Question

Describe the flap planning and operative steps of a radial forearm flap phalloplasty.

Hint:

Radial forearm flap phalloplasty is a complex but highly effective procedure for creating a neophallus, offering excellent aesthetic and functional outcomes when performed with careful planning and microsurgical techniques.

Answer 1

Radial forearm flap phalloplasty is one of the most commonly used techniques for genital reconstruction in transgender men. The procedure involves using a flap of tissue from the forearm to create a neophallus, often combined with urethral reconstruction. The planning and surgical steps require careful consideration of anatomical, functional, and aesthetic goals.
Step 1: Preoperative Planning:
- Marking the Flap: The radial forearm flap is marked on the patient’s forearm. The area of skin and subcutaneous tissue, which includes the radial artery, is marked to ensure adequate tissue for creating the neophallus. The flap is usually harvested from the non-dominant arm to minimize postoperative functional impairment.
- Vascular Considerations: The radial artery, along with the vena comitantes, is preserved during dissection to ensure proper blood supply to the flap. The length and width of the flap must be tailored to the size of the neophallus to be created.
Step 2: Flap Harvesting:
- Incision and Dissection: A careful incision is made along the radial forearm, ensuring that the radial artery and veins are preserved. The flap is elevated in a manner that maintains the vascularity of the flap, and the underlying structures, such as nerves and muscles, are preserved.
- Harvesting the Radial Forearm Flap: The radial forearm flap is harvested as a thin, pliable tissue, which includes both skin and subcutaneous tissue. The radial artery is carefully dissected to ensure it can be used for anastomosis later in the procedure.
Step 3: Creation of the Neophallus:
- Flap Tubularization: Once the flap is harvested, it is tubularized to form the shaft of the neophallus. The skin is sutured to create a cylindrical shape that matches the desired appearance of the phallus.
- Urethral Reconstruction: The urethra is reconstructed using tissue from the radial forearm flap or other donor sites. The neourethra is created in a tubular fashion to allow for future micturition. The urethral anastomosis is performed in stages, ensuring a watertight closure.
Step 4: Surgical Steps for Phalloplasty:
- Attachment of the Flap: The neophallus is then attached to the pubic area or pelvic region. The radial artery and vein are connected to recipient vessels in the groin or other appropriate anatomical locations using microsurgical techniques to ensure proper blood flow to the flap.
- Urethra Construction: The neourethra is carefully connected to the perineum, ensuring the urethra can be used for urination. Anastomosis is performed under magnification to ensure patency and prevent complications such as fistulas or strictures.
Step 5: Postoperative Care and Monitoring:
- Monitoring the Flap: The flap is closely monitored for signs of ischemia, infection, or other complications. Regular checks are performed to ensure adequate blood flow and proper function of the neophallus.
- Rehabilitation: Postoperative rehabilitation, including pelvic floor therapy and the use of a urinary catheter, is essential for ensuring that the patient can urinate properly and that the flap heals without complications.