[Phalloplasty by radial forearm free flap in the context of female-to-male gender reassignment surgery]

Abdominal wall complications: An unknown aspect of morbidity in phalloplasty. A comprehensive analysis and clinical implications

BACKGROUND

Phalloplasty is a complex reconstructive procedure with complications broadly categorized as urinary, vascular, or donor-site related. This study investigates abdominal wall complications, such as bulging and lateral hernias, associated with the use of the inferior epigastric artery as the recipient vessel in microsurgical phalloplasty-a rare and underreported complication.

METHODS

A retrospective review was conducted on 37 patients who underwent microsurgical phalloplasty at a university hospital from January 2016 to February 2020. The most commonly employed technique was forearm flap phalloplasty, followed by the MSLD flap technique. The inferior epigastric artery was accessed via a 7cm oblique incision. Data collected included demographic details, BMI, smoking status, surgical technique, recipient vessel used, and postoperative complications. Follow-up evaluations were performed at 15 days, 3 months, 6 months, and 1 year postoperatively.

RESULTS

Of the 37 patients, the mean age was 33 years, with 84% undergoing phalloplasty for gender affirmation. Abdominal wall complications occurred in 11% of patients (n=4). Three patients developed parietal complications (hernia or bulging), all requiring surgical revision. All three were smokers, one had a BMI>28, and none had prior abdominal surgeries. Contributing factors included musculoaponeurotic disruption, relative denervation from vessel exposure, and smoking-related wound healing impairment.

CONCLUSIONS

The use of the inferior epigastric artery in microsurgical phalloplasty may increase the risk of abdominal wall complications, particularly in smokers and patients with elevated BMI. Optimizing preoperative risk factors, including smoking cessation and careful vessel selection, is essential for reducing these complications. To reduce the occurrence of these complications, the choice of the recipient vessel should be considered alongside the surgical technique during operative planning. Further studies should explore technical refinements to minimize abdominal wall morbidity.

3D printing for an anterolateral thigh phalloplasty

BACKGROUND

Phalloplasty procedures are performed to create a phallus, typically as a gender-affirming surgery for treating gender dysphoria. Due to the controversial nature of this specific procedure, more innovation is needed to directly assist surgical teams in this field. As a result, surgeons are left to improvise and adapt tools created for other procedures to improve surgical outcomes. This study developed a patient-specific 3D printed model from segmented computed tomography (CT) scans to accurately represent the relevant vasculature necessary for anterolateral thigh (ALT) flap phalloplasty. The surgical procedure seeks to maintain intact vessels that derive from the descending branch of the lateral circumflex femoral artery, typically found traveling within the intermuscular septum between the rectus femoris and vastus lateralis.

METHODS

In this study, we created and printed 3D models of the leg and vasculature using two techniques: (1) a standard segmentation technique with the addition of a reference grid and (2) a bitmap method in which the total CT volume is colorized and printed.

RESULTS

The results gathered included the physician's view on the model's accuracy and visualization of relevant anatomy. Bitmap-printed models resulted in a high amount of detail, eliciting surgeons' undesirable reactions due to the excess of information. The hybrid method produced favorable results, indicating positive feasibility.

CONCLUSIONS

This study tested the ability to accurately print a patient-specific 3D model that could represent the vasculature necessary for ALT flap procedures and potentially be used in surgical reference and planning in the future. A surgeon performing phalloplasty procedures discussed their approval of both models and their preference for grid creation and application.