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Pre- and post-operative care with associated intra-operative techniques for phalloplasty in female-to-male patients.

Phalloplasty, or creation of the penis, is one of the steps in gender confirming surgery for a female-to-male patient and for males with absence or malformation of the penis. Here, the most common techniques for phalloplasty, along with the pre-operative and post-operative care are discussed.

Key Words: Phalloplasty, pre-op care, post-op care, female-to-male trans gender surgery, sex reassignment surgery.

doi: 10.7257/1053-816X.2015.35-3.134

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Numerous phalloplasty techniques exist for construction of the penis in transgender males electing to undergo sex reassignment surgery, and in cis-gender males with penile malformation or absence secondary to trauma, malignancy, or congenital abnormality (Babaei, Safarinejad, Farrokhi, & Iran-Pour, 2010; Salgado, Chim, Tang, Monstrey, & Mardini, 2011; Selvaggi & Bellringer, 2011). The primary goals of phalloplasty include creating a functional and aesthetically similar phallus as that of a natal male, retaining erogenous and tactile sensation, and facilitating standing micturition and penetrative sexual intercourse (Garaffa, Christopher, & Ralph, 2010; Monstrey et ah, 2009). Creation of the phallus to meet the primary goals has been difficult because there are, as of yet, no optimal replacement tissues for both the urethra and muscles composing the shaft. Still, plastic surgeons and urologists have developed approaches to create a functional phallus.

The radial forearm free flap and anterior lateral thigh flap are the most commonly used phalloplasty methods. Using these techniques, the flap is harvested with the associated neurovascular supply to construct a phallus that maintains erogenous and tactile sensation (Felici & Felici, 2006; Ma, Cheng, & Liu, 2011; Monstrey et al., 2009; Selvaggi et al., 2007). Favorable functional and aesthetic outcomes after phalloplasty using the radial forearm free flap or anterior lateral thigh flap are well documented (Garaffa et al., 2010; Monstrey et al., 2009; Morrison et al., 2014; Rubino et al., 2009). In this article, we discuss our approach to the radial forearm free flap and anterior lateral thigh flap techniques for phalloplasty in female-to-male transsexual patients, along with pre-operative and post-operative care.

Methods

Pre-Operative Care

Prior to scheduling a procedure, it is important to review the past history of the patient, including whether they are following the World Professional Association for Transgender Health (WPATH) guidelines (Deutsch & Feldman, 2013). Centers that offer this procedure as an option will only schedule an appointment with patients if they have documented gender dysphoria by two separate mental health professionals (including one MD), a real-life experience of at least a year (meaning that the patient has lived as their true gender and not the gender assigned to them at birth), and the initiation of medical transition with hormones. The rationale for following these guidelines ensures that potential surgical patients have adequately been provided with information and are approaching this procedure after informed decision-making has taken place.

On the initial visit, the radial forearm or anterior lateral thigh is selected as the donor site. Consideration is given to the location of the donor site scar after phalloplasty (radial arm vs. anterior thigh), available tissue at each site, amount of hair at each area, potential use of micro surgery with ischemia time (radial forearm free flap is ischemic once it is procured until placed on recipient site), size and shape of the desired phallus, medical co-morbidities, and use of agents that may adversely affect the surgery, including anticoagulation and tobacco use. The anterolateral thigh flap generally results in a more bulky phallus with a less prominent donor site scar on the thigh, while the radial forearm flap produces a thinner more moldable phallus with an obvious donor site scar on the arm.

Hair removal via laser therapy or electrolysis begins four to six months prior to surgery. These methods of hair removal are preferred due to their permanence, and prior to any phalloplasty, the donor site should be free of hair since part of the donor site will become the urethra. Hysterectomy is performed at least three months in advance. Testosterone or any androgen-containing supplements are held two weeks pre-operatively to reduce the risk of thrombotic events. Anti-platelet agents, such as clopidogrel, are held for two weeks prior to surgery. The patient must be tobacco-free for two months prior to surgery. Bowel prep begins 24 hours preoperatively: magnesium citrate, bisacodyl, two saline enemas, and a clear liquid diet.

Intra-Operative Techniques

Radial forearm free flap. Prior to the operation, the hair along the radial forearm should be removed to the extent possible along an 18--to 20-centimeter circumferential pattern. In the preoperative area, the design of the radial forearm free flap (RFFF) is completed taking into account the necessity for a tube-in-tube design, and the marking of the radial artery and cephalic vein (see Figure 1A). The flap is harvested distal to proximal, and includes the radial artery, its venae commitans, and the cephalic vein. The median and lateral antebrachial nerves are incorporated for sensibility of the phallus. The tube-in-tube design of the phallus is constructed prior to ligation of the vessels. The Norfolk technique is sometimes included at this stage where the skin approximately two centimeters from the tip is rolled up 0.5 centimeters to create a corona (Selvaggi & Bellringer, 2011). Ischemia time is initiated by ligation of the vessels and the radial forearm-based phallus is transferred to the groin where the recipient vessels (either the common femoral or the deep inferior epigastric vessels along with the greater saphenous vein) have been prepared. The ilioinguinal, and the dorsal nerve of the clitoris (or deep pudendal) nerves are also prepared for coaptation (Kim, Lee, Kwon, & Cha, 2009; Ma et al., 2011; Monstrey et al., 2009). After vascular and nerve anastomosis, the phallus is positioned over the denuded clitoris, and the urethra is anastomosed to the internal tube with interdigitating darts (Hage, Bouman, & Bloem, 1993; Rohrmann & Jakse, 2003). The flap is inset, and Doppler signals are used to assess perfusion of the flap. A split thickness skin graft is harvested from the thigh and used for coverage of the radial forearm donor site. The final outcome of a phallus from the RFFF is shown in Figure 1C.

Occasionally, a portion of the radius can be harvested in an osteocutaneous fashion, but because the donor site is more prone to fracture, it is not used for our patients (Kim et al., 2009). Semi-rigid prostheses are the option of choice for the RFFF, and have been shown to have exceptional outcomes with the included risk of protrusion (Hoebeke et al., 2010). Implantation of a prosthetic is a secondary procedure and takes place at least a year after the initial operation because monitoring for stricture and fistula formation is necessary after the first procedure, and regained tactile sensation is a prerequisite for prosthetic placement (Hoebeke et al., 2005; Hu et al., 2005; Monstrey et al., 2009). Jackson-Pratt drains are placed to prevent accumulation of seroma or hematoma, and a suprapubic catheter is placed to divert urine from the neourethra.

Pedicled anterolateral thigh flap. Prior to the operation, the hair along the thigh should be removed to the extent possible along a 25x25 centimeter semi-circumferential pattern (see Figure 1B). In the pre-operative area, the design of the pedicled anterolateral thigh flap (pALT) is completed, taking into account the necessity for a tube-in-tube design, and the marking of the perforators from the descending branch of the lateral circumflex femoral artery (LCFA) (Lee, Lim, & Bird, 2009; Mutaf, Isik, Bulut, & Buyukgural, 2006). The flap is elevated from anterior to posterior, taking care to expose the proper perforators from the LCFA that supply the flap. The dominant perforator and its venae commitans are dissected back as far as possible to allow for sufficient pedicle length. With the pedicle freed, the phallus can be formed either prior to or after passage of the flap in a subcutaneous tunnel into the groin. For creation of the corona, the Norfolk technique can be used, or a semicircular extension of the distal portion of the flap can be used (referred to as the mushroom flap) (Morrison et al., 2014). Once passed into the groin, the pALT can be placed over the denuded clitoris and lateral cutaneous nerve of the thigh anastomosed to either the dorsal clitoral nerve or the deep pudendal nerve. The urethra is connected to the inner tube of the flap with interdigitating darts. Doppler signals are used to assess flow and ensure there is no kinking of the pedicle with transfer. The donor site on the thigh can either be closed primarily or with a split thickness skin graft from the opposite thigh. Jackson-Pratt drains are placed to prevent accumulation of seroma or hematoma, and a suprapubic catheter is placed to divert urine from the neourethra. The final outcome from a phallus after pALT is shown in Figure 1D.

This flap has been previously described as a free flap, similar to that of the RFFF, but the pALT is preferred because the vascular supply does not have to be reanastomosed to another vessel (Felici & Felici, 2006). Semi-rigid prostheses are the option of choice for the pALT. Implantation of a prosthetic is a secondary procedure and takes place at least a year after the initial operation because monitoring for stricture and fistula formation is necessary after the first procedure, and return of tactile sensation is a prerequisite for prosthetic placement (Felici & Felici, 2006; Hoebeke et al., 2010; Lee et al., 2009).

Post-Operative Care

After the procedure, patients are transferred to the step down unit for hourly flap monitoring and kept NPO (nothing by mouth). Antibiotics are started and continued 10 to 14 days after the operation to prevent infection. Drains are removed when the output is sufficiently low (generally less than 30 cc per day for two consecutive days) to prevent the risk of infection from having a foreign object in the body. As with most flap procedures, patients are kept in the step down unit generally for 24 hours to monitor the flap. This is because within the 24 hours period there is an increased risk of thrombosis within the anastomotic sites, and close Doppler signal monitoring is imperative. Upon transfer to the floor, the patient is encouraged to ambulate, advanced on diet, and transitioned to oral pain medications. Flap monitoring is decreased to every two hours then every four hours prior to discharge.

In the early post-operative period, complications are largely flap-related and urologic in nature. Monstrey et al. (2009) show that flap-related complications account for 20% of postoperative complications, and urologic complications, including fistula or stricture formation, constitute greater than 40% of complications in the medium/ long-term. Frequent monitoring of flap appearance and flap perfusion via Doppler is critical to detect changes in perfusion or the collection of hematoma. Changes in Doppler signal, the appearance of the flap, or the time needed for capillary refill could represent the need for flap revision, and thus, monitored closely by nursing.

After discharge, normal restrictions apply, including no lifting more than 20 pounds, and no smoking or consumption of alcohol for one month. The neophallus is to be kept dry, and pressure is avoided on it; elevation is encouraged while in bed or resting. Urination through the phallus can take place approximately two weeks after the operation, but continued use of the suprapubic catheter is encouraged to ensure complete bladder emptying; the catheter will be removed once urine is sufficiently emptied through the neourethra. Xeroform over the skin graft sites are placed and allowed to fall off on their own. Follow up with the surgeon occurs at two and four weeks post-operatively; at these times, it is determined when the suprapubic catheter can be removed and when the patient can engage in sexual activity. Generally, this determination is made after fluoroscopic urethrograms show patency of the neourethra.

Discussion

Phalloplasty is used in genital reconstruction and as part of gender-confirming surgery for femaleto-male transsexual patients. Donor tissue used for construction of the neophallus is most frequently harvested from the radial forearm or the anterolateral thigh depending on patient preferences for aesthetic outcome of the phallus and donor site morbidity. However, there have been numerous other techniques trialed (Babaei et al., 2010; Salgado et al., 2011; Selvaggi & Bellringer, 2011; Selvaggi, Dhejne, Landen, & Elander, 2012).

Pre-operatively, it is important to pre-screen patients to establish that they have been diagnosed with gender dysphoria and are following the WPATH Standards of Care (Deutsch & Feldman, 2013; Selvaggi et al., 2012). It is also critical to confirm that the patient is aware of the severity of the operation, as well as associated complications and current technical barriers to minimize the potential for patient regret, and to define realistic expectations (Selvaggi & Bellringer, 2011).

Unfortunately, significant limitations still remain for all phalloplasty techniques. Complications are frequent, with rates reaching 40% for urethra fistulas and strictures, and revision surgeries are often required leading to a lengthy recovery process (Monstrey et al., 2009; Selvaggi & Bellringer, 2011; Wroblewski, Gustafsson, & Selvaggi, 2013). Yet most of these complications are not seen in the immediate post-operative period or with patient follow-up. Thus, following post-operative care instructions is of the upmost importance to minimize the occurrence of complications and unfavorable outcomes. Failure to comply with appropriate post-operative care may impair wound healing and increase the risk of surgical site infection, seroma, or hematoma, which could result in partial or total flap failure. The role of urological nurses is valuable in assisting patients through all aspects of their phalloplasty, and the more informed nursing staff are, the better they are able to provide quality care to all patients.

References

Babaei, A., Safarinejad, M.R., Farrokhi, F., & Iran-Pour, E. (2010). Penile reconstruction: Evaluation of the most accepted techniques. Urology Journal, 7(2), 71-78.

Deutsch, M.B., & Feldman, J.L. (2013). Updated recommendations from the World professional association for transgender health standards of care. American Family Physician, 87(2), 89-93.

Felici, N., & Felici, A. (2006). A new phalloplasty technique: the free anterolateral thigh flap phalloplasty. Journal of Plastic, Reconstructive, and Aesthetic Surgery, 59(2), 153157.

Garaffa, G., Christopher, N.A., & Ralph, D.J. (2010). Total phallic reconstruction in female-to-male transsexuals. European Urology, 57(4), 715-722. doi:10.1016/j.eururo.2009.05.018

Hage, J.J., Bouman, F.G., & Bloem, J.J. (1993). Construction of the fixed part of the neourethra in female-to-male transsexuals: Experience in 53 patients. Plastic and Reconstructive Surgery, 91(5), 904-910; discussion 911-903.

Hoebeke, P.B., Decaestecker, K., Beysens, M., Opdenakker, Y., Lumen, N., & Monstrey, S.M. (2010). Erectile implants in female-to-male transsexuals: Our experience in 129 patients. European Urology, 57(2), 334-340. doi:10.1016/j.eururo.2009.03.013

Hoebeke, P., Selvaggi, G., Ceulemans, P., De Cuypere, G., T'Sjoen, G., Weyers, S., ... Monstrey, S. (2005). Impact of sex reassignment surgery on lower urinary tract function. European Urology, 47(3), 398-402. doi:10.10 16/j.eururo.2004.10.008

Hu, Z.Q., Hyakusoku, H., Gao, J.H., Aoki, R., Ogawa, R., & Yan, X. (2005). Penis reconstruction using three different operative methods. British Journal of Plastic Surgery, 58(4), 487-492. doi:10.1016/j.bjps.2004.11.007

Kim, S.K., Lee, K.C., Kwon, Y.S., & Cha, B.H. (2009). Phalloplasty using radial forearm osteocutaneous free flaps in female-to-male transsexuals. Journal of Plastic, Reconstructive, and Aesthetic Surgery, 62(3), 309-317. doi:10.1016/j.bjps.2007.11.011

Lee, G.K., Lim, A.F., & Bird, E.T. (2009). A novel single-flap technique for total penile reconstruction: The pedicled anterolateral thigh flap. Plastic and Reconstructive Surgery, 124(1), 163166. doi:10.1097/PRS.0b013e3181a b2593

Ma, S., Cheng, K., & Liu, Y. (2011). Sensibility following innervated free radial forearm flap for penile reconstruction. Plastic and Reconstructive Surgery, 127(1), 235-241. doi:10.10 97/PRS.0b013e3181fad371

Monstrey, S., Hoebeke, P., Selvaggi, G., Ceulemans, P., Van Landuyt, K., Blondeel, P., ... De Cuypere, G. (2009). Penile reconstruction: Is the radial forearm flap really the standard technique? Plastic and Reconstructive Surgery, 124(2), 510-518. doi:10.1097/PRS.0b013e3181aeeb06

Morrison, S.D., Son, J., Song, J., Berger, A., Kirby, J., Ahdoot, M., & Lee, G.K. (2014). Modification of the tube-in-tube pedicled anterolateral thigh flap for total phalloplasty: the mushroom flap. Annals of Plastic Surgery, 72(Suppl. 1), S22-S26. doi:10.1097/ SAP.0000000000000072

Mutaf, M., Isik, D., Bulut, O., & Buyukgural, B. (2006). A true one-stage nonmicrosurgical technique for total phallic reconstruction. Annals of Plastic Surgery, 57(1), 100-106. doi:10.1097/01.sap.000020 8991.22264.b5

Rohrmann, D., & Jakse, G. (2003). Urethroplasty in female-to-male transsexuals. European Urology, 44(5), 611-614.

Rubino, C., Figus, A., Dessy, L.A., Alei, G., Mazzocchi, M., Trignano, E., & Scuderi, N. (2009). Innervated island pedicled anterolateral thigh flap for neo-phallic reconstruction in female-to-male transsexuals. Journal of Plastic, Reconstructive, and Aesthetic Surgery, 62(3), e45-49. doi:10.1016/j.bjps.2007.11.056

Salgado, C. J., Chim, H., Tang, J.C., Monstrey, S. J., & Mardini, S. (2011). Penile reconstruction. Seminars in Plastic Surgery, 25(3), 221-228. doi:10.1055/s-0031-1281492

Selvaggi, G., & Bellringer, J. (2011). Gender reassignment surgery: An overview. Nature Reviews Urology, 8(5), 274-282. doi:10.1038/nrurol. 2011.46

Selvaggi, G., Dhejne, C., Landen, M., & Elander, A. (2012). The 2011 WPATH standards of care and penile reconstruction in female-to-male transsexual individuals. Advances in Urology, 2012, 581712. doi:10.11 55/2012/581712

Selvaggi, G., Monstrey, S., Ceulemans, P., T'Sjoen, G., De Cuypere, G., & Hoebeke, P. (2007). Genital sensitivity after sex reassignment surgery in transsexual patients. Annals of Plastic Surgery, 58(4), 427-433. doi: 10.1097/01.sap.0000238428.91834.be

Wroblewski, P., Gustafsson, J., & Selvaggi, G. (2013). Sex reassignment surgery for transsexuals. Current Opinion in Endocrinology, Diabetes and Obesity, 20(6), 570-574. doi:10.1097/ 01.med.0000436190.80104.56

Shane D. Morrison, MD, MS, is a Resident Physician, University of Washington, Seattle, WA.

Marcelina G. Perez is a Medical Student, Stanford University School of Medicine, Stanford, CA.

Cayden K. Carter, is an Undergraduate Student, University of California San Diego, LaJolla, CA.

Curtis N. Crane, MD, is Owner, President, and Plastic Surgeon/Reconstructive Urologist, Brownstein and Crane Surgical Services, Green brae, CA.

Table 1.
Common Complications Following Phalloplasty and
Their Clinical Signs

Complication           Clinical Correlate

Venous insufficiency   * Congested and blue color of flap
                       * Very fast capillary refill
                       * Rapid extrusion of dark red blood on poking
                         the flap with a needle

Arterial               * Pale flap
insufficiency          * Very delayed capillary refill
                       * No extrusion of blood on poking flap with a
                         needle

Necrosis               * Darkening of portions of flap
                       * Changes in odor
                       * Changing of skin quality to more leathery
                         feeling

Infection of flap or   * Erythema of area
donor site/            * Discharge of purulent material
split-thickness skin   * Warmth
graft site             * Increased pain

Hematoma               * Darkening of flap
                       * Swelling of skin
                       * Increased turgor

Seroma                 * Swelling of skin
                       * Increased turgor of skin

Urethral fistula       * Opening of skin around flap with urine
(generally not an        leakage
acute post-            * Pain at site
operative problem)     * Cellulitis like changes
                       * Recurrent infections possible
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Title Annotation:General Clinical Practice
Author:Morrison, Shane D.; Perez, Marcelina G.; Carter, Cayden K.; Crane, Curtis N.
Publication:Urologic Nursing
Article Type:Report
Date:May 1, 2015
Words:3116
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