Primary Use of the Deep Inferior Epigastric Pedicle for Free-flap Phalloplasty: Rationale, Technique, and Outcomes

Abstract

Background: Most free-flap phalloplasty reports describe the femoral artery and great saphenous vein as recipient vessels, with the deep inferior epigastric artery and venae comitantes (DIEA/V) only rarely reported. We review our experience with preferentially using the DIEA/V as recipient vessels in gender-affirming free-flap phalloplasty, with DIEV as primary venous outflow. Methods: We retrospectively reviewed consecutive patients who underwent gender-affirming free-flap phalloplasty at our single institution from June 2017 through June 2021. The DIEA/V was used as recipient vessels, with the DIEA/V pedicle externalized via a passageway made through the external inguinal ring. Results: Thirty-eight consecutive free flaps (26 radial forearm free-flap phalloplasties, 10 anterolateral thigh phalloplasties, and two radial forearm free-flap urethroplasties) were performed. Mean age was 37.3 years; mean BMI was 25.7. Mean follow-up was 17.9 months. All flaps were anastomosed to the DIEA/V, without use of vein grafts. Most flaps (89.5%) had at least two veins anastomosed. To augment outflow, a saphenous vein branch was used in one of 38 (2.6%) cases and other superficial veins were used in two of 38 (5.3%) cases. One of 38 (2.6%) cases (early in our experience) resulted in total flap loss. Conclusions: Advantages of the DIEA/V as free-flap phalloplasty recipient vessels include a short, direct pathway for vessels, excellent donor-recipient vessel size match that allows end-to-end anastomoses, and elimination of risks associated with arterialized interposed veins. When venous outflow appears compromised, we recommend a low threshold to use additional local or saphenous veins, though this is rarely needed given the DIEV’s reliability.

30 Years of Experience in Musculocutaneous Latissimus Dorsi Flap Phalloplasty with Reinnervation: Optimal Principles

“…Using the deep epigastric vascular bundle for microsurgical revascularization, 29 we isolated the vessels from a relatively small incision in the contralateral pararectal side of the abdomen, approximately 10 to 12 cm long. The vascular bundle was prominent from the iliac vessels to the point where it entered the rectus abdominis muscle (Fig.…”

“…In the case of total loss, we performed repeated phalloplasty with an LDF from the opposite side in six cases. Autodermoplasty (36, including primary and secondary) is required in patients with partial flap loss (29). Debridement was performed in 37 cases, eight cases required complete necrectomy, and 29 cases required partial necrectomy.…”