Addressing the ideal requirements by free flap phalloplasty: Some reflections on refinements of technique

Abstract

Ideally, in phalloplasty one should aim at 1) a one-stage procedure that can be predictably reproduced, 2) creation of a competent neo-urethra to allow for voiding while standing, 3) return of both tactile and erogenous sensibility, 4) enough bulk to tolerate the insertion of a prosthetic stiffener, and 5) a result that is aesthetically acceptable to the patient. We consider 6) minimal scarring or disfigurement, and 7) no functional loss in the donor area further requirements for any ideal procedure. Thanks to ongoing refinements, microsurgical free flap phalloplasty techniques lead to the best results, both functionally and cosmetically. These refinements are presented and discussed, as are our experiences applying them.

A Systematic Review of Metoidioplasty and Radial Forearm Flap Phalloplasty in Female-to-male Transgender Genital Reconstruction: Is the “Ideal” Neophallus an Achievable Goal?

“…According to Hage and De Graaf 9,10 , the “ideal” neophallus is crafted reproducibly in a single-stage procedure, is aesthetic, has tactile and erogenous sensation, has a functional neourethra to permit standing urination, and is associated with minimal complications and donor-site morbidity. Despite recent advances, no singular surgical technique is yet capable of effectively and reliably meeting all of these goals.…”

“…In accordance with description of the “ideal” neophallus by Hage and De Graaf, 9 the following primary outcome measures were utilized: proportion of reconstructions performed in a single-stage, degree of aesthetic satisfaction and erogenous/tactile sensation, rate of neourethral stricture and fistulas, proportion of patients able to successfully penetrate partner during intercourse, rate of standing micturition, and rates of donor-site morbidity and overall complications. A systematic review was carried out in accordance with PRISMA guidelines.…”

“…Similarly, the notion of an “ideal” bottom surgery outcome has not been articulated from the perspective of patients’ whose desires and preferences have scarcely been queried in a formal research capacity. In 1993, Hage and De Graaf 9,10 described the “ideal” neophallus as one that is crafted reproducibly in a single-stage procedure, is aesthetically pleasing to the patient, has tactile and erogenous sensation, has a functional neourethra that permits standing urination, and confers minimal complications and donor-site morbidity. This list was subsequently amended by Monstrey et al 11 who added the creation of an aesthetic neoscrotum.…”

“…Without comparative studies and/or a standardized system to evaluate outcomes, it is difficult to determine which technique is most capable of producing a neophallus close to the “ideal” standard described by Hage and De Graaf. 9 For this reason, we set out to examine the existing literature on outcomes in metoidioplasty and RFFP in the context of GCS and to investigate which procedure is most likely to procure an outcome closest to the “ideal” standards described by Hage and De Graaf. 9 …”

“…9 For this reason, we set out to examine the existing literature on outcomes in metoidioplasty and RFFP in the context of GCS and to investigate which procedure is most likely to procure an outcome closest to the “ideal” standards described by Hage and De Graaf. 9 …”