Introduction:The complex anatomy and function of the native penis is difficult to surgically replicate. Metoidioplasty and radial forearm flap phalloplasty (RFFP) are the 2 most commonly utilized procedures for transgender neophallus construction.Methods:A MEDLINE search for metoidioplasty and RFFP in female-to-male genital reconstruction was performed. Primary outcome measures were subsequently compared. A systematic review was planned in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyse guidelines. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was utilized to evaluate the quality of evidence.Results:Using Population, Intervention, Comparison and Outcomes tool criteria, a total of 188 articles were identified; 7 articles related to metoidioplasty and 11 articles related to RFFP met inclusion criteria. The GRADE quality of evidence was low to very low for all included studies. In studies examining metoidioplasty, the average study size and length of follow-up were 54 patients and 4.6 years, respectively (1 study did not report [NR]). Eighty-eight percent underwent a single-stage reconstruction (0 NR), 87% reported an aesthetic neophallus (3 NR), and 100% reported erogenous sensation (2 NR). Fifty-one percent of patients reported successful intercourse (3 NR), and 89% of patients achieved standing micturition (3 NR). In studies examining RFFP, the average study size and follow-up were 60.4 patients and 6.23 years, respectively (6 NR). No patients underwent single-stage reconstructions (8 NR). Seventy percent of patients reported a satisfactorily aesthetic neophallus (4 NR), and 69% reported erogenous sensation (6 NR). Forty-three percent reported successful penetration of partner during intercourse (6 NR), and 89% achieved standing micturition (6 NR). Compared with RFFP, metoidioplasty was significantly more likely to be completed in a single stage (P < 0.0001), have an aesthetic result (P = 0.0002), maintain erogenous sensation (P < 0.0001), achieve standing micturition (P = 0.001), and have a lower overall complication rate (P = 0.02).Conclusions:Although the current literature suggests that metoidioplasty is more likely to yield an “ideal” neophallus compared with RFFP, any conclusion is severely limited by the low quality of available evidence.

Although many transgender individuals are able to realize their gender identity without surgical intervention, a significant and increasing portion of the trans population is seeking gender-confirming surgery (alternatively, gender reassignment surgery, sexual reassignment surgery, or gender-affirming surgery). This review presents a robust overview of genital reconstruction in the female-to-male transgender patient-an operation that, historically, was seldom performed and has remained less surgically feasible than its counterpart (male-to-female genital reconstruction). However, as the visibility and public awareness of the trans community continues to increase, the demand for plastic surgeons equipped to perform these reconstructions is rising. The "ideal" neophallus is aesthetic, maintains tactile and erogenous sensibility, permits sexual function and standing urination, and possesses minimal donor-site and operative morbidity. This article reviews current techniques for surgical construction, including metoidioplasty and phalloplasty, with both pedicled and free flaps. Emphasis is placed on the variety of techniques available for constructing a functional neophallus and neourethra. Preparative procedures (such as vaginectomy, hysterectomy, and oophorectomy) and adjunctive reconstructive procedures (including scrotoplasty and genital prosthesis insertion) are also discussed.

Therapeutic, III.

Background:The availability of acellular dermal matrix (ADM) and synthetic mesh products has prompted plastic surgeons to revisit subcutaneous implant-based breast reconstruction. The literature is limited, however, with regards to evidence on patient selection, techniques, and outcomes.Methods:A systematic review of the Medline and Cochrane databases was performed for original studies reporting breast reconstruction with ADM or mesh, and subcutaneous implant placement. Studies were analyzed for level of evidence, inclusion/exclusion criteria for subcutaneous reconstruction, reconstruction characteristics, and outcomes.Results:Six studies (186 reconstructions) were identified for review. The majority of studies (66.7%) were level IV evidence case series. Eighty percent of studies had contraindications for subcutaneous reconstruction, most commonly preoperative radiation, high body mass index, and active smoking. Forty percent of studies commenting on patient selection assessed mastectomy flap perfusion for subcutaneous reconstruction. Forty-five percent of reconstructions were direct-to-implant, 33.3% 2-stage, and 21.5% single-stage adjustable implant, with ADM utilized in 60.2% of reconstructions versus mesh. Pooled complication rates included: major infection 1.2%, seroma 2.9%, hematoma 2.3%, full nipple-areola complex necrosis 1.1%, partial nipple-areola complex necrosis 4.5%, major flap necrosis 1.8%, wound healing complication 2.3%, explantation 4.1%, and grade III/IV capsular contracture 1.2%.Conclusions:Pooled short-term complication rates in subcutaneous alloplastic breast reconstruction with ADM or mesh are low in preliminary studies with selective patient populations, though techniques and outcomes are variable across studies. Larger comparative studies and better-defined selection criteria and outcomes reporting are needed to develop appropriate indications for performing subcutaneous implant-based reconstruction.