RECONSTRUCTIVE SURGERY
Modification of the Tube-in-Tube Pedicled Anterolateral Thigh Flap for Total Phalloplasty The Mushroom Flap Shane D. Morrison, MS,* Ji Son, MD,Þ Jeonghoon Song, MD,þ Aaron Berger, MD, PhD,§ Johanna Kirby, BA,* Michael Ahdoot, MD,|| and Gordon K. Lee, MD, FACS§ Background: Malformation or absence of the penis can lead to physical and psychological problems for male patients. Reconstruction of the phallus should optimally be completed in a single procedure, be aesthetically pleasing, retain erogenous and tactile sensation, enable micturition in the standing position, and allow for penetrative sexual intercourse. The tube-in-tube flap was described nearly 30 years ago and forms both a urethra and an outer penile shaft with a single flap. Here we present our modification of the original tube-in-tube design with the pedicled anterolateral thigh (ALT) flap and an extension for the neoglans, which we have termed the ‘‘mushroom flap’’ because of its shape and design. Methods: The flap is based on the ALT flap; however, the area that will become the neoglans is shaped with a semicircular extension, resembling the head of a mushroom. When the flap is tubularized, the neoglans has the proper anatomic landmarks such as the corona and more closely approximates a circumcised penis. When used in conjunction with the tube-in-tube design, the neophallus, neoglans, and neourethra can all be constructed in a single stage with a single flap. Results: We have performed total phalloplasties in three patients using the pedicled ALT flap, and the mushroom flap design evolved as we sought to improve the aesthetics of the neoglans. In comparing the aesthetic results among our patients as well as those published in the literature, the mushroom flap design seems to provide the most natural and aesthetically pleasing appearance. Conclusions: The pedicled ALT flap can be used to reconstruct an entire penis, as well as a urethra, without the need for microsurgery. By modifying the original tube-in-tube design to include a semicircular extension (a.k.a. the ‘‘mushroom flap’’), we feel that we have been able to achieve a more natural-appearing neoglans. Key Words: phalloplasty, anterolateral thigh flap, pedicled flap, penile reconstruction, mushroom flap, and tube-in-tube (Ann Plast Surg 2014;72: S22YS26)
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otal penile defects can arise from congenital malformations and traumatic and medically indicated amputations, and are a consideration that must be taken into account for individuals undergoing gender reassignment surgery.1Y15 Major physical and psychological sequelae can arise as a result of total penile defects leading to adverse effects on the patients’ quality of life.16Y18 Reconstruction of the penis has been shown to improve the patients’ quality of life and is Received June 27, 2013, and accepted for publication, after revision, October 28, 2013. From the *Stanford University School of Medicine, Palo Alto, CA; †Department of Plastic Surgery, University Hospitals Case Medical Center, Cleveland, Ohio; ‡Wonkwang University School of Medicine, Iksan, South Korea; §Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Palo Alto, CA; and ||Department of Urology, University of Miami/Jackson Memorial Medical Center, Miami, FL. S.D. Morrison and J. Son contributed equally for this study. Conflicts of interest and sources of funding: none declared. Reprints: Gordon K. Lee, MD, FACS, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd, Suite 400, Palo Alto, CA 94304-5715. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7201-S022 DOI: 10.1097/SAP.0000000000000072
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currently one of the accepted methods of treatment for individuals with gender identity disorder.14,19Y23 Phalloplasty was initially pioneered by Borgoras24 in 1936, and major innovations have occurred in the field since then, including the development of the tube-in-tube design by Gilles and Millard.5 Yet penile reconstruction still remains one of the more complex procedures for the plastic surgeon because there are currently no replacements for urethral and erectile tissues. Ideally, phalloplasty should restore form and function of the penis, including adequate bulk and proper anatomic approximation of the phallus, the ability to micturate in a standing position, retention of erogenous and tactile sensation, and the ability to engage in penetrative sexual intercourse. The reconstructive approach should be reliable, minimize donor-site morbidity, and allow for reconstruction in a single procedure. Arguably, the most accepted technique for phalloplasty is the radial forearm free f lap, with the osteocutaneous free fibula f lap as a distant second.12,25Y28 However, there are various drawbacks to both of these procedures, including the conspicuous donor-site morbidity, atrophy of bulk over time, color mismatch, and the necessity for microsurgery, along with the retention of a permanent erection in the osteocutaneous free fibula f lap.27Y30 We have previously reported on the use of the pedicled anterolateral thigh (ALT) f lap as a means to circumvent many of the drawbacks of the most common approaches in phalloplasty.8 Here we present the modification of the pedicled ALT f lap with a semicircular extension at the distal portion of the f lap to construct a more aesthetically pleasing phallus, which we term the ‘‘mushroom f lap.’’
MATERIALS AND METHODS Our approach to the dissection of the pedicled ALT f lap for phalloplasty has been described previously.8 Flap measurements were kept the same, with a semicircular extension added at the distal portion of the f lap, centered on the path of the lateral circumf lex femoral artery. The semicircular extension was developed in an attempt to construct a more aesthetically pleasing phallus that more closely approximated the anatomic landmarks of the circumcised male penis, including the corona. A reverse-engineered approach was used, in which the phallus was initially constructed using a paper model, and upon curling the base of the glans outward, the resultant shape resembled a mushroom (Fig. 1). The design of the f lap is seen in Figure 2A, with on-patient design in Figure 2B. Before the formation of the phallus, the flap is tunneled into the pelvis, neurorrhaphy is performed between the dorsal pudendal nerves and the medial and lateral femoral cutaneous nerves, and the urethra anastomosis is achieved through the creation of triangular flaps with the native urethra, resulting in slight modifications from the previously reported method.8 Follow-up at 1 month after surgery assesses urodynamics as well as looking specifically for urethrocutaneous fistulae or strictures. If there is no evidence of complication and the patient voids freely, the Foley catheter is removed and the suprapubic catheter (SPC) is capped. The SPC is removed after 3 days if there is no evidence of retention. Annals of Plastic Surgery
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Mushroom Flap
FIGURE 1. Reverse engineering approach to the mushroom flap. A, The initial paper construction of the phallus is shown on the right, with it unfolded on the left. The inner portion represents the neourethra bordered by a shaded region that will allow for de-epithelialized tissue to form the tube-in-tube design. The mushroom flap is at the superior portion of the drawings and is the semicircular extension of the flap. B, The initial paper construction is shown as a digital representation for more accurate depiction of the mushroom flap.
CASE REPORT A 60-year-old man presented with a total penectomy after necrosis from prolonged priapism from a paraphimotic event; he was uncircumcised at the time of the event (Fig. 3, left). An indwelling Foley catheter was present since the total penectomy 1.5 years prior,
which was changed every three to four weeks. His quality of life was extremely compromised. He had hypothyroidism and hypertension at the time of presentation and was a current smoker with a 94-packyear history. His thighs had sparse hair, with a pinch thickness of 3 cm. He had a previous exploratory laparotomy for a perforated
FIGURE 2. A, Schematic representation of the tube-in-tube design with the mushroom f lap incorporated (left). The inner conduit becomes the neourethra, the outer tube becomes the penile shaft, and the distal mushroom portion becomes the neoglans. Schematic f lap design on the thigh (Right). B, Photograph showing the mushroom f lap drawn on the patient. * 2014 Lippincott Williams & Wilkins
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FIGURE 3. Patient example of the mushroom f lap: preoperative frontal view (A), partial f lap necrosis at 1 month after surgery (B), postoperative neophallus with neoglans (C), and postoperative neophallus with neoglans shown with patient in standing position (D).
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* 2014 Lippincott Williams & Wilkins
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colon, with three incisional ventral hernia repairs. He had nearly total absence of the penis and was requested to stop smoking for a minimum of four weeks before he would be considered as a candidate for phalloplasty. Four months after the initial visit with the plastic surgery team, he presented back to the clinic having quit smoking for a month and requested reconsideration for phalloplasty. He was offered the procedure, and reconstruction with the pedicled ALT f lap and ‘‘mushroom f lap’’ modification proceeded as described above a month later (the patient had not smoked for two months prior). The operation was performed in collaboration with the urology team, who placed the initial SPC and conducted neurolysis of the dorsal pudendal nerves. Both medial and lateral femoral cutaneous nerves were preserved during f lap dissection, and neurorrhaphy was completed with the left and right dorsal pudendal nerves. There was difficulty in closing the f lap primarily because of swelling and thickness of the thigh tissues, so the f lap was thinned in a subscarpal plane. Because of continued difficulty in closing the f lap due to vascular pedicle compression, a split-thickness skin graft was harvested from the right thigh and was applied to the ventral surface of the penis. The f lap was noted to have ischemic changes, with left-sided vascular congestion on postoperative day (POD) 0. Leech therapy was started and continued until POD 5. Topical wound management was continued after the conclusions of leech therapy. On POD 10, the patient was broadened to intravenous vancomycin and zosyn for possible right-sided cellulitis of the f lap, which resolved by discharge on POD 14. He continued oral antibiotics for ten days. On the one-month postoperative clinic visit, he was noted to have partial f lap necrosis of the left side of the f lap (4 10 cm) and urethrocutaneous fistula (Fig. 3, middle). Two months after his initial reconstruction, he underwent further debridement and coverage with a pedicled left superficial circumf lex iliac artery f lap and a full-thickness skin graft of 10 cm to the base of the penis. His urethrocutaneous fistula had healed by secondary intention at the time of operation. It was noted that there was still a small area of ischemia at the distal tip, which was stable by discharge on POD 5. On POD 11, he developed left-sided groin cellulitis and was admitted for intravenous antibiotic treatment. Earlier in the day before readmission, at two months after surgery for the initial mushroom flap, urodynamic studies showed no evidence of strictures or fistulae so the Foley catheter was removed and the SPC was capped. He was able to void freely with resolving cellulitis and was discharged four days after readmission. Five days later, he developed meatal stenosis, requiring use of dilators at home, but because of his continued ability to urinate freely, the SPC was removed. Four months after surgery, he continued to have a small degree of meatal stenosis with continued dilator use. He regained sensation to the proximal half of his phallus and had successfully engaged in penetrative sexual intercourse. Seven months after surgery, he developed a urethral stricture at the neourethra and native urethra anastomosis site. Stricturoplasty was completed with a left-sided coronaplasty. The Foley catheter and SPC were replaced. Eight months after surgery, there was no evidence of urinary leak or stricture on retrograde urethrogram, so the Foley catheter was removed and the SPC was capped, which was removed three days later with no complications in voiding. Eleven months after surgery, a small urethral stricture was noted and an 18 French catheter was placed, which was removed a month later. No further complications were noted at two years after reconstruction (Fig. 3, right). The patient reports satisfaction with the phallus, noting that it is aesthetically pleasing and provides the ability to micturate in a standing position and engage in sexual intercourse. * 2014 Lippincott Williams & Wilkins
Mushroom Flap
DISCUSSION The use of the pedicled ALT f lap for a single-stage reconstruction of the penis was initially reported by our group as a means to minimize a variety of the drawbacks of the currently accepted methods of phalloplasty. More specifically, the pedicled ALT f lap does not require microsurgery and thus reduces ischemia time associated with other free f laps (radial forearm and osteocutaneous fibula) while supplying adequate bulk and proper coloration. Indeed, we have reported that our previous reconstructions were successful in that patients were able to micturate in a standing position, retain tactile and erogenous sensation with coaptation of the medial and lateral femoral cutaneous nerves, and allow for penetrative sexual intercourse without the need for a prosthesis due to the bulk supplied by the ALT f lap.8 As we sought to improve the aesthetic quality of the neoglans constructed with the pedicled ALT f lap, we developed the semicircular extension of the distal end of the f lap termed the ‘‘mushroom f lap’’ to more closely approximate the anatomic landmarks, such as the corona, of a circumcised penis. We have used this reconstruction in a single patient, reported above, and attained a neophallus that closely resembled a circumcised penis (Fig. 3, right). The patient reported satisfaction with the aesthetic quality of his neophallus, with all other goals of phalloplasty being met. Although there were complications noted in this patient, these can occur with any of the previously described phalloplasty techniques and will mostly consist of urethral strictures and urethrocutaneous fistulae.14,17,27,31 In our case, partial necrosis of the f lap because of excessive thinning was successfully managed with a pedicled superficial circumf lex iliac artery f lap. The mushroom f lap has an advantage over other methods of coronaplasty, such as the ability to recreate the neoglans in a single procedure with the neophallus and neourethra. The Norfolk technique, which has been described in conjunction with the radial forearm free f lap, requires modification of the neophallus through rolling up a portion of the distal skin f lap, which later requires splitthickness skin grafting.14 This requires an extra operation, which places the f lap under undue stress, and it is not required in the mushroom f lap technique. It may also be argued that penile allotransplantation can circumvent the need for reconstructive methods, yet this requires long-term immunosuppression and has been associated with psychological sequelae.32Y34 We believe that, in an appropriate patient, the mushroom f lap used in conjunction with the pedicled ALT f lap should be the preferred technique for total penile reconstruction owing to its ability to reconstruct the neoglans, neophallus, and neourethra in a single procedure. The mushroom f lap is also likely to benefit other f laps used in penile reconstruction to prevent the necessity for another procedure to recreate the glans. With the incorporation of the mushroom f lap, a more aesthetically pleasing f lap that resembles a circumcised penis can be created with a variety of phalloplasty techniques. REFERENCES 1. Akoz T, Erdogan B, Gorgu M, et al. Penile reconstruction in children using a double vascular pedicle composite groin flap. Scand J Urol Nephrol. 1998; 32:225Y230. 2. Akoz T, Kargi E. Phalloplasty in a female-to-male transsexual using a doublepedicle composite groin flap. Ann Plast Surg. 2002;48:423Y427; discussion 427. 3. Gilbert DA, Horton CE, Terzis JK, et al. New concepts in phallic reconstruction. Ann Plast Surg. 1987;18:128Y136. 4. Gillies H. Congenital absence of the penis. Br J Plast Surg. 1948;1:8Y28. 5. Gillies H, Millard R. The Principles and Art of Plastic Surgery, Vol. II. Boston, MA: Little, Brown & Company; 1957. 6. Hester TR, Hill HL, Jurkiewicz MJ. One-stage reconstruction of the penis. Br J Plast Surg. 1978;31:279Y285.
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7. Hu ZQ, Hyakusoku H, Gao JH, et al. Penis reconstruction using three different operative methods. Br J Plast Surg. 2005;58:487Y492. 8. Lee GK, Lim AF, Bird ET. A novel single-flap technique for total penile reconstruction: the pedicled anterolateral thigh flap. Plast Reconstr Surg. 2009;124:163Y166. 9. Lumen N, Monstrey S, Ceulemans P, et al. Reconstructive surgery for severe penile inadequacy: phalloplasty with a free radial forearm flap or a pedicled anterolateral thigh flap. Adv Urol. 2008;704343:1Y5. 10. Ma S, Liu Y, Chang T, et al. Long-term follow-up of sensation recovery of the penis reconstructed by Cheng’s method. Plast Reconstr Surg. 2011;127: 1546Y1552. 11. Orticochea M. A new method of total reconstruction of the penis. Br J Plast Surg. 1972;25:347Y366. 12. Sadove RC, Sengezer M, McRoberts JW, et al. One-stage total penile reconstruction with a free sensate osteocutaneous fibula flap. Plast Reconstr Surg. 1993;92:1314Y1323; discussion 1324Y1315. 13. Santi P, Berrino P, Canavese G, et al. Immediate reconstruction of the penis using an inferiorly based rectus abdominis myocutaneous flap. Plast Reconstr Surg. 1988;81:961Y964. 14. Selvaggi G, Bellringer J. Gender reassignment surgery: an overview. Nature reviews Urology. 2011;8:274Y282. 15. Sun GC, Huang JJ. One-stage reconstruction of the penis with composite iliac crest and lateral groin skin flap. Ann Plast Surg. 1985;15:519Y528. 16. Garaffa G, Raheem AA, Ralph DJ. An update on penile reconstruction. Asian J Androl. 2011;13:391Y394. 17. Salgado CJ, Chim H, Tang JC, et al. Penile reconstruction. Semin Plast Surg. 2011;25:221Y228. 18. Selvaggi G, Elander A. Penile reconstruction/formation. Curr Opin Urol. 2008;18:589Y597. 19. Babaei A, Safarinejad MR, Farrokhi F, et al. Penile reconstruction: evaluation of the most accepted techniques. Urol J. 2010;7:71Y78. 20. Byne W, Bradley SJ, Coleman E, et al. Report of the American Psychiatric Association task force on treatment of gender identity disorder. Arch Sex Behav. 2012;41:759Y796.
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21. Gooren LJ. Clinical practice. Care of transsexual persons. N Engl J Med. 2011;364:1251Y1257. 22. Hoopes JE. Surgical construction of the male external genitalia. Clin Plast Surg. 1974;1:325Y334. 23. Selvaggi G, Dhejne C, Landen M, et al. The 2011 WPATH standards of care and penile reconstruction in female-to-male transsexual individuals. Adv Urol. 2012;2012:581712. ¨ ber die volle plastische Wiederherstellung eines zum Koitus 24. Bogoras N. U fa¨higen Penis (Peniplastica totalis). Zentralbl Chir. 1936;1271Y1276. 25. McRoberts JW, Sadove RC. Penile reconstruction with a free sensate osteocutaneous fibula flap in the surgical management of the intersex patient. Adv Exp Med Biol. 2002;511:283Y287; discussion 287Y288. 26. Monstrey S, Hoebeke P, Dhont M, et al. Radial forearm phalloplasty: a review of 81 cases. Eur J Plast Surg. 2005;28:206Y212. 27. Monstrey S, Hoebeke P, Selvaggi G, et al. Penile reconstruction: is the radial forearm flap really the standard technique? Plast Reconstr Surg. 2009;124: 510Y518. 28. Sengezer M, Ozturk S, Deveci M, et al. Long-term follow-up of total penile reconstruction with sensate osteocutaneous free fibula flap in 18 biological male patients. Plast Reconstr Surg. 2004;114:439Y450; discussion 451Y432. 29. Papadopulos NA, Schaff J, Biemer E. Usefulness of free sensate osteofasciocutaneous forearm and fibula flaps for neophallus construction. J Reconstr Microsurg. 2001;17:407Y412. 30. Papadopulos NA, Schaff J, Biemer E. The use of free prelaminated and sensate osteofasciocutaneous fibular flap in phalloplasty. Injury. 2008;39(Suppl. 3):S62YS67. 31. Hage JJ, Bloem JJ, Suliman HM. Review of the literature on techniques for phalloplasty with emphasis on the applicability in female-to-male transsexuals. J Urol. 1993;150:1093Y1098. 32. Hu W, Lu J, Zhang L, et al. A preliminary report of penile transplantation: part 2. Eur Urol. 2006;50:1115Y1116; discussion 1116. 33. Hu W, Lu J, Zhang L, et al. A preliminary report of penile transplantation. Eur Urol. 2006;50:851Y853. 34. Zhang LC, Zhao YB, Hu WL. Ethical issues in penile transplantation. Asian J Androl. 2010;12:795Y800.
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Modification of the Tube-in-Tube Pedicled Anterolateral Thigh Flap for Total Phalloplasty The Mushroom Flap Shane D. Morrison, MS,* Ji Son, MD,Þ Jeonghoon Song, MD,þ Aaron Berger, MD, PhD,§ Johanna Kirby, BA,* Michael Ahdoot, MD,|| and Gordon K. Lee, MD, FACS§ Background: Malformation or absence of the penis can lead to physical and psychological problems for male patients. Reconstruction of the phallus should optimally be completed in a single procedure, be aesthetically pleasing, retain erogenous and tactile sensation, enable micturition in the standing position, and allow for penetrative sexual intercourse. The tube-in-tube flap was described nearly 30 years ago and forms both a urethra and an outer penile shaft with a single flap. Here we present our modification of the original tube-in-tube design with the pedicled anterolateral thigh (ALT) flap and an extension for the neoglans, which we have termed the ‘‘mushroom flap’’ because of its shape and design. Methods: The flap is based on the ALT flap; however, the area that will become the neoglans is shaped with a semicircular extension, resembling the head of a mushroom. When the flap is tubularized, the neoglans has the proper anatomic landmarks such as the corona and more closely approximates a circumcised penis. When used in conjunction with the tube-in-tube design, the neophallus, neoglans, and neourethra can all be constructed in a single stage with a single flap. Results: We have performed total phalloplasties in three patients using the pedicled ALT flap, and the mushroom flap design evolved as we sought to improve the aesthetics of the neoglans. In comparing the aesthetic results among our patients as well as those published in the literature, the mushroom flap design seems to provide the most natural and aesthetically pleasing appearance. Conclusions: The pedicled ALT flap can be used to reconstruct an entire penis, as well as a urethra, without the need for microsurgery. By modifying the original tube-in-tube design to include a semicircular extension (a.k.a. the ‘‘mushroom flap’’), we feel that we have been able to achieve a more natural-appearing neoglans. Key Words: phalloplasty, anterolateral thigh flap, pedicled flap, penile reconstruction, mushroom flap, and tube-in-tube (Ann Plast Surg 2014;72: S22YS26)
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otal penile defects can arise from congenital malformations and traumatic and medically indicated amputations, and are a consideration that must be taken into account for individuals undergoing gender reassignment surgery.1Y15 Major physical and psychological sequelae can arise as a result of total penile defects leading to adverse effects on the patients’ quality of life.16Y18 Reconstruction of the penis has been shown to improve the patients’ quality of life and is Received June 27, 2013, and accepted for publication, after revision, October 28, 2013. From the *Stanford University School of Medicine, Palo Alto, CA; †Department of Plastic Surgery, University Hospitals Case Medical Center, Cleveland, Ohio; ‡Wonkwang University School of Medicine, Iksan, South Korea; §Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Palo Alto, CA; and ||Department of Urology, University of Miami/Jackson Memorial Medical Center, Miami, FL. S.D. Morrison and J. Son contributed equally for this study. Conflicts of interest and sources of funding: none declared. Reprints: Gordon K. Lee, MD, FACS, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd, Suite 400, Palo Alto, CA 94304-5715. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7201-S022 DOI: 10.1097/SAP.0000000000000072
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currently one of the accepted methods of treatment for individuals with gender identity disorder.14,19Y23 Phalloplasty was initially pioneered by Borgoras24 in 1936, and major innovations have occurred in the field since then, including the development of the tube-in-tube design by Gilles and Millard.5 Yet penile reconstruction still remains one of the more complex procedures for the plastic surgeon because there are currently no replacements for urethral and erectile tissues. Ideally, phalloplasty should restore form and function of the penis, including adequate bulk and proper anatomic approximation of the phallus, the ability to micturate in a standing position, retention of erogenous and tactile sensation, and the ability to engage in penetrative sexual intercourse. The reconstructive approach should be reliable, minimize donor-site morbidity, and allow for reconstruction in a single procedure. Arguably, the most accepted technique for phalloplasty is the radial forearm free f lap, with the osteocutaneous free fibula f lap as a distant second.12,25Y28 However, there are various drawbacks to both of these procedures, including the conspicuous donor-site morbidity, atrophy of bulk over time, color mismatch, and the necessity for microsurgery, along with the retention of a permanent erection in the osteocutaneous free fibula f lap.27Y30 We have previously reported on the use of the pedicled anterolateral thigh (ALT) f lap as a means to circumvent many of the drawbacks of the most common approaches in phalloplasty.8 Here we present the modification of the pedicled ALT f lap with a semicircular extension at the distal portion of the f lap to construct a more aesthetically pleasing phallus, which we term the ‘‘mushroom f lap.’’
MATERIALS AND METHODS Our approach to the dissection of the pedicled ALT f lap for phalloplasty has been described previously.8 Flap measurements were kept the same, with a semicircular extension added at the distal portion of the f lap, centered on the path of the lateral circumf lex femoral artery. The semicircular extension was developed in an attempt to construct a more aesthetically pleasing phallus that more closely approximated the anatomic landmarks of the circumcised male penis, including the corona. A reverse-engineered approach was used, in which the phallus was initially constructed using a paper model, and upon curling the base of the glans outward, the resultant shape resembled a mushroom (Fig. 1). The design of the f lap is seen in Figure 2A, with on-patient design in Figure 2B. Before the formation of the phallus, the flap is tunneled into the pelvis, neurorrhaphy is performed between the dorsal pudendal nerves and the medial and lateral femoral cutaneous nerves, and the urethra anastomosis is achieved through the creation of triangular flaps with the native urethra, resulting in slight modifications from the previously reported method.8 Follow-up at 1 month after surgery assesses urodynamics as well as looking specifically for urethrocutaneous fistulae or strictures. If there is no evidence of complication and the patient voids freely, the Foley catheter is removed and the suprapubic catheter (SPC) is capped. The SPC is removed after 3 days if there is no evidence of retention. Annals of Plastic Surgery
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Volume 72, Supplement 1, May 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 72, Supplement 1, May 2014
Mushroom Flap
FIGURE 1. Reverse engineering approach to the mushroom flap. A, The initial paper construction of the phallus is shown on the right, with it unfolded on the left. The inner portion represents the neourethra bordered by a shaded region that will allow for de-epithelialized tissue to form the tube-in-tube design. The mushroom flap is at the superior portion of the drawings and is the semicircular extension of the flap. B, The initial paper construction is shown as a digital representation for more accurate depiction of the mushroom flap.
CASE REPORT A 60-year-old man presented with a total penectomy after necrosis from prolonged priapism from a paraphimotic event; he was uncircumcised at the time of the event (Fig. 3, left). An indwelling Foley catheter was present since the total penectomy 1.5 years prior,
which was changed every three to four weeks. His quality of life was extremely compromised. He had hypothyroidism and hypertension at the time of presentation and was a current smoker with a 94-packyear history. His thighs had sparse hair, with a pinch thickness of 3 cm. He had a previous exploratory laparotomy for a perforated
FIGURE 2. A, Schematic representation of the tube-in-tube design with the mushroom f lap incorporated (left). The inner conduit becomes the neourethra, the outer tube becomes the penile shaft, and the distal mushroom portion becomes the neoglans. Schematic f lap design on the thigh (Right). B, Photograph showing the mushroom f lap drawn on the patient. * 2014 Lippincott Williams & Wilkins
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FIGURE 3. Patient example of the mushroom f lap: preoperative frontal view (A), partial f lap necrosis at 1 month after surgery (B), postoperative neophallus with neoglans (C), and postoperative neophallus with neoglans shown with patient in standing position (D).
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colon, with three incisional ventral hernia repairs. He had nearly total absence of the penis and was requested to stop smoking for a minimum of four weeks before he would be considered as a candidate for phalloplasty. Four months after the initial visit with the plastic surgery team, he presented back to the clinic having quit smoking for a month and requested reconsideration for phalloplasty. He was offered the procedure, and reconstruction with the pedicled ALT f lap and ‘‘mushroom f lap’’ modification proceeded as described above a month later (the patient had not smoked for two months prior). The operation was performed in collaboration with the urology team, who placed the initial SPC and conducted neurolysis of the dorsal pudendal nerves. Both medial and lateral femoral cutaneous nerves were preserved during f lap dissection, and neurorrhaphy was completed with the left and right dorsal pudendal nerves. There was difficulty in closing the f lap primarily because of swelling and thickness of the thigh tissues, so the f lap was thinned in a subscarpal plane. Because of continued difficulty in closing the f lap due to vascular pedicle compression, a split-thickness skin graft was harvested from the right thigh and was applied to the ventral surface of the penis. The f lap was noted to have ischemic changes, with left-sided vascular congestion on postoperative day (POD) 0. Leech therapy was started and continued until POD 5. Topical wound management was continued after the conclusions of leech therapy. On POD 10, the patient was broadened to intravenous vancomycin and zosyn for possible right-sided cellulitis of the f lap, which resolved by discharge on POD 14. He continued oral antibiotics for ten days. On the one-month postoperative clinic visit, he was noted to have partial f lap necrosis of the left side of the f lap (4 10 cm) and urethrocutaneous fistula (Fig. 3, middle). Two months after his initial reconstruction, he underwent further debridement and coverage with a pedicled left superficial circumf lex iliac artery f lap and a full-thickness skin graft of 10 cm to the base of the penis. His urethrocutaneous fistula had healed by secondary intention at the time of operation. It was noted that there was still a small area of ischemia at the distal tip, which was stable by discharge on POD 5. On POD 11, he developed left-sided groin cellulitis and was admitted for intravenous antibiotic treatment. Earlier in the day before readmission, at two months after surgery for the initial mushroom flap, urodynamic studies showed no evidence of strictures or fistulae so the Foley catheter was removed and the SPC was capped. He was able to void freely with resolving cellulitis and was discharged four days after readmission. Five days later, he developed meatal stenosis, requiring use of dilators at home, but because of his continued ability to urinate freely, the SPC was removed. Four months after surgery, he continued to have a small degree of meatal stenosis with continued dilator use. He regained sensation to the proximal half of his phallus and had successfully engaged in penetrative sexual intercourse. Seven months after surgery, he developed a urethral stricture at the neourethra and native urethra anastomosis site. Stricturoplasty was completed with a left-sided coronaplasty. The Foley catheter and SPC were replaced. Eight months after surgery, there was no evidence of urinary leak or stricture on retrograde urethrogram, so the Foley catheter was removed and the SPC was capped, which was removed three days later with no complications in voiding. Eleven months after surgery, a small urethral stricture was noted and an 18 French catheter was placed, which was removed a month later. No further complications were noted at two years after reconstruction (Fig. 3, right). The patient reports satisfaction with the phallus, noting that it is aesthetically pleasing and provides the ability to micturate in a standing position and engage in sexual intercourse. * 2014 Lippincott Williams & Wilkins
Mushroom Flap
DISCUSSION The use of the pedicled ALT f lap for a single-stage reconstruction of the penis was initially reported by our group as a means to minimize a variety of the drawbacks of the currently accepted methods of phalloplasty. More specifically, the pedicled ALT f lap does not require microsurgery and thus reduces ischemia time associated with other free f laps (radial forearm and osteocutaneous fibula) while supplying adequate bulk and proper coloration. Indeed, we have reported that our previous reconstructions were successful in that patients were able to micturate in a standing position, retain tactile and erogenous sensation with coaptation of the medial and lateral femoral cutaneous nerves, and allow for penetrative sexual intercourse without the need for a prosthesis due to the bulk supplied by the ALT f lap.8 As we sought to improve the aesthetic quality of the neoglans constructed with the pedicled ALT f lap, we developed the semicircular extension of the distal end of the f lap termed the ‘‘mushroom f lap’’ to more closely approximate the anatomic landmarks, such as the corona, of a circumcised penis. We have used this reconstruction in a single patient, reported above, and attained a neophallus that closely resembled a circumcised penis (Fig. 3, right). The patient reported satisfaction with the aesthetic quality of his neophallus, with all other goals of phalloplasty being met. Although there were complications noted in this patient, these can occur with any of the previously described phalloplasty techniques and will mostly consist of urethral strictures and urethrocutaneous fistulae.14,17,27,31 In our case, partial necrosis of the f lap because of excessive thinning was successfully managed with a pedicled superficial circumf lex iliac artery f lap. The mushroom f lap has an advantage over other methods of coronaplasty, such as the ability to recreate the neoglans in a single procedure with the neophallus and neourethra. The Norfolk technique, which has been described in conjunction with the radial forearm free f lap, requires modification of the neophallus through rolling up a portion of the distal skin f lap, which later requires splitthickness skin grafting.14 This requires an extra operation, which places the f lap under undue stress, and it is not required in the mushroom f lap technique. It may also be argued that penile allotransplantation can circumvent the need for reconstructive methods, yet this requires long-term immunosuppression and has been associated with psychological sequelae.32Y34 We believe that, in an appropriate patient, the mushroom f lap used in conjunction with the pedicled ALT f lap should be the preferred technique for total penile reconstruction owing to its ability to reconstruct the neoglans, neophallus, and neourethra in a single procedure. The mushroom f lap is also likely to benefit other f laps used in penile reconstruction to prevent the necessity for another procedure to recreate the glans. With the incorporation of the mushroom f lap, a more aesthetically pleasing f lap that resembles a circumcised penis can be created with a variety of phalloplasty techniques. REFERENCES 1. Akoz T, Erdogan B, Gorgu M, et al. Penile reconstruction in children using a double vascular pedicle composite groin flap. Scand J Urol Nephrol. 1998; 32:225Y230. 2. Akoz T, Kargi E. Phalloplasty in a female-to-male transsexual using a doublepedicle composite groin flap. Ann Plast Surg. 2002;48:423Y427; discussion 427. 3. Gilbert DA, Horton CE, Terzis JK, et al. New concepts in phallic reconstruction. Ann Plast Surg. 1987;18:128Y136. 4. Gillies H. Congenital absence of the penis. Br J Plast Surg. 1948;1:8Y28. 5. Gillies H, Millard R. The Principles and Art of Plastic Surgery, Vol. II. Boston, MA: Little, Brown & Company; 1957. 6. Hester TR, Hill HL, Jurkiewicz MJ. One-stage reconstruction of the penis. Br J Plast Surg. 1978;31:279Y285.
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7. Hu ZQ, Hyakusoku H, Gao JH, et al. Penis reconstruction using three different operative methods. Br J Plast Surg. 2005;58:487Y492. 8. Lee GK, Lim AF, Bird ET. A novel single-flap technique for total penile reconstruction: the pedicled anterolateral thigh flap. Plast Reconstr Surg. 2009;124:163Y166. 9. Lumen N, Monstrey S, Ceulemans P, et al. Reconstructive surgery for severe penile inadequacy: phalloplasty with a free radial forearm flap or a pedicled anterolateral thigh flap. Adv Urol. 2008;704343:1Y5. 10. Ma S, Liu Y, Chang T, et al. Long-term follow-up of sensation recovery of the penis reconstructed by Cheng’s method. Plast Reconstr Surg. 2011;127: 1546Y1552. 11. Orticochea M. A new method of total reconstruction of the penis. Br J Plast Surg. 1972;25:347Y366. 12. Sadove RC, Sengezer M, McRoberts JW, et al. One-stage total penile reconstruction with a free sensate osteocutaneous fibula flap. Plast Reconstr Surg. 1993;92:1314Y1323; discussion 1324Y1315. 13. Santi P, Berrino P, Canavese G, et al. Immediate reconstruction of the penis using an inferiorly based rectus abdominis myocutaneous flap. Plast Reconstr Surg. 1988;81:961Y964. 14. Selvaggi G, Bellringer J. Gender reassignment surgery: an overview. Nature reviews Urology. 2011;8:274Y282. 15. Sun GC, Huang JJ. One-stage reconstruction of the penis with composite iliac crest and lateral groin skin flap. Ann Plast Surg. 1985;15:519Y528. 16. Garaffa G, Raheem AA, Ralph DJ. An update on penile reconstruction. Asian J Androl. 2011;13:391Y394. 17. Salgado CJ, Chim H, Tang JC, et al. Penile reconstruction. Semin Plast Surg. 2011;25:221Y228. 18. Selvaggi G, Elander A. Penile reconstruction/formation. Curr Opin Urol. 2008;18:589Y597. 19. Babaei A, Safarinejad MR, Farrokhi F, et al. Penile reconstruction: evaluation of the most accepted techniques. Urol J. 2010;7:71Y78. 20. Byne W, Bradley SJ, Coleman E, et al. Report of the American Psychiatric Association task force on treatment of gender identity disorder. Arch Sex Behav. 2012;41:759Y796.
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21. Gooren LJ. Clinical practice. Care of transsexual persons. N Engl J Med. 2011;364:1251Y1257. 22. Hoopes JE. Surgical construction of the male external genitalia. Clin Plast Surg. 1974;1:325Y334. 23. Selvaggi G, Dhejne C, Landen M, et al. The 2011 WPATH standards of care and penile reconstruction in female-to-male transsexual individuals. Adv Urol. 2012;2012:581712. ¨ ber die volle plastische Wiederherstellung eines zum Koitus 24. Bogoras N. U fa¨higen Penis (Peniplastica totalis). Zentralbl Chir. 1936;1271Y1276. 25. McRoberts JW, Sadove RC. Penile reconstruction with a free sensate osteocutaneous fibula flap in the surgical management of the intersex patient. Adv Exp Med Biol. 2002;511:283Y287; discussion 287Y288. 26. Monstrey S, Hoebeke P, Dhont M, et al. Radial forearm phalloplasty: a review of 81 cases. Eur J Plast Surg. 2005;28:206Y212. 27. Monstrey S, Hoebeke P, Selvaggi G, et al. Penile reconstruction: is the radial forearm flap really the standard technique? Plast Reconstr Surg. 2009;124: 510Y518. 28. Sengezer M, Ozturk S, Deveci M, et al. Long-term follow-up of total penile reconstruction with sensate osteocutaneous free fibula flap in 18 biological male patients. Plast Reconstr Surg. 2004;114:439Y450; discussion 451Y432. 29. Papadopulos NA, Schaff J, Biemer E. Usefulness of free sensate osteofasciocutaneous forearm and fibula flaps for neophallus construction. J Reconstr Microsurg. 2001;17:407Y412. 30. Papadopulos NA, Schaff J, Biemer E. The use of free prelaminated and sensate osteofasciocutaneous fibular flap in phalloplasty. Injury. 2008;39(Suppl. 3):S62YS67. 31. Hage JJ, Bloem JJ, Suliman HM. Review of the literature on techniques for phalloplasty with emphasis on the applicability in female-to-male transsexuals. J Urol. 1993;150:1093Y1098. 32. Hu W, Lu J, Zhang L, et al. A preliminary report of penile transplantation: part 2. Eur Urol. 2006;50:1115Y1116; discussion 1116. 33. Hu W, Lu J, Zhang L, et al. A preliminary report of penile transplantation. Eur Urol. 2006;50:851Y853. 34. Zhang LC, Zhao YB, Hu WL. Ethical issues in penile transplantation. Asian J Androl. 2010;12:795Y800.
* 2014 Lippincott Williams & Wilkins
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