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COMPLETE PHALLOPLASTY WITH A PRELAMINATED OSTEOCUTANEOUS FIBULA FLAP
0022-5347/97/1586-2236$03.oQlo l'm JoUBNAL OF UROLOCY Copyright 8 1997 by ADdE~lcmUROLOCICAL A~SOCIATION, INC.
Vol. 158,2238-2239.December 1997 Printed in U.S.A.
COMPLETE PHALLOPLASTY WITH A PRELAMINATED OSTEOCUTANEOUS FIBULA FLAP CARL C. CAPELOUTO, DENNIS P. ORGILL
AND
KEVIN R. LOUGHLIN
From the Divisions of Urology and Plastic Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
KEY WORDS:penis, skin transplantation, surgical flaps
Penile reconstruction is one of the most challenging procedures in reconstructive surgery. Requirements include shape, patency of the neourethra, skin texture, sensation and rigidity. Developments in penile reconstruction have paralleled the evolution of reconstructive surgery. Initially tubed pedicled skin flaps were used, followed by myocutaneous flaps. Recently microsurgical-free flaps were introduced in the mid 1980s.l While radical forearm flaps have provided an esthetically pleasing phallus, achieving rigidity with a prosthesis often leads to complications and failure.2.3 In addition the forearm flap donor site requires the loss of most of the skin of the forearm.4 In 1993 Sadove et a1 reported the first penile reconstruction with an osteocutaneous-free fibula flap.4 Results were excellent except for the development of a urethrocutaneous fistula in 2 of 3 patients in whom a neourethra had been constructed. In another patient a urethral stricture developed that required internal urethrotomy. We decribe total penile reconstruction using a prelaminated osteocutaneous-free fibula flap. The urethral reconstruction using a skin graft was tubularized and implanted in the lower leg skin before microvascular transfer. We report our modification of this technique using a prelaminated flap. Our modification uses a free gr& as the neourethra, which is transferred into a tunnel of the recipient flap on the lateral aspect of the lower leg. Three months later the neourethra and recipient flap are harvested en bloc to optimize blood supply to the neophallus and neourethra.
FIG.1. A, full-thickness skin graft to fashion neourethra. B, neourethra tunneled in lower leg.
CASE REPORT
A 23-year-old man had severe second and third degree burns on the lower abdomen, genitalia and anterior thighs. After multiple debridements for necrotic tissue the patient was ultimately left with nearly complete loss of the phallus. Three months later a full-thickness 20 X 2.4 cm. skin graft was harvested from a hairless region of the left upper lateral chest wall. The skin graft was everted and sutured in 2 layers with 4-zero polyglactin and 5-zero chromic suture over a 16F Foley catheter (fig. 1, A). The catheter was then placed in a tunnel in the lateral aspect of the lower leg (fig. 1,B).Flexible endoscopy of the neourethra 6 weeks later confirmed adequate viability of the skin graft. Three months later the patient underwent penile reconstruction. A lateral lower leg 11 x 12 cm. area of skin was diagrammed with a pedicle based on the peroneal artery and vein. The flap included the neourethra that was placed 4 '/2 months before final reconstruction. A fasciocutaneous flap was elevated under tourniquet control. The lateral sural nerve was identified and preserved. The fibula was divided 8 cm. proximal to the lateral malleolus and 8 cm. distal to the fibular head. The flap was then tubularized in situ (fig. 2). The femoral vessels on the right were exposed. In addition the native penile stump was mobilized to expose the corporeal bodies, urethra and dorsal nerves of the penis (fig. 3). The peroneal were divided to their Origin- and the flap was transferred to the recipient site. A subcutaneous was made O' m the area t' the scrotum t' allow passage of the peroneal vessels without tension. A Accepted for publication May 23, 1997.
FIG. 2. Graft harvested from lower leg
microscopic end-to-side anastomosis was created between the superficial femoral artery and peroneal artery with a running 6-zero polypropylene suture. The peroneal vein was anastomosed to the saphenous vein in a similar fashion. A single anastomosis was constructed between the neourethra
2238
2239
COMPLETE PHALLOPLASTY
The patient voids with a strong stream and tactile but not erogenous sensation is present. He is sexually active and reports that seminal emission is intact. There is full range of motion of the neophallus and erections are transmitted to the fibula via the corporeal stumps, resulting in elevation of the entire neophallus. The flap donor site is well healed. DISCUSSION
The goals of total penile reconstruction include function and esthetics. There should be a shaft of adequate length for intromission, a urethra able to transmit urine and semen, and a glans with at least tactile and preferably erogenous sensation and rigidity to allow penetration during interFIG. 3. Graft sites prepared before anastomoses. u., vein. a., course. The fibula phallus offers several advantages over the artery. radial forearm flap. The fibula flap has intrinsic rigidity due to its bone content, thus, avoiding the need for a penile and the native urethra over a 16F Foley catheter with a prosthesis and its attendant complications. The long-term 4-zero polyglactin suture. A tension-free neurorrhaphy was functional loss from the use of the fibula in other reconstructive procedures is minimal.5 The donor site is also much less performed between the lateral sural and dorsal nerves of the penis with 9-zero nylon. The corporeal stumps were secured disfiguring and can be covered by a sock. The vascular anastomosis for the fibula flap is easier to construct, since the to the base of the fibula with 2, 2-zero polypropylene sutures passed through small drill holes in the fibula (fig. 4). The pedicle is long enough to allow direct anastomosis with the neophallus was sutured to the penile skin in 2 layers with femoral artery. We believe that our technique of a prelami4-Zero polyglactin and 4-Zero chromic sutures. At the conclu- nated neourethra has several benefits. It is technically easy sion of the procedure a strong Doppler ultrasound signal was to perform, is the risk of fistula formation and urethral stricture is possibly decreased as a result of improved vascularity present t o the tip of the neophallus. A retrograde urethrogram at 3 weeks showed no extrava- to the neourethra. sation and the catheter was removed. At 1-year followup the REFERENCES patient has had no complications and cosmesis is excellent. 1. Hage, J.J.,Bloem, J. J. A. M. and Suliman, H. M.: Review of the literature on techniques for phalloplasty with emphasis on the applicability in female-to-male transsexuals. J. Urol., 1M): 1093, 1993. 2. Upton, J., Mutimer, K. L., Loughlin, K. and Ritchie, J.: Penile reconstruction wine the lateral arm flaD. J. Rov. Coll. Sure. Edinburgh, 3 2 97,7987. 3. Jordan. G. H.. Alter. G. J., Gilbert, D. A,, Horton. C. E. and Devine, C. J., Jr.: Penile prosthesis implantation in total phalloplasty. J. Urol., 1 6 2 410, 1994. 4. Sadove, R. C., Sengezer, M., McRoberts, J. W. and Wells, M. D.: One-stage total penile reconstruction with a free sensate osteocutaneous fibula flap. Plast. Reconstr. Surg., 92: 1314, 1993. 5. Ganel, A. and Yaffe, B.: Ankle instability of the donor site following removal of vascularized fibula bone graft. Ann. Plast. Surg., 24: 7, 1990. I
FIG. 4. Neophallus in place. u., vein. a., artery
Vol. 158,2238-2239.December 1997 Printed in U.S.A.
COMPLETE PHALLOPLASTY WITH A PRELAMINATED OSTEOCUTANEOUS FIBULA FLAP CARL C. CAPELOUTO, DENNIS P. ORGILL
AND
KEVIN R. LOUGHLIN
From the Divisions of Urology and Plastic Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
KEY WORDS:penis, skin transplantation, surgical flaps
Penile reconstruction is one of the most challenging procedures in reconstructive surgery. Requirements include shape, patency of the neourethra, skin texture, sensation and rigidity. Developments in penile reconstruction have paralleled the evolution of reconstructive surgery. Initially tubed pedicled skin flaps were used, followed by myocutaneous flaps. Recently microsurgical-free flaps were introduced in the mid 1980s.l While radical forearm flaps have provided an esthetically pleasing phallus, achieving rigidity with a prosthesis often leads to complications and failure.2.3 In addition the forearm flap donor site requires the loss of most of the skin of the forearm.4 In 1993 Sadove et a1 reported the first penile reconstruction with an osteocutaneous-free fibula flap.4 Results were excellent except for the development of a urethrocutaneous fistula in 2 of 3 patients in whom a neourethra had been constructed. In another patient a urethral stricture developed that required internal urethrotomy. We decribe total penile reconstruction using a prelaminated osteocutaneous-free fibula flap. The urethral reconstruction using a skin graft was tubularized and implanted in the lower leg skin before microvascular transfer. We report our modification of this technique using a prelaminated flap. Our modification uses a free gr& as the neourethra, which is transferred into a tunnel of the recipient flap on the lateral aspect of the lower leg. Three months later the neourethra and recipient flap are harvested en bloc to optimize blood supply to the neophallus and neourethra.
FIG.1. A, full-thickness skin graft to fashion neourethra. B, neourethra tunneled in lower leg.
CASE REPORT
A 23-year-old man had severe second and third degree burns on the lower abdomen, genitalia and anterior thighs. After multiple debridements for necrotic tissue the patient was ultimately left with nearly complete loss of the phallus. Three months later a full-thickness 20 X 2.4 cm. skin graft was harvested from a hairless region of the left upper lateral chest wall. The skin graft was everted and sutured in 2 layers with 4-zero polyglactin and 5-zero chromic suture over a 16F Foley catheter (fig. 1, A). The catheter was then placed in a tunnel in the lateral aspect of the lower leg (fig. 1,B).Flexible endoscopy of the neourethra 6 weeks later confirmed adequate viability of the skin graft. Three months later the patient underwent penile reconstruction. A lateral lower leg 11 x 12 cm. area of skin was diagrammed with a pedicle based on the peroneal artery and vein. The flap included the neourethra that was placed 4 '/2 months before final reconstruction. A fasciocutaneous flap was elevated under tourniquet control. The lateral sural nerve was identified and preserved. The fibula was divided 8 cm. proximal to the lateral malleolus and 8 cm. distal to the fibular head. The flap was then tubularized in situ (fig. 2). The femoral vessels on the right were exposed. In addition the native penile stump was mobilized to expose the corporeal bodies, urethra and dorsal nerves of the penis (fig. 3). The peroneal were divided to their Origin- and the flap was transferred to the recipient site. A subcutaneous was made O' m the area t' the scrotum t' allow passage of the peroneal vessels without tension. A Accepted for publication May 23, 1997.
FIG. 2. Graft harvested from lower leg
microscopic end-to-side anastomosis was created between the superficial femoral artery and peroneal artery with a running 6-zero polypropylene suture. The peroneal vein was anastomosed to the saphenous vein in a similar fashion. A single anastomosis was constructed between the neourethra
2238
2239
COMPLETE PHALLOPLASTY
The patient voids with a strong stream and tactile but not erogenous sensation is present. He is sexually active and reports that seminal emission is intact. There is full range of motion of the neophallus and erections are transmitted to the fibula via the corporeal stumps, resulting in elevation of the entire neophallus. The flap donor site is well healed. DISCUSSION
The goals of total penile reconstruction include function and esthetics. There should be a shaft of adequate length for intromission, a urethra able to transmit urine and semen, and a glans with at least tactile and preferably erogenous sensation and rigidity to allow penetration during interFIG. 3. Graft sites prepared before anastomoses. u., vein. a., course. The fibula phallus offers several advantages over the artery. radial forearm flap. The fibula flap has intrinsic rigidity due to its bone content, thus, avoiding the need for a penile and the native urethra over a 16F Foley catheter with a prosthesis and its attendant complications. The long-term 4-zero polyglactin suture. A tension-free neurorrhaphy was functional loss from the use of the fibula in other reconstructive procedures is minimal.5 The donor site is also much less performed between the lateral sural and dorsal nerves of the penis with 9-zero nylon. The corporeal stumps were secured disfiguring and can be covered by a sock. The vascular anastomosis for the fibula flap is easier to construct, since the to the base of the fibula with 2, 2-zero polypropylene sutures passed through small drill holes in the fibula (fig. 4). The pedicle is long enough to allow direct anastomosis with the neophallus was sutured to the penile skin in 2 layers with femoral artery. We believe that our technique of a prelami4-Zero polyglactin and 4-Zero chromic sutures. At the conclu- nated neourethra has several benefits. It is technically easy sion of the procedure a strong Doppler ultrasound signal was to perform, is the risk of fistula formation and urethral stricture is possibly decreased as a result of improved vascularity present t o the tip of the neophallus. A retrograde urethrogram at 3 weeks showed no extrava- to the neourethra. sation and the catheter was removed. At 1-year followup the REFERENCES patient has had no complications and cosmesis is excellent. 1. Hage, J.J.,Bloem, J. J. A. M. and Suliman, H. M.: Review of the literature on techniques for phalloplasty with emphasis on the applicability in female-to-male transsexuals. J. Urol., 1M): 1093, 1993. 2. Upton, J., Mutimer, K. L., Loughlin, K. and Ritchie, J.: Penile reconstruction wine the lateral arm flaD. J. Rov. Coll. Sure. Edinburgh, 3 2 97,7987. 3. Jordan. G. H.. Alter. G. J., Gilbert, D. A,, Horton. C. E. and Devine, C. J., Jr.: Penile prosthesis implantation in total phalloplasty. J. Urol., 1 6 2 410, 1994. 4. Sadove, R. C., Sengezer, M., McRoberts, J. W. and Wells, M. D.: One-stage total penile reconstruction with a free sensate osteocutaneous fibula flap. Plast. Reconstr. Surg., 92: 1314, 1993. 5. Ganel, A. and Yaffe, B.: Ankle instability of the donor site following removal of vascularized fibula bone graft. Ann. Plast. Surg., 24: 7, 1990. I
FIG. 4. Neophallus in place. u., vein. a., artery