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A method of phalloplasty using the deep inferior epigastric flap
Er~frsh Journalof Plastic Surgery (1988L 41, 165-168 tc 1988 The Trustees of British Association of Plastic Surgeons
A method of phalloplasty epigastric flap
using the deep inferior
D. M. DAVIES and B. A. MAlTI Department
of Plastic Surgery, West Middlesex
University
Hospital, Isleworth,
Middlesex
Summary-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.
The ideal phallus reconstruction of producing a normal-looking and functioning penis is impossible. To produce an organ capable of transmitting urine to the tip remains extremely difficult and our previous experience has been disappointing (Matti et al., 1988). As a result of this we now counsel our patients that we are only prepared to try and produce a phallus with little function other than as a male symbol and do not undertake urinary diversion. Operative technique The anatomy of the deep inferior epigastric flap has been described in detail by Taylor et aE. (1983) and Corlett and Taylor (1980). The flap is based on the large umbilical perforators (umbilical hub) which are the terminal branches of the deep inferior epigastric artery and allow large skin flaps to be safely raised well lateral to the border of the rectus sheath. A skin flap of variable size is marked out usually as large as is consistent with primary closure (Fig. 1). The dissection is started laterally and the flap is raised including the deep fascia, dissecting medially to the lateral border of the rectus sheath. The anterior rectus sheath and rectus muscle are then divided along the upper border of the flap, ligating the connection between the superior and inferior epigastric vascular system. The incision then passes along the medial border of the flap, skirting the umbilicus. The anterior rectus sheath is divided just lateral to the major skin perforators to leave a fringe of rectus sheath to facilitate primary closure of the sheath. The lower border of the skin flap is divided anteriorly and the incision in the anterior 165
rectus sheath is completed, taking care to incise the sheath above the level of the arcuate line. This isolates the skin flap which is now attached to the underlying muscle by a disc of anterior rectus sheath. The pedicle is dissected from the underside of the rectus muscle laterally towards the external iliac vessels. The rectus muscle is divided transversely inferiorly below the point where the vascular pedicle enters the muscle, leaving the remaining part of the muscle to give extra support to the anterior abdominal wall below the arcuate line. The flap is transposed inferiorly and inset into an incision placed transversely in the mons pubis superior to the clitoris which then lies at the base of the new phallus (Fig. 2). The flap itself is tubed. The donor site of the flap and rectus sheath are closed primarily. In one case we used a prolene mesh to supplement the anterior rectus sheath. In two cases a malleable penile prosthesis was attached with wire sutures to the superior pubic ramus and inserted within the tubed skin paddle which formed the shaft of the penis.
Case reports Case 1
A 27-year-old female pseudohermaphrodite, assigned to a male gender at birth with a chromosomal analysis showing a female 46XX with normal FSH, LH and testosterone levels, was referred for phallus construction. A 15 x 20 cm skin paddle rectus abdominis musculocutaneous flap based on the deep inferior epigastric artery was raised. The flap was extremely thick due to the excessive subcutaneous fat and it was difficult to tube the flap completely and therefore a skin graft was required
BRITISH JOURNAL OF PLASTIC SURGERY
Fig. 2
Fig. 1
Figure l-The design of a right deep inferior epigastric flap measuring 15 x 10 cm based on the umbilical hub. Figure 2-The is transposed inferiorly under a bridge of abdominal skin and tubed and inset into a transverse incision in the mom pubis.
to complete the ventral surface skin cover. Further thinning to this flap will be required at a later date and at present no silastic prosthesis is required because of the inherent stiffness of the organ provided by fat and oedema (Fig. 3).
Case 2 A 30-year-old transsexual was referred, being well integrated in the male role, and requested construction of a phallus prior to living with a female. He had previously undergone a mastectomy and hysterectomy and had had hormone treatment (testosterone) in the past. He underwent a one-stage phalloplasty using the same flap with a skin paddle of 12 x 20 cm. The flap was tubed completely and no skin graft was required for closure. The stiffness of the new phallus was provided by a malleable penile prosthesis (Fig. 4).
Case 3 A 50-year-old transsexual living for many years in the male role with a “wife” had previously undergone unsuccessful radial artery forearm flap phallus construc-
flap
tion due to thrombosis. He subsequently underwent phallus reconstruction using the deep inferior epigastric flap with a skin paddle measuring 15 x 10 cm. The skin tube was closed primarily around a malleable penile prosthesis and the patient made an uneventful postoperative recovery (Fig. 5). At 6 months follow-up the patient maintains the phallus is being used successfully for intercourse.
Case 4 A 33-year-old female-to-male transsexual living as a man from the age of 18 was referred for phallus construction, hysterectomy and mastectomy already having been carried out. He had previously undergone first stage urethral reconstruction whereby two labia minora flaps had been raised to bring the urethral opening forward under the mons pubis. An appropriate radial artery forearm flap was raised and tubed inwards to form a urethra and this was placed within the tubed rectus abdominis flap. The skin paddle measuring 20 x 12 cm could not be tubed completely in the proximal one-third and therefore this part was covered with a skin graft. Two-and-a-half weeks postoperatively all wounds were
A METHOD OF PHALLOPLASTY
USING THE DEEP INFERIOR
Fig. 3
Fig. 5
EPIGASTRIC
167
FLAP
Fig. 4
Fig. 6
Figure 3 Cme I. Result of phallus construction using the deep inferior epigastric flap in a 2i’-year-old pseudohermaphrodite. A skin graft was required to complete the tube. Figure 4-Case 2. A phallus construction stiffened by asilastic prosthesis. Figure 5. Case 3. Phallus construction in a 50-year-old transsexual. Figure bCnsp 4. Phallus construction using a radial artery free flap for urethral construction and a deep inferior epigastric flap for external skin cover.
completely healed and the patient was able to pass his urine successfully from the tip of the reconstructed phallus. with no fistula (Fig. 6).
Discussion Phalloplasty in transsexuals is a formidable task and obtaining a water-tight urethra remains an extremely difficult proposition. Bogoras (1936) was one of the first to construct a penis from an abdominal skin tube in which rib cartilage was implanted. Gillies and Harrison (1948) described a
multi-staged tube pedicle for penile reconstruction using a small tube within a large one and stiffened by a shaft of costal cartilage. Little advance was made until Kaplan and Wesser (1971) combined the use of a scrotal tube with a medial thigh flap which, for the first time, introduced innervated skin to the phalloplasty. They mention the possible apphcation of this flap in female transsexuals. Orticochea (1972) reported a Sstage technique using a gracilis musculocutaneous flap incorporating a silicone rod. This resulted in a semi-erectile, slightly sensate organ but only after 2 years of
168 surgery. Hester et al. (1978) described a similar technique using both gracilis muscles, and tubing a full thickness skin graft for a urethra. They gained external cover by means of scrotal flaps to the shaft base and split skin to the remaining part of the muscle. This was insensitive and non-erectile. Puckett et al. (1982) reported a free flap phalloplasty using a free groin flap which survived in two patients and failed in one. Chang and Hwang (1984) reported the use of a radial artery flap in a single-stage penis reconstruction incorporating autogenous cartilage graft in seven cases (of penile reconstruction in males) with satisfactory results and only one case of fistula. Having previously been unsuccessful, in general, in producing a water-tight urethra using a radial forearm flap, we have decided to compromise in the goals of our surgery in phallus reconstruction. From patient interviews, our operation provides a major goal for female gender reassignment, giving a patient the male symbol of a phallus even if it does not function correctly. Whilst some stiffness to the organ was provided in two cases with a malleable penile prosthesis, this remains experimental, and in our first case the silastic was extruded at one-and-a-half months from the tip of the organ, although in the second case it remains very successful. All our patients were extremely grateful for their surgery and we feel that this simple musculocutaneous flap construction of a phallus allows us to contribute successfully to the process of gender reassignment. In Case 4, the incorporation of a second flap, i.e. the radial forearm flap purely as a simple tube for urethral construction, was undertaken despite the failure of using the radial forearm flap in phallus reconstruction which we have reported earlier. In this particular case the patient had undergone the first stage of urethral diversion 6 months prior to our intended use of the radial forearm flap for total reconstruction of the phallus. This was before the introduction of the rectus abdominis flap described above. The combination of two flaps may allow a safer urethral reconstruction but we caution the use of free flaps in transsexuals who have undergone any period of hormone treatment as it is our experience that some of these patients have a higher incidence of premature atherosclerosis than one would expect.
BRITISH JOURNAL
OF PLASTIC SURGERY
Conclusion
A technique of phallus reconstruction is presented in detail. The extended deep inferior epigastric flap is used to provide a one-staged phallus construction. Appearance of the new phallus is satisfactory and allows a normal sized organ to be produced, and appears to fulfil some of the expectations of these demanding patients.
References Bogoras, N. (1936). Uber die volle plastische Wie derherstellung eines Cum Koitus Fahigen penis (peniplastica Totalis). Zentralblatt Chirurgie, 63,121l. Chang, T. S. and Hwang, W. Y. (1984). Forearm flap in onestage reconstruction of the penis. Plastic and Reconstructive Surgery, 74,25 1. Corlett, R. and Taylor, G. I. (1980). The angiotomes of the body and their relation to local and distant tissue transfer. Paper presented at the British Association of Plastic Surgeons, Summer Meeting, July. GiIlies, H. and Harrison, R. J. (1948). Congenital absence of penis. British Journal of Plastic Surgery, 1,8. Hester, T. R., Hill, H. L. and Jurkiewicz, M. J. (1978). One stage reconstruction of the penis. British Journal of Plastic Surgery, 31,279. Kaplan, I. and Wesser, D. (1971). A rapid method of constructing a functional sensitive penis. British Journal of Plastic Surgery, 24,342. Mat& B. A., Matthews, R. N. and Davies, D. M. (1988). Phalloplasty using the free radial forearm flap. British Journal of Plastic S~rgery~41,OOO. Ortkochea. M. (1972). A new method of total reconstruction of the penis. Briiish Jkrnalof Plastic Surgery, 25,347. Puckett, C. L., R&is&, J. F. and Montie, J. E. (1982). Free flap phalloplasty. Journal of Urology, 128,294. Taylor, G. I., Corlett, R. and Boyd, B. (1983). The extended deep inferior epigastric flap: A clinical technique. Plastic and Reconstructive Surgery, 12,75 1.
The Authors D. M. Davies, FRCS, Consultant Plastic Surgeon. B. A. Mattl, FRCS, Senior Registrar in Plastic Surgery. Department of Plastic Surgery, West Middlesex Hospital, Isleworth, Middlesex TW7 6AF. Requests
for reprints
to Mr D. M. Davies.
Paper received 25 March 1987. Accepted 3 September 1987 after revision.
University
A method of phalloplasty epigastric flap
using the deep inferior
D. M. DAVIES and B. A. MAlTI Department
of Plastic Surgery, West Middlesex
University
Hospital, Isleworth,
Middlesex
Summary-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.
The ideal phallus reconstruction of producing a normal-looking and functioning penis is impossible. To produce an organ capable of transmitting urine to the tip remains extremely difficult and our previous experience has been disappointing (Matti et al., 1988). As a result of this we now counsel our patients that we are only prepared to try and produce a phallus with little function other than as a male symbol and do not undertake urinary diversion. Operative technique The anatomy of the deep inferior epigastric flap has been described in detail by Taylor et aE. (1983) and Corlett and Taylor (1980). The flap is based on the large umbilical perforators (umbilical hub) which are the terminal branches of the deep inferior epigastric artery and allow large skin flaps to be safely raised well lateral to the border of the rectus sheath. A skin flap of variable size is marked out usually as large as is consistent with primary closure (Fig. 1). The dissection is started laterally and the flap is raised including the deep fascia, dissecting medially to the lateral border of the rectus sheath. The anterior rectus sheath and rectus muscle are then divided along the upper border of the flap, ligating the connection between the superior and inferior epigastric vascular system. The incision then passes along the medial border of the flap, skirting the umbilicus. The anterior rectus sheath is divided just lateral to the major skin perforators to leave a fringe of rectus sheath to facilitate primary closure of the sheath. The lower border of the skin flap is divided anteriorly and the incision in the anterior 165
rectus sheath is completed, taking care to incise the sheath above the level of the arcuate line. This isolates the skin flap which is now attached to the underlying muscle by a disc of anterior rectus sheath. The pedicle is dissected from the underside of the rectus muscle laterally towards the external iliac vessels. The rectus muscle is divided transversely inferiorly below the point where the vascular pedicle enters the muscle, leaving the remaining part of the muscle to give extra support to the anterior abdominal wall below the arcuate line. The flap is transposed inferiorly and inset into an incision placed transversely in the mons pubis superior to the clitoris which then lies at the base of the new phallus (Fig. 2). The flap itself is tubed. The donor site of the flap and rectus sheath are closed primarily. In one case we used a prolene mesh to supplement the anterior rectus sheath. In two cases a malleable penile prosthesis was attached with wire sutures to the superior pubic ramus and inserted within the tubed skin paddle which formed the shaft of the penis.
Case reports Case 1
A 27-year-old female pseudohermaphrodite, assigned to a male gender at birth with a chromosomal analysis showing a female 46XX with normal FSH, LH and testosterone levels, was referred for phallus construction. A 15 x 20 cm skin paddle rectus abdominis musculocutaneous flap based on the deep inferior epigastric artery was raised. The flap was extremely thick due to the excessive subcutaneous fat and it was difficult to tube the flap completely and therefore a skin graft was required
BRITISH JOURNAL OF PLASTIC SURGERY
Fig. 2
Fig. 1
Figure l-The design of a right deep inferior epigastric flap measuring 15 x 10 cm based on the umbilical hub. Figure 2-The is transposed inferiorly under a bridge of abdominal skin and tubed and inset into a transverse incision in the mom pubis.
to complete the ventral surface skin cover. Further thinning to this flap will be required at a later date and at present no silastic prosthesis is required because of the inherent stiffness of the organ provided by fat and oedema (Fig. 3).
Case 2 A 30-year-old transsexual was referred, being well integrated in the male role, and requested construction of a phallus prior to living with a female. He had previously undergone a mastectomy and hysterectomy and had had hormone treatment (testosterone) in the past. He underwent a one-stage phalloplasty using the same flap with a skin paddle of 12 x 20 cm. The flap was tubed completely and no skin graft was required for closure. The stiffness of the new phallus was provided by a malleable penile prosthesis (Fig. 4).
Case 3 A 50-year-old transsexual living for many years in the male role with a “wife” had previously undergone unsuccessful radial artery forearm flap phallus construc-
flap
tion due to thrombosis. He subsequently underwent phallus reconstruction using the deep inferior epigastric flap with a skin paddle measuring 15 x 10 cm. The skin tube was closed primarily around a malleable penile prosthesis and the patient made an uneventful postoperative recovery (Fig. 5). At 6 months follow-up the patient maintains the phallus is being used successfully for intercourse.
Case 4 A 33-year-old female-to-male transsexual living as a man from the age of 18 was referred for phallus construction, hysterectomy and mastectomy already having been carried out. He had previously undergone first stage urethral reconstruction whereby two labia minora flaps had been raised to bring the urethral opening forward under the mons pubis. An appropriate radial artery forearm flap was raised and tubed inwards to form a urethra and this was placed within the tubed rectus abdominis flap. The skin paddle measuring 20 x 12 cm could not be tubed completely in the proximal one-third and therefore this part was covered with a skin graft. Two-and-a-half weeks postoperatively all wounds were
A METHOD OF PHALLOPLASTY
USING THE DEEP INFERIOR
Fig. 3
Fig. 5
EPIGASTRIC
167
FLAP
Fig. 4
Fig. 6
Figure 3 Cme I. Result of phallus construction using the deep inferior epigastric flap in a 2i’-year-old pseudohermaphrodite. A skin graft was required to complete the tube. Figure 4-Case 2. A phallus construction stiffened by asilastic prosthesis. Figure 5. Case 3. Phallus construction in a 50-year-old transsexual. Figure bCnsp 4. Phallus construction using a radial artery free flap for urethral construction and a deep inferior epigastric flap for external skin cover.
completely healed and the patient was able to pass his urine successfully from the tip of the reconstructed phallus. with no fistula (Fig. 6).
Discussion Phalloplasty in transsexuals is a formidable task and obtaining a water-tight urethra remains an extremely difficult proposition. Bogoras (1936) was one of the first to construct a penis from an abdominal skin tube in which rib cartilage was implanted. Gillies and Harrison (1948) described a
multi-staged tube pedicle for penile reconstruction using a small tube within a large one and stiffened by a shaft of costal cartilage. Little advance was made until Kaplan and Wesser (1971) combined the use of a scrotal tube with a medial thigh flap which, for the first time, introduced innervated skin to the phalloplasty. They mention the possible apphcation of this flap in female transsexuals. Orticochea (1972) reported a Sstage technique using a gracilis musculocutaneous flap incorporating a silicone rod. This resulted in a semi-erectile, slightly sensate organ but only after 2 years of
168 surgery. Hester et al. (1978) described a similar technique using both gracilis muscles, and tubing a full thickness skin graft for a urethra. They gained external cover by means of scrotal flaps to the shaft base and split skin to the remaining part of the muscle. This was insensitive and non-erectile. Puckett et al. (1982) reported a free flap phalloplasty using a free groin flap which survived in two patients and failed in one. Chang and Hwang (1984) reported the use of a radial artery flap in a single-stage penis reconstruction incorporating autogenous cartilage graft in seven cases (of penile reconstruction in males) with satisfactory results and only one case of fistula. Having previously been unsuccessful, in general, in producing a water-tight urethra using a radial forearm flap, we have decided to compromise in the goals of our surgery in phallus reconstruction. From patient interviews, our operation provides a major goal for female gender reassignment, giving a patient the male symbol of a phallus even if it does not function correctly. Whilst some stiffness to the organ was provided in two cases with a malleable penile prosthesis, this remains experimental, and in our first case the silastic was extruded at one-and-a-half months from the tip of the organ, although in the second case it remains very successful. All our patients were extremely grateful for their surgery and we feel that this simple musculocutaneous flap construction of a phallus allows us to contribute successfully to the process of gender reassignment. In Case 4, the incorporation of a second flap, i.e. the radial forearm flap purely as a simple tube for urethral construction, was undertaken despite the failure of using the radial forearm flap in phallus reconstruction which we have reported earlier. In this particular case the patient had undergone the first stage of urethral diversion 6 months prior to our intended use of the radial forearm flap for total reconstruction of the phallus. This was before the introduction of the rectus abdominis flap described above. The combination of two flaps may allow a safer urethral reconstruction but we caution the use of free flaps in transsexuals who have undergone any period of hormone treatment as it is our experience that some of these patients have a higher incidence of premature atherosclerosis than one would expect.
BRITISH JOURNAL
OF PLASTIC SURGERY
Conclusion
A technique of phallus reconstruction is presented in detail. The extended deep inferior epigastric flap is used to provide a one-staged phallus construction. Appearance of the new phallus is satisfactory and allows a normal sized organ to be produced, and appears to fulfil some of the expectations of these demanding patients.
References Bogoras, N. (1936). Uber die volle plastische Wie derherstellung eines Cum Koitus Fahigen penis (peniplastica Totalis). Zentralblatt Chirurgie, 63,121l. Chang, T. S. and Hwang, W. Y. (1984). Forearm flap in onestage reconstruction of the penis. Plastic and Reconstructive Surgery, 74,25 1. Corlett, R. and Taylor, G. I. (1980). The angiotomes of the body and their relation to local and distant tissue transfer. Paper presented at the British Association of Plastic Surgeons, Summer Meeting, July. GiIlies, H. and Harrison, R. J. (1948). Congenital absence of penis. British Journal of Plastic Surgery, 1,8. Hester, T. R., Hill, H. L. and Jurkiewicz, M. J. (1978). One stage reconstruction of the penis. British Journal of Plastic Surgery, 31,279. Kaplan, I. and Wesser, D. (1971). A rapid method of constructing a functional sensitive penis. British Journal of Plastic Surgery, 24,342. Mat& B. A., Matthews, R. N. and Davies, D. M. (1988). Phalloplasty using the free radial forearm flap. British Journal of Plastic S~rgery~41,OOO. Ortkochea. M. (1972). A new method of total reconstruction of the penis. Briiish Jkrnalof Plastic Surgery, 25,347. Puckett, C. L., R&is&, J. F. and Montie, J. E. (1982). Free flap phalloplasty. Journal of Urology, 128,294. Taylor, G. I., Corlett, R. and Boyd, B. (1983). The extended deep inferior epigastric flap: A clinical technique. Plastic and Reconstructive Surgery, 12,75 1.
The Authors D. M. Davies, FRCS, Consultant Plastic Surgeon. B. A. Mattl, FRCS, Senior Registrar in Plastic Surgery. Department of Plastic Surgery, West Middlesex Hospital, Isleworth, Middlesex TW7 6AF. Requests
for reprints
to Mr D. M. Davies.
Paper received 25 March 1987. Accepted 3 September 1987 after revision.
University