Transsexualism - PhalloplastyTotal phalloplasty presents one of the most demanding tasks in genital reconstructive surgery. The penis has some unique characteristics and restoring its psychosexual function in both the flaccid and erect state, and the possibility of sexual intercourse with full erogenous sensation, is almost impossible Many techniques using different free transfer flaps have been described but none of them satisfy all the goals of modern penile reconstruction. Reproducibility, tactile and erogenous sensation, a competent neourethra with a meatus at the top of the glans, large size that enables safe insertion of a prosthesis, satisfactory aesthetic appearance with hairless, normally coloured skin and an acceptable donor site morbidity. The most widely used flap for total phalloplasty is the radial forearm flap, but it has many drawbacks, e.g. an unsightly donor site scar, very frequent urethral complications, and a small penis that does not allow the safe insertion of a prosthesis in many patients. The main reason why Prof. Sava Perovic developed a technique using the musculocutaneous latissimus dorsi (MLD) free transfer flap, which mostly satisfies the requirements noted above.
>> Read More
The LD muscle has a reliable and suitable anatomy (i.e. good size, volume and length of neurovascular pedicle) to meet the aesthetic and functional needs for phallic reconstruction. It can be also used successfully in children.
>> Read More
The total phalloplasty is done in several stagesThe donor site was prepared before surgery by superficial skin massage using 'antiscarring' ointment 2 months before surgery, to improve skin elasticity and allow direct donor-site closure. In obese patients the donor site was treated by liposuction 3 months before surgery, to decrease flap thickness and enable safe tubularization without compromising the blood supply.
Massage for total phalloplasty
Thoracodorsal musculocutaneous flapThoracodorsal musculocutaneous flap includes lateral thoracic skin with underlying subcutaneous tissue, m. latissimus dorsi, thoracodorsal artery, vein and nerve. Revascularisation of thoracodorsal flap is performed through anastomosis with femoral vessels, "end-to-side" or "end-to-end" type. Thoracodorsal nerve innervates m. latissimus dorsi and could be used for recovery of the motor function of neophallus by anastomosing with motor nerve of m. gracilis for reinnervation. The tension of the muscle base of neophallus affords an opportunity to imitate erection and to perform penetration. The flap allows forming the body of the penis of a sufficient size without any significant losses in donor area. The average size of the flap range from 15-18 cm in length to 12-15 in girth what depends on patient's constitution. The donor area can be covered primarily by using direct suture or rotational flaps. The signs of the neophallus muscle reinnervation began to appear 3-4 months after the surgery, the motor activity increased. Its disadvantage is low phallus sensitivity.
Fig.1 - The design of the MLD flap.
Fig.2 - The design of the MLD flap.
Fig.3 - The design of the MLD flap.
Fig.4 - The design of the MLD flap.
Fig.5 - Flap elevation on a long neurovascular pedicle and muscle tailoring
Fig.6 - Direct donor-site closure
Surgical Formation of the GlansThe neoglans has a urethral meatus structured as a sagital spit at its tip. It is conic and has a circumferential ridge (corona glandis) at its base. Sculpturing the glans in phalloplasty is performed simultaneously or as a separate procedure by using a modified Norfolk technique. The skin of the neophallus is de-epithelialized circumferentially (at approximately 1 cm skin strip) in the region of the future collum glandis. From this area two skin flaps are created distally and proximally in a circumferential manner and are sutured to its base to form a ridge. The remaining de-epithelialized area between the two ridges may be covered with a split thickness skin graft.
Fig.7 - On-site creation of the neophallus, including the glans.
Fig.8 - Flap transfer to the pubic region and microsurgical anastomoses.
Fig.9 - Appearance at the end of surgery.
Urethroplasty techniquesConstruction of neouretha is necessary to achieve the goal of voiding while standing. Neourethra in phallic reconstruction consists of fixed and pendular part. Construction of the fixed part of the neourethra involves anterior vaginal wall, urethral plate and labia minora. Pendular, phallic part can be formed simultaneously usually from the centrally located part of the microsurgical free vascularized flap. Full thickness skin or buccal mucosa graft can also be used for neourethra simultaneously with phalloplasty or as a separate procedure. Urethral fistulas, strictures and diverticulum are the main problems, especially in one-stage total phalloplasty and urethroplasty. Its complication rate is over 50%. However, these complications can be minimized by using principles of modern urethral surgery.
Fig.10 - Buccal mucosa graft urethroplasty; first stage.
Fig.11a - Second-stage urethroplasty; the urethral plate mobilization.
Fig.11b - Second-stage midline incision.
Fig.11c - Second-stage tubularization.
Fig.12 - The outcome 6 months after surgery.
Fig.12a - The outcome 6 months after surgery.
Fig.12b - The outcome 6 months after surgery.
Fig.12c - The outcome 6 months after surgery.
Fig.12d - The outcome 6 months after surgery.
Fig.12e - The outcome 6 months after surgery.
Penile prosthesis implantationProsthesis placement is necessary to accomplish sexual function and vaginal penetration. The implant is inserted after the completed neophallus construction and the neourethra should also be patent and proved durable before implantation. A patient must be free of urinary tract infections and voiding difficulties. Creation of a sensible neophallus enables safer usage and less complication rate of an implant. If a patient has poor sensation, a hydraulic penile prosthesis is the implant of choice. Different kind of prostheses may be used - malleable (soft-silicone) or inflatable (two or three component). Inflatable prostheses are preferred, though the non-inflatable type is safe when protective sensation has developed. In cases where the girth of the neophallus does not allow safe placement of two cylinders it is recommended to implant single-cylinder prosthesis. If no proximal corpora remain, the prosthesis is secured by formation of a sleeve from different graft material so that it will not migrate. The prosthesis is secured into this sleeve, which is anchored to the periosteum of the pubic symphisis. The pump may be implanted in neoscrotum, and take the place of an artificial testicle. If neoscrotum is too small, medial thigh pouch can be used. Prosthesis inflation should be delayed for at least 6 to 8 weeks while edema resolves and some encapsulation occurs around the cylinder. Sexual intercourse may be initiated safely after three months. The patient must be made aware of the significant chance of future complications such as erosion or extrusion because of pressure necrosis. >> Read More
The neo-tunica for the penile prosthesis is created from synthetic vascular grafts (a) and fixed to the pubic bones (b); the inflated prosthesis provides an erection.
Fig.(a) - Penile prosthesis.
Fig.(b) - Penile prosthesis.
Fig.(c) - Penile prosthesis.
Fig.(d) - Penile prosthesis.
- Sava Perovic technique