The anatomy of free fibula osteoseptocutaneous flap in neophalloplasty in transgender surgery

Abstract

The Free Fibula Osteoseptocutaneous flap is a reliable option when used in neophalloplastic procedures. It possesses intrinsic rigidity that is sufficient for penetrative intercourse, and satisfactory sensation. We review the pros and cons of this procedure, as well the anatomy and surgical steps involved. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. Anatomy of the donor and recipient sites, as well as the surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. The free fibula osteoseptocutaneous flap provides the neophallus with many desirable characteristics. Its thick subcutaneous and fascial layer, along with the thicker fibula (compared to the radius), allows for a neophallus of greater diameter. Skin marking, flap lifting, and transfer to the perineum with all relevant neurovascular anastomosis; fibular artery is anastomosed with the femoral artery, while the fibular veins are anastomosed to branches of the saphenous vein, as well as neurorrhaphy of the dorsal nerves of the clitoris and the LSCN are demonstrated. The osteomatized fibula is fixed to the periosteum of the pubic symphysis as shown. Anatomical traits of the Free Fibula Osteoseptocutaneous flap allow intercourse without prosthesis. The donor-site scar in this procedure can be covered by a long sock, and donor site morbidity is acceptable. Clin. Anat. 31:169-174, 2018. © 2018 Wiley Periodicals, Inc.

Total phallic construction techniques in transgender men: an updated narrative review

“…Since the skin of the fibular flap is somewhat stiff and not free to be rolled on itself to create the neourethra, some authors have proposed to prelaminate the neourethra with STSG 6 months prior to the FOFF (71)(72)(73)(74). Donor site scarring is much reduced compared to other flap options, and can be easily covered by a sock or long trousers (75).…”

“…Similarly, the LSCN is coapted to one dorsal nerves of the clitoris. Since LSCN and clitoral nerves coaption often results in poor erogenous phallic sensation, it is highly suggested that the contralateral clitoral nerve should be preserved (70)(71)(72)75). The donor site is covered by full-thickness skin graft (74).…”

The evolution of transgender surgery

“…A free osteofasciocutaneous fibula flap was also presented by Sadove et al (). With this technique, the number of required procedures and complications were fewer than with the radial forearm flap (Zaheer et al ). It offered several advantages for cisgender males who suffered traumatic amputations, as well as for female‐to‐male transgender individuals.…”

Partial flap loss in transgender phalloplasty using the anterolateral thigh or forearm - a systematic literature review

“…This has ushered in the current era of phalloplasty for the treatment of gender dysphoria, where the focus is on achieving the best possible phallus reconstruction while minimizing overall morbidity. While many donor sites have been explored and are still currently utilized, the radial forearm and the anterolateral thigh are the most commonly used in phalloplasty surgery for gender dysphoria [6][7][8][9] [Figures 1 and 2]. Current techniques and surgical staging vary widely between institutions and individual surgeons, thus making it difficult to draw conclusions regarding the frequency and extent of complications.…”