Peter Ceulemans

Penile reconstruction: is the radial forearm flap really the standard technique?

Background: The ideal goals in penile reconstruction are well described, but the multitude of flaps used for phalloplasty only demonstrates that none of these techniques is considered ideal. Still, the radial forearm flap is the most frequently used flap and universally considered as the standard technique. Methods: In this article, the authors describe the largest series to date of 287 radial forearm phalloplasties performed by the same surgical team. Many different outcome parameters have been described separately in previously published articles, but the main purpose of this review is to critically evaluate to what degree this supposed standard technique has been able to meet the ideal goals in penile reconstruction. Results: Outcome parameters such as number of procedures, complications, aesthetic outcome, tactile and erogenous sensation, voiding, donor-site morbidity, scrotoplasty, and sexual intercourse are assessed. Conclusions: In the absence of prospective randomized studies, it is not possible to prove whether the radial forearm flap truly is the standard technique in penile reconstruction. However, this large study demonstrates that the radial forearm phalloplasty is a very reliable technique for the creation, mostly in two stages, of a normal-appearing penis and scrotum, always allowing the patient to void while standing and in most cases also to experience sexual satisfaction. The relative disadvantages of this technique are the rather high number of initial fistulas, the residual scar on the forearm, and the potential long-term urologic complications. Despite the lack of actual data to support this statement, the authors feel strongly that a multidisciplinary approach with close cooperation between the reconstructive/plastic surgeon and the urologist is an absolute requisite for obtaining the best possible results.

Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals.

Learning Objectives: After studying this article, the participant should be able to discuss: 1. The terminology related to male-to-female gender dysphoria. 2. The different theories regarding cause, epidemiology, and treatment of gender dysphoria. 3. The surgical goals of sex reassignment surgery in male-to-female transsexualism. 4. The surgical techniques available for sex reassignment surgery in male-to-female transsexualism. Background: Gender identity disorder (previously “transsexualism”) is the term used for individuals who show a strong and persistent cross-gender identification and a persistent discomfort with their anatomical sex, as manifested by a preoccupation with getting rid of ones sex characteristics, or the belief of being born in the wrong sex. Since 1978, the Harry Benjamin International Gender Dysphoria Association (in honor of Dr. Harry Benjamin, one of the first physicians who made many clinicians aware of the potential benefits of sex reassignment surgery) has played a major role in the research and treatment of gender identity disorder, publishing the Standards of Care for Gender Dysphoric Persons. Methods: The authors performed an overview of the terminology related to male-to-female gender identity disorder; the different theories regarding cause, epidemiology, and treatment; the goals expected; and the surgical technique available for sex reassignment surgery in male-to-female transsexualism. Results: Surgical techniques available for sex reassignment surgery in male-to-female transsexualism, with advantages and disadvantages offered by each technique, are reviewed. Other feminizing nongenital operative interventions are also examined. Conclusions: This review describes recent etiopathogenetic theories and actual guidelines on the treatment of the gender identity disorder in male-to-female transsexuals; the penile-scrotal skin flap technique is considered the state of the art for vaginoplasty in male-to-female transsexuals, whereas other techniques (rectosigmoid flap, local flaps, and isolated skin grafts) should be considered only in secondary cases. As techniques in vaginoplasty become more refined, more emphasis is being placed on aesthetic outcomes by both surgeons and patients.

Genital sensitivity after sex reassignment surgery in transsexual patients.

Background:Tactile and erogenous sensitivity in reconstructed genitals is one of the goals in sex reassignment surgery. Since November 1993 until April 2003, a total of 105 phalloplasties with the radial forearm free flap and 127 vaginoclitoridoplasties with the inverted penoscrotal skin flap and the dorsal glans pedicled flap have been performed at Ghent University Hospital. The specific surgical tricks used to preserve genital and tactile sensitivity are presented. In phalloplasty, the dorsal hood of the clitoris is incorporated into the neoscrotum; the clitoris is transposed, buried, and fixed directly below the reconstructed phallic shaft; and the medial and lateral antebrachial nerves are coapted to the inguinal nerve and to one of the 2 dorsal nerves of the clitoris. In vaginoplasty, the clitoris is reconstructed from a part of the glans penis inclusive of a part of the corona, the inner side of the prepuce is used to reconstruct the labia minora, and the penile shaft is inverted to line the vaginal cavity. Material and Methods:A long-term sensitivity evaluation (performed by the Semmes-Weinstein monofilament and the Vibration tests) of 27 reconstructed phalli and 30 clitorises has been performed. Results:The average pressure and vibratory thresholds values for the phallus tip were, respectively, 11.1 g/mm2 and 3 &mgr;m. These values have been compared with the ones of the forearm (donor site). The average pressure and vibratory thresholds values for the clitoris were, respectively, 11.1 g/mm2 and 0.5 &mgr;m. These values have been compared with the ones of the normal male glans, taken from the literature. We also asked the examined patients if they experienced orgasm after surgery, during any sexual practice (ie, we considered only patients who attempted to have orgasm): all female-to-male and 85% of the male-to-female patients reported orgasm. Conclusion:With our techniques, the reconstructed genitalia obtain tactile and erogenous sensitivity. To obtain a good tactile sensitivity in the reconstructed phallus, we believe that the coaptation of the cutaneous nerves of the flap with the ilioinguinalis nerve and with one of the 2 nerves of the clitoris is essential in obtaining this result. To obtain orgasm after phalloplasty, we believe that preservation of the clitoris beneath the reconstructed phallus and some preservation of the clitoris hood are essential. To obtain orgasm after a vaginoplasty, the reconstruction of the clitoris from the neurovascular pedicled glans flap is essential.

Chest-wall contouring surgery in female-to-male transsexuals: a new algorithm.

Background: In female-to-male transsexuals, the first surgical procedure in their reassignment surgery consists of the subcutaneous mastectomy. The goals of subcutaneous mastectomy are removal of breast tissue, removal of excess skin, reduction and proper positioning of the nipple and areola, and ideally, minimization of chest-wall scars. The authors present the largest series to date of female-to-male transsexuals who have undergone subcutaneous mastectomy. Methods: A total of 184 subcutaneous mastectomies were performed in 92 female-to-male transsexuals, using the following five techniques: semicircular, transareolar, concentric circular, extended concentric circular, and free nipple graft. The technique used depended on the breast size and envelope, the aspect and position of the nipple-areola complex, and the skin elasticity. To best meet the goals of creating a normal male thorax, the authors have developed an algorithm to aid in choosing the appropriate procedure. Results: The overall postoperative complication rate was 12.5 percent (23 of 184 subcutaneous mastectomies), and in eight of these cases (4.3 percent), an additional operative intervention was required because of hematoma, infection, and/or wound dehiscence. Despite this low complication rate, additional procedures for improving aesthetic results were performed on 59 breasts (32.1 percent). The semicircular and concentric circular techniques produced the highest rating of the overall result by patient and surgeon, whereas the extended concentric circular technique produced the lowest rating. Conclusions: Skin excess and skin elasticity are the key factors in choosing the appropriate technique for subcutaneous mastectomy, which is reflected in the algorithm. Although the complication rate is low and patient satisfaction is high, secondary aesthetic corrections are often indicated.

Obtaining Rigidity in Total Phalloplasty: Experience With 35 Patients

PURPOSE The combination of a neourethra and erection prosthesis in a single neophallus in the female-to-male transsexual remains a challenge. The outcome reported in the literature is disappointing. We report our experience with 35 patients. MATERIALS AND METHODS Between August 1996 and December 2001, 35 patients underwent implantation surgery. A 1-piece hydraulic Dynaflex prosthesis (American Medical Systems, Minnetonka, Minnesota) was used in 10 patients, while a 3-piece hydraulic CXM and CX (American Medical Systems) prosthesis was placed in 9 and 16, respectively. The 1-piece model was withdrawn from the market in 1997. Thereafter a 3-piece prosthesis was implanted. RESULTS Of 10 patients in the 1-piece group prosthesis implantation was uneventful in 8. In 2 patients with technical failure the prosthesis was replaced, including 1 in whom the new prosthesis was removed due to infection and successfully replaced by a 3-piece prosthesis. To date at a mean followup of 3.5 years 9 patients have a 1-piece hydraulic prosthesis in place. In the 3-piece prosthesis group of 25 patients implantation was uneventful in 20. In 1 patient infection and partial necrosis of the neophallus developed, 2 had infection, in 1 a cylinder perforated the tip of the phallus and in 1 technical failure occurred. Of the latter 4 patients the prosthesis was replaced successfully in 2 patients, while the other 2 are on the waiting list. The patient with partial necrosis of the phallus is no longer a candidate for an erection prosthesis. To date at a mean followup of 1.8 years 23 patients have a 3-piece hydraulic prosthesis in place. A single patient in the 1-piece group has a 3-piece CX prosthesis. CONCLUSIONS Good results were observed after implantation of the Dynaflex prosthesis in patients who underwent total phalloplasty. This model is no longer available today. For the more complex 3-piece CX and CXM prostheses implantation results are comparable to those of the 1-piece model.

Sex Reassignment Surgery in the Female-to-Male Transsexual

In female-to-male transsexuals, the operative procedures are usually performed in different stages: first the subcutaneous mastectomy which is often combined with a hysterectomy-ovarectomy (endoscopically assisted). The next operative procedure consists of the genital transformation and includes a vaginectomy, a reconstruction of the horizontal part of the urethra, a scrotoplasty and a penile reconstruction usually with a radial forearm flap (or an alternative). After about one year, penile (erection) prosthesis and testicular prostheses can be implanted when sensation has returned to the tip of the penis. The authors provide a state-of-the-art overview of the different gender reassignment surgery procedures that can be performed in a female-to-male transsexual.

Phalloplasty: a valuable treatment for males with penile insufficiency

OBJECTIVES To apply a phalloplasty technique used in female-to-male transsexual surgery in male patients with penile insufficiency. METHODS Seven male patients (aged 15 to 42 years) were treated with phalloplasty (6 with radial forearm free flap and one with anterolateral thigh flap) between March 2004 and April 2006 (follow-up, 9 to 34 months). All patients suffered psychologically from their condition, with low self-esteem and sexual and relational dysfunction. They were evaluated by a sexologist-psychiatrist before and after surgery. Erectile implant surgery is offered approximately 1 year after the phallic reconstruction. RESULTS There were no complications concerning the flap. Two complications were reported in the early postoperative period. Two patients developed urinary complications (stricture and/or fistula). Patient satisfaction after surgery was high in 6 cases and moderate in 1 case. Psychological evaluation confirms this, especially on the self-esteem level. Four patients underwent erectile implant surgery. In 2 patients the erectile implant had to be removed. CONCLUSIONS This success has convinced us that phalloplasty is a valuable treatment for penile insufficiency. It has good results in terms of patient self-esteem and sexual well-being. This technique opens new horizons for the treatment of penile agenesis, micropenis, crippled penis, shrivelled penis, some disorders of sexual development, traumatic amputations, and cloacal exstrophy.

Donor-site morbidity of the radial forearm free flap after 125 phalloplasties in gender identity disorder.

The ideal phalloplasty should include all of the following: a one-stage procedure that is predictable and reproducible; minimal donor-site disfigurement; no functional loss; and an aesthetically acceptable phallus, including a competent neourethra that will allow for voiding while standing, with tactile and erogenous sensation, and enough bulk to tolerate the insertion of an erectile prosthesis for sexual intercourse.1–3 Many of these goals can be met with a large radial forearm free flap, which has become the accepted standard for the creation of a phallus in female-to-male transsexuals.1 Most commonly, however, the radial forearm free flap is harvested as a small to moderate-sized flap, often for use in head and neck reconstruction. The reported morbidity is not negligible and includes impaired healing, poor scarring, and unaesthetic results, as well as varying degrees of functional loss.4–11 When the flap is used to construct a phallus, a considerably larger flap is required, often involving the entire circumference of the forearm. The major disadvantage of the flap is its donor-site morbidity, including a readily apparent and potentially stigmatizing scar on the forearm. Several techniques have been described to improve the functional and aesthetic outcome of the donor site following the harvest of a radial forearm free flap, including primary closure12; purse-string closure13; split-thickness skin grafts14; full-thickness skin grafts14 –16; tissue expansion17–19; closure with local flaps12,20 –22; cross-suturing23; the use of artificial dermis24–26; the use of local fascial flaps27–29; and the mobilization and approximation of adjacent muscles.4,30–31 In most of these cases, however, the reported techniques apply to small flaps used mainly for head and neck reconstruction. Similarly, long-term follow-up studies of donor-site morbidity following a radial forearm free flap focus almost exclusively on smaller dimension flaps. Reported problems include bone fracture, limited range of motion, decreased pinch and grip strength, graft loss, and sensory changes.4–8 No publication was found focusing on functional and aesthetic improvement of the donor site when a large radial forearm free flap is harvested for use in phalloplasty. The dimensions of the flap for this specific indication always exceed 14 cm in both directions, often utilizing the entire circumference of the forearm. It usually includes all superficial veins and both medial and lateral antebrachial cutaneous nerves. To investigate the hypothesis that the use of a large radial forearm free flap would result in significantly more donor-site morbidity, a retrospective examination was conducted of early and late results in a long-term follow-up study. Specifically, the focus was on the occurrence of functional compromise and how the long-term aesthetic outcome of the donor site was perceived by both patient and surgeon. This article presents the first long-term follow-up study of donor-site morbidity following the harvest of a very large radial forearm free flap with the specific indication of constructing a phallus in the feFrom the Departments of Plastic Surgery and Urology, University Hospital. Received for publication June 2, 2005; accepted September 13, 2005. Copyright ©2006 by the American Society of Plastic Surgeons

Scrotal Reconstruction in Female-to-Male Transsexuals: A Novel Scrotoplasty

Background: One of the goals of genital construction in female-to-male transsexuals is the creation of an aesthetically acceptable result, both for phallus and scrotum, leaving minimal morbidity and recreating function. In the last 15 years, transsexuals have become more demanding, and scrotoplasty has received more attention than before. Traditional flaps for scrotal reconstruction in a biological male do not really apply in transsexuals: the labia majora seem to achieve the best results; still, they may not provide enough tissue and can be located much too posteriorly. Methods: Since November of 1993, more than 300 scrotal reconstructions (and radial forearm flap phalloplasties) have been performed in female-to-male transsexuals by the authors’ gender team. Based on the authors’ large experience, they modified previous techniques and developed a novel scrotoplasty consisting of a V-Y advancement of the major labia together with a rotation of these superiorly based labial flaps. Refinements (to achieve better sensation and shaping) are described. Twelve months after the original operation, one testicle implant and erection prosthesis procedures were performed. Results: No major complications related to scrotoplasty occurred in the authors’ series. Patients were all pleased at short- or long-term follow-up with their scrotum, located in its natural position in front of the legs. Conclusion: The authors’ novel scrotoplasty can become the ultimate surgical technique to reconstruct the scrotum in female-to-male transsexual patients, further improving the final cosmetic result, with the possibility of enhanced erogenous sensitivity.

Reconstructive Surgery for Severe Penile Inadequacy: Phalloplasty with a Free Radial Forearm Flap or a Pedicled Anterolateral Thigh Flap

Objectives. Severe penile inadequacy in adolescents is rare. Phallic reconstruction to treat this devastating condition is a major challenge to the reconstructive surgeon. Phallic reconstruction using the free radial forearm flap (RFF) or the pedicled anterolateral thigh flap (ALTF) has been routinely used in female-to-male transsexuals. Recently we started to use these techniques in the treatment of severe penile inadequacy. Methods. Eleven males (age 15 to 42 years) were treated with a phallic reconstruction. The RFF is our method of choice; the ALTF is an alternative when a free flap is contraindicated or less desired by the patient. The RFF was used in 7 patients, the ALTF in 4 patients. Mean followup was 25 months (range: 4–49 months). Aesthetic and functional results were evaluated. Results. There were no complications related to the flap. Aesthetic results were judged as “good” in 9 patients and “moderate” in 2 patients. Sensitivity in the RFF was superior compared to the ALTF. Four patients developed urinary complications (stricture and/or fistula). Six patients underwent erectile implant surgery. In 2 patients the erectile implant had to be removed due to infection or erosion. Conclusion. In case of severe penile inadequacy due to whatever condition, a phalloplasty is the preferred treatment nowadays. The free radial forearm flap is still the method of choice. The anterolateral thigh flap can be a good alternative, especially when free flaps are contraindicated, but sensitivity is markedly inferior in these flaps.