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ASRM #2 A Single Institution Experience with 116 Consecutive Free-Flap and Pedicled Phalloplasties
Bauback Safa, MD, MBA, FACS1; Andrew J. Watt, MD1; Curtis Crane, MD2
1The Buncke Clinic, San Francisco, CA, 2Brownstein & Crane Surgical Services, Greenbrae, CA

Introduction: Numerous phalloplasty techniques have been described for the female-to-male transgender population. Three of the most common flaps used today are the radial forearm flap, the anterolateral thigh flap, and the musculocutaneous latissimus dorsi flap. While there has been a large series of radial forearm flaps published in the past, there has not been a large series published in the United States. Also, no large series has been published comparing outcomes of these three flaps.

Materials and Methods: A retrospective review of all female-to-male phalloplasties from April 2013 to June 2015 was done. Complications including total flap loss, partial flap loss, flap take-back, hematomas, urethral strictures, fistulas, and meatal stenosis were reviewed. Outcomes measured included flap survival, sensory return, the ability to urinate through the phallus, and patient satisfaction.

Results: In total, 116 phalloplasties were performed at our institution. These included 71 radial forearm flaps (61%), 43 anterolateral thigh flaps (37%), and 2 musculocutaneous latissimus dorsi flaps (2%). There were no flap losses (0%) and four partial flap losses (3%). None of the partial losses exceeded 30% of the flap. Five flaps (4%) were re-explored for vascular compromise (three for arterial compromise, two for venous compromise) and all flaps were salvaged. The take-back rate for the first 16 flaps was 19%; the take-back rate for the remaining 100 flaps was 2%. The hematoma rate was 6% (n=7; three donor site hematomas, four groin hematomas). Of the 73 radial forearm flaps, the common femoral or superficial femoral artery were used as recipient vessels (end-to-side) in 71 cases (97%); a side branch was used in two cases (3%). The saphenous vein or a branch off the sapheno-femoral junction was used for all venous anastomoses. Urethral fistula and stenosis rates were 16% and 20% respectively. The rate of meatal stenosis was 5%. Of the radial forearm and ALT flaps that have reached an end-point of nerve regeneration, 99% have had return of tactile sensation; 85% have had return of erogenous sensation. There were no significant differences between the two groups. Neither latissimus musculocutaneous flap patients had return of tactile or erogenous sensation.

Conclusions: To our knowledge, this is the largest presented series of phalloplasties in the United States. This series shows that both the radial forearm and the anterolateral thigh flap (in select patients) can be viable options for an aesthetic and functional phalloplasty with good sensation and low fistula rates compared to other published series.

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