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.     

An algorithm to improve outcomes of radial forearm flap donor site

Background: Due to the high rate of donor site complications the Radial Forearm Flap (RFF) has lost ground in favor of the Antero-lateral tight flap (ALT) and other flaps. We have designed a reconstruction algorithm for reconstruction of its donor site. The goal of this study was to retrospectively evaluate the impact of this algorithm on RFF donor site complication rates.

Methods: The authors analyzed retrospectively 31 patients who underwent free radial forearm flap reconstruction between November 2009 and May 2013. Donor site complications were compared with data from patients treated before introdutction of the algorithm. Within the group were compared patients in which the flap was harvested suprafascial with those in which the flap was harvested as subfascial.

Results: Before application of the algorithm, there was a 23.3% complication rate at the RFF donor site, in our experience. After introduction of the algorithm, complication rate has dropped to 3.2%, consisting in a partial skin graft necrosis treated by local wound-care and healed without further intervention.

Conclusions: Application of the algorithm described has led to a significant reduction in RFF donor site complication rates. This demonstrates that if flap donor sites are analyzed and tailor treated in the same way as primary defects are, instead of being given secondary importance and just grafted, outcomes improve.     

Long-term fate of vascularized iliac bone flap as a source for phallic rigidity

One of the surgical goals of phalloplasty is to obtain sufficient rigidity for sexual penetration. This is also important for patients with erectile dysfunction. Different kinds of techniques have described phalloplasty and obtaining rigidity in patients with erectile dysfunction, but there is no good substitute for the erectile tissue of the penis. The authors used an iliac osteocutaneous flap for phalloplasty and a vascularized bone flap for imitating penile erection. Five patients who had undergone either phalloplasty or correction of erectile dysfunction are presented. Long-term results are promising in adults and the authors advocate using vascularized iliac bone for sufficient rigidity of a (neo)phallus. However, the results are moderate for children who have undergone previous phalloplasty.     

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.     

Treatment of pharyngocutaneous fistulae with a cork-design radial forearm free flap

Pharyngocutaneous fistula is a dreaded complication after ablative surgery of the aerodigestive tract including the pharynx and larynx. This is a common problem for the surgeon. Two cases are presented with pharyngocutaneous fistula developing after total laryngectomy and radiation therapy. The fistula was reconstructed using a cork-design radial forearm free flap. Total obliteration of the fistula was obtained without complications. This new design provides the following advantages: extensive contact area between the flap and the inflamed surrounding tissue, discontinuity between the suture lines of the inner lining and the outer cover, and reinforcement of the suture line of the outer covering with skin graft. This method can be useful in reconstructing irradiated pharyngocutaneous fistulas.     

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.     

A method of phalloplasty using the deep inferior epigastric flap

Penile reconstruction remains a difficult surgical problem. To produce a phallus capable of erection and with a water-tight urethra to the tip has not been solved satisfactorily even by the introduction of free flap transfers. We present a method used in four cases, three transsexuals and one pseudohermaphrodite, in which a phallus was successfully constructed using the deep inferior epigastric flap.     

Pharyngostome closure using the radial forearm free flap

A technique is described using the radial forearm free flap for pharyngostome closure. The flap may be used in combination with local flaps for external cover only or may be raised as a double paddle for external and internal lining.     

应用腹膜管联合皮瓣行兔阴茎再造的初步研究

目的：建立皮瓣包绕游离腹膜管再造阴茎的动物模型，探索在阴茎再造术中使用腹膜再造尿道的新方法。方法：成年雄性新西兰大白兔24只，随机分成腹膜组和腹膜皮片组各12只。再造阴茎时，腹膜组中将腹膜浆膜面向内缝合成腹膜管替代尿道，腹膜皮片组则在腹膜管前端吻接一段1cm长的阴囊皮片，形成腹膜皮片复合管，并以此管替代尿道，两组均以腹壁浅血管筋膜蒂皮瓣包绕再造尿道形成阴茎体，观察阴茎成活和尿道通畅情况。结果：再造阴茎全部成活，无尿道狭窄发生，作为尿道衬里的腹膜浆膜面光滑、湿润、富有光泽，未见溃疡及纤维化。腹膜组8只兔尿道口闭合，同时伴有尿瘘。腹膜皮片组3只兔各1处尿瘘。结论：使用皮瓣包绕游离腹膜管再造阴茎的方法可以成功构建阴茎再造的动物模型，为游离腹膜联合皮瓣转移阴茎再造术的临床应用提供了实验依据。     

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.     

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.     

The shamrock flap: a three-paddle radial forearm flap

The radial forearm flap has been well described for reconstruction of the oral cavity. The flap is most commonly used as a single-paddle flap with or without a segment of vascularised radius. Double-paddle radial flaps may be required to reconstruct defects of intraoral lining and overlying skin following excision of extensive tumours. We wish to report the first described case of reconstruction using a triple-paddle radial forearm flap including a segment of vascularised radius.     

Prelaminated free radial forearm flap for a total nasal reconstruction.

A prelaminated osteocutaneous radial forearm flap has previously been described for total nasal reconstruction, but achieving good aesthetics at the dorsum and tip tends to be difficult with a flap that can be too bulky. We present a case of total nasal reconstruction in a burns patient where a tight adherent scar at the forehead precluded the use of a forehead flap, ideal for such reconstructions. We successfully used a prelaminated free radial forearm flap, with a non-vascularised bone graft. The existing scarred skin at the dorsum was turned down as pedicled flaps for the lining. We were able to achieve a successful total nasal reconstruction which was aesthetically pleasing and made a tremendous impact on the quality of life of the patient.     

Free radial forearm flap versatility for the head and neck and lower extremity

Microsurgical techniques have developed numerous territories suitable for free tissue transfer. However, the demand for thin cutaneous resurfacing limits the choice of flaps available to the reconstructive microsurgeon. The radial forearm flap is a thin, axial, fasciocutaneous flap, offering pliable cutaneous resurfacing, with or without sensation. We have used 15 flaps to reconstruct defects in the head and neck and lower extremity resulting from burns, blunt and avulsive trauma, radiation necrosis, and tumor ablation. Two flaps (15 percent) developed venous congestion and were salvaged by reoperation. One retrograde flap (7.5 percent) developed partial necrosis from arterial insufficiency. Neural re-innervation was successful in two out of three patients in whom it was attempted. Two patients (15 percent) sustained minor donor site skin graft loss that healed secondarily. In our series of predominantly older patients the donor sites have been relatively inconspicuous at one year follow-up. A functional restoration was achieved in all patients.     

Full-thickness cheek and lip reconstruction with the radial forearm free flap

The radial forearm free flap has proven versatility in head and neck reconstruction. It is superior to regional alternatives such as the pectoralis flap because it is thin, pliable, and predominantly hairless. A more recent application is the use of the folded forearm flap to replace both the skin and inner lining, simultaneously, in full-thickness cheek and lip defects. Nine such cases are presented in this report. Each patient had a recurrent lesion that had been reconstructed previously with local flaps, and all but one were treated with postoperative radiation therapy. The average size of the external defects after resection was 27 cm2, and of the intraoral defects, 18 cm2. All free flaps survived completely. The folded forearm flap solved the reconstructive problem for each patient in a single-stage procedure, providing good contour and a reasonable color match. The flap is easy to raise, has a long pedicle with large-diameter vessels, and has an acceptable donor site defect not associated with long-term morbidity.     

Mandibular reconstruction using osteocutaneous radial forearm flap

Objective: To describe the use of radial forearm osteocutaneous free flap in complex mandibular reconstruction. Study Design: A case series. Place and Duration of Study: Combined Military Hospital, Rawalpindi, from January 1998 to January 2008. Methodology: Patients having a small bony component and a large soft tissue mandibular defect requiring reconstruction were selected. These defects include composite through-and-through defects of the cheek in the retromolar trigone, small lateral bony defects with large intra and extra oral soft tissue defects and small central bony defects with large extra oral tissue loss. Radial forearm osteocutaneous free flap was employed. Complications and graft acceptance were determined at follow-up. Results: Patients were followed-up for an average period of 28 months. Complications occurred in 8 patients. Wound infection and partial wound dehiscence were the most common complication observed in 3 patients. Non-union at recipient site was seen in 2 patients. Flap donor site healed uneventfully in all patients with no fractures at the donor site. Conclusion: The radial forearm osteocutaneous flap covers oromandibular defects with large intra-oral and extra oral soft tissue losses. Lateral and anterior mandibular defects were reconstructed satisfactorily in our series.     

Microsurgical penile reconstruction with a sensitive radial forearm free flap

A series of six consecutive cases of total penile reconstruction with a sensitive forearm free flap based on the radial artery is presented. A simple, reliable, and easily reproducible technique with an acceptable aesthetic appearance is described. No partial or complete flap losses were found. The only complication found in three patients was a urinary fistula on the distal third of the flap, which was repaired successfully with a secondary surgical procedure. The aesthetic and functional outcome was satisfactory to the patient and surgical team in all cases. A sensitive radial forearm free flap is a good choice of treatment for total penile reconstruction.     

Total phalloplasty using a musculocutaneous latissimus dorsi flap

OBJECTIVE: To present total phalloplasty in children and adults using a musculocutaneous latissimus dorsi (MLD) free flap to create a large neophallus, that allows easy urethroplasty and implantation of a prosthesis. PATIENTS AND METHODS: From April 1999 to January 2006, 16 patients (mean age 24 years, range 10-34) had a total phalloplasty; the indications were congenital anomalies of the penis in 12, iatrogenic in two and accidental penile trauma in two. The MLD flap is mobilized on a subscapular artery and vein, and a thoracodorsal nerve. The neophallus is created on-site and after dividing the neurovascular pedicle, transferred to the pubic region, where it is anastomosed with the femoral artery, saphenous vein and ilio-inguinal nerve. The donor site was closed directly in 15 patients while in one a split-thickness skin graft was used to cover the defect. In the following stages, two- or three-stage buccal mucosa urethroplasty was used in 11 patients; a penile prosthesis was implanted in seven. RESULTS: The mean (range) follow-up was 31 (12-74) months; the penis was 14-18 cm long and 11-15 cm in circumference. There was no partial or total flap necrosis; the donor site healed satisfactorily in 13 patients while in the remaining three there was moderate scarring. The patency of the urethra was good in all patients. Two urethrocutaneous fistulae developed; one closed spontaneously and the other was successfully treated with minor surgery. The function of the implanted penile prostheses was satisfactory in all patients. CONCLUSIONS: The MLD flap allows the creation of a neophallus of good size and with a good aesthetic appearance; it allows urethroplasty and safe implantation of a penile prosthesis, and it can also be used in children.     

Salvage of a free radial forearm flap by creation of an arteriovenous fistula at the distal arterial pedicle

Interdisciplinary approaches with infrainguinal bypass grafts and free flaps between the plastic and vascular surgery may well offer an opportunity for diabetic patients with peripheral vascular disease to salvage their critically affected limbs. A free flap transfer combined with an autologous vein graft can cover large tissue defects and simultaneously improve distal perfusion even in patients with arterial occlusive disease. We are presenting a case of bypass‐free radial forearm flap used to cover a foot defect in an old diabetic patient with peripheral arterial disease. The flap perfusion deteriorated significantly during the early postoperative period. The patient was brought back to the operating room with acute thrombosis of the popliteal‐radial venous graft and the arterial pedicle of the flap. The flap was salvaged by thrombectomy and creation of an additional arteriovenous fistula at the distal arterial pedicle. The procedure improved the flap perfusion and decreased the high internal resistance that was noticed in the flap when trying to flush the radial artery during the revision surgery and was evident by continuous wave ‐Doppler sonography. The successful salvage of the flap in the presented case and the convenient long‐term follow up suggest that this technique may be safe and helpful as a last effort to salvage a bypass‐free flap with a suspected high internal resistance. © 2013 Wiley Periodicals, Inc. Microsurgery 33:391–395, 2013.     

The combined use of hyoid bone flap and radial forearm free flap for reconstruction following partial laryngopharyngectomy

In hypopharyngeal carcinoma, even partial laryngopharyngectomy, results in functional disorders involving swallowing and speaking. We reconstructed partial defects following partial laryngopharyngectomy using a combined flap of a hyoid bone flap and radial forearm free flap. Before ablative surgery, we prepared an ipsilateral hyoid bone as a bone flap with sternohyoidal muscle. Then a radial forearm free flap was prepared simultaneously with tumor surgery. Thereafter, we reconstructed the epiglottis and pyriform recess using the combined flap. We successfully reconstructed 7 patients suffering from squamous cell carcinoma of the hypopharynx. The tracheostoma in all patients could be closed. Six patients could swallow without dysphagia within 48 days. This is the first report of the successful combined use of a hyoid bone flap and radial forearm free flap for hypopharyngeal carcinoma.