients needed inferior pubectomy to facilitate high proximal placement of the flap. RESULTS: Both groups had statistically similar ages, number of previous interventions, stricture site, length and follow-up. After a median follow-up of 27.5 months, the stricture recurred in three (24%) of the VO and two (11%) of the DO groups (P > 0.05). One patient in the VO group required surgical closure of the urethral fistula. Flap pseudo-diverticulum and/or sacculation with postvoid dribble occurred in six patients in the VO and none in the DO group (P = 0.01). CONCLUSIONS: Dorsal placement of the pedicled flap is anatomically and functionally more appropriate than the traditional VO placement. DO preputial/penile flap urethroplasty is a versatile procedure and can be applied even for long anterior urethral strictures, including reconstruction of the meatus and high proximal bulbar strictures.     

Penile reconstruction by the free scapular flap and malleable penis prosthesis

BACKGROUND:: Penile reconstruction has always been a challenging problem for plastic surgeons while facing patients with severe congenital deformities and gender dysphoria and those who have suffered penile loss because of trauma, self-amputation, malignancy, and so on. Since 1936, when Bogoras first constructed a total penis, attempts have been made by different techniques, including skin flaps or myocutaneous flaps. And with development of free tissue transfer and microsurgical techniques, various free skin flaps, such as the radial free forearm flap, the superficial inferior epigastric artery flap, the superficial circumflex iliac artery flap, have been attempted for phallic construction, with the goal of functional (including a competent neourethra that allows voiding while standing and sexual intercourse) and cosmetic result. The purpose of our study was to evaluate the scapular free flap and implantation of malleable penile prosthesis for penile reconstruction. PATIENTS AND METHODS:: Since March 2000, 20 patients with penile loss were reconstructed in a 1-stage procedure by transferring scapular flap and implantation of a malleable penile prosthesis. The age of the patients ranged between 21 and 36 years old. Of these patients, 12 had penile amputation resulting from an electric accident; the other 8 were self-amputated. RESULTS:: All the flaps remained 100% viable postoperatively. Follow-up ranged from 1 to 5 years. There were no cases of urethral fistula, urethral stenosis, prosthesis extrusion, or infection. The reconstructed penis yielded satisfactory function and esthetic appearance. CONCLUSION:: The scapular free flap is an ideal flap that achieves satisfactory function and esthetic appearance for penile reconstruction because of its adequate amount of tissue, reliable vascularity, acceptable donor-site morbidity, and reliable blood supply.     

Long-term outcome of forearm flee-flap phalloplasty in the treatment of transsexualism

OBJECTIVE

To assess the long‐term outcome of forearm free‐flap phalloplasty in transsexuals, as obtaining a satisfying neophallus in female‐to‐male transsexuals is a surgical challenge.

PATIENTS AND METHODS

We analysed retrospectively 56 transsexuals who had a phalloplasty using a radial forearm free‐flap in our department from 1986 to 2002. The complication rate was assessed by regular examination. Patient satisfaction was evaluated by a questionnaire about cosmetic aspects, sexual life and overall satisfaction.

RESULTS

The mean follow up was 110 months; 53 of the 56 patients (95%) currently have a neophallus, after a mean of six surgical procedures. Satisfaction was assessed in 53 patients using a specific questionnaire: 51 (93%) of the patients reported that the phalloplasty allowed them to accord their physical appearance with their feeling of masculinity. There were flap complications in 14 patients (25%); three (5%) flaps were lost, with one each due to early haematoma, cellulitis and late arterial thrombosis. The other 11 flap complications were all transitory, e.g. infection, haematomas and vascular thrombosis. There were prosthesis complications in 11 of 38 patients (29%). Moreover, seven of 19 patients (37%) who had a urethroplasty presented with complex strictures and fistulae that led to perineal urethrostomy.

CONCLUSION

Our study shows that phalloplasty with a forearm free‐flap leads to good results in term of flap survival and patient satisfaction. However, there was a high rate of complications. Patients must be clearly informed that the procedure can seldom be achieved in one stage.     

COMPLETE PHALLOPLASTY USING THE FREE RADIAL FOREARM FLAP FOR CORRECTING MICROPENIS ASSOCIATED WITH VESICAL EXSTROPHY

PURPOSE: We present a new surgical technique for reconstructing the penis in a man with micropenis associated with vesical exstrophy. MATERIALS AND METHODS: A free radial forearm flap was used to create a penis of normal length and diameter. The flap was wrapped around the native micropenis. A penile prosthesis was then inserted in the flap to provide erection. RESULTS: The flap was well vascularized and no skin damage was observed 6 years after reconstruction. The patient achieved sexual intercourse on a regular basis. He is satisfied with the result. CONCLUSIONS: Free transfer of the radial forearm flap may be done in select men with micropenis associated with vesical exstrophy for penile reconstruction. An inflatable prosthesis may be inserted in the flap to provide erection. The results of this technique have remained stable in the long term. This method provides a new tool for phalloplasty in these difficult cases.