In performing a phalloplasty for a FTM transsexual, the surgeon should reconstruct an aesthetically appealing neophallus, with erogenous and tactile sensation, which enables the patient to void while standing and have sexual intercourse like a natural male, in a one-stage procedure.17,18 The reconstructive procedure should also provide a normal scrotum, be predictably reproducible without functional loss in the donor area, and leave the patient with minimal scarring or disfigurement.
Despite the multitude of flaps that have been employed and described (often as Case Reports), the radial forearm is universally considered the gold standard in penile reconstruction.17,19,20,21,22,23,24,25,26,27,28
In the largest series to date (almost 300 patients), Monstrey et al29 recently described the technical aspects of radial forearm phalloplasty and the extent to which this technique, in their hands approximates the criteria for ideal penile reconstruction.
For the genitoperineal transformation (vaginectomy, urethral reconstruction, scrotoplasty, phalloplasty), two surgical teams operate at the same time with the patient first placed in a gynecological (lithotomy) position. In the perineal area, a urologist may perform a vaginectomy, and lengthen the urethra with mucosa between the minor labiae. The vaginectomy is a mucosal colpectomy in which the mucosal lining of the vaginal cavity is removed. After excision, a pelvic floor reconstruction is always performed to prevent possible diseases such as cystocele and rectocele. This reconstruction of the fixed part of the urethra is combined with a scrotal reconstruction by means of two transposition flaps of the greater labia resulting in a very natural looking bifid scrotum.
Simultaneously, the plastic surgeon dissects the free vascularized flap of the forearm. The creation of a phallus with a tube-in-a-tube technique is performed with the flap still attached to the forearm by its vascular pedicle (Fig. 8A). This is commonly performed on the ulnar aspect of the skin island. A small skin flap and a skin graft are used to create a corona and simulate the glans of the penis (Fig. 8B).
(A–D) Phallic reconstruction with the radial forearm flap: creation of a tube (urethra) within a tube (penis).
Once the urethra is lengthened and the acceptor (recipient) vessels are dissected in the groin area, the patient is put into a supine position. The free flap can be transferred to the pubic area after the urethral anastomosis: the radial artery is microsurgically connected to the common femoral artery in an end-to-side fashion and the venous anastomosis is performed between the cephalic vein and the greater saphenous vein (Fig. 8C). One forearm nerve is connected to the ilioinguinal nerve for protective sensation and the other nerve of the arm is anastomosed to one of the dorsal clitoral nerves for erogenous sensation. The clitoris is usually denuded and buried underneath the penis, thus keeping the possibility to be stimulated during sexual intercourse with the neophallus.
In the first 50 patients of this series, the defect on the forearm was covered with full-thickness skin grafts taken from the groin area. In subsequent patients, the defect was covered with split-thickness skin grafts harvested from the medial and anterior thigh (Fig. 8D).
All patients received a suprapubic urinary diversion postoperatively.
The patients remain in bed during a one-week postoperative period, after which the transurethral catheter is removed. At that time, the suprapubic catheter was clamped, and voiding was begun. Effective voiding might not be observed for several days. Before removal of the suprapubic catheter, a cystography with voiding urethrography was performed.
The average hospital stay for the phalloplasty procedure was 2½ weeks.
Tattooing of the glans should be performed after a 2- to 3-month period, before sensation returns to the penis.
Implantation of the testicular prostheses should be performed after 6 months, but it is typically done in combination with the implantation of a penile erection prosthesis. Before these procedures are undertaken, sensation must be returned to the tip of the penis. This usually does not occur for at least a year.
The Ideal Goals of Penile Reconstruction in FTM Surgery
What can be achieved with this radial forearm flap technique as to the ideal requisites for penile reconstruction?
A ONE-STAGE PROCEDURE
In 1993, Hage20 stated that a complete penile reconstruction with erection prosthesis never can be performed in one single operation. Monstrey et al,29 early in their series and to reduce the number of surgeries, performed a (sort of) all-in-one procedure that included a SCM and a complete genitoperineal transformation. However, later in their series they performed the SCM first most often in combination with a total hysterectomy and ovariectomy.
The reason for this change in protocol was that lengthy operations (>8 hours) resulted in considerable blood loss and increased operative risk.30 Moreover, an aesthetic SCM is not to be considered as an easy operation and should not be performed “quickly” before the major phalloplasty operation.
AN AESTHETIC PHALLUS
Phallic construction has become predictable enough to refine its aesthetic goals, which includes the use of a technique that can be replicated with minimal complications. In this respect, the radial forearm flap has several advantages: the flap is thin and pliable allowing the construction of a normal sized, tube-within-a-tube penis; the flap is easy to dissect and is predictably well vascularized making it safe to perform an (aesthetic) glansplasty at the distal end of the flap. The final cosmetic outcome of a radial forearm phalloplasty is a subjective determination, but the ability of most patients to shower with other men or to go to the sauna is the usual cosmetic barometer (Fig. 9A-C).
(A–C) Late postoperative results of radial forearm phalloplasties.
The potential aesthetic drawbacks of the radial forearm flap are the need for a rigidity prosthesis and possibly some volume loss over time.
TACTILE AND EROGENOUS SENSATION
Of the various flaps used for penile reconstruction, the radial forearm flap has the greatest sensitivity.1 Selvaggi and Monstrey et al. always connect one antebrachial nerve to the ilioinguinal nerve for protective sensation and the other forearm nerve with one dorsal clitoral nerve. The denuded clitoris was always placed directly below the phallic shaft. Later manipulation of the neophallus allows for stimulation of the still-innervated clitoris. After one year, all patients had regained tactile sensitivity in their penis, which is an absolute requirement for safe insertion of an erection prosthesis.31
In a long-term follow-up study on postoperative sexual and physical health, more than 80% of the patients reported improvement in sexual satisfaction and greater ease in reaching orgasm (100% in practicing postoperative FTM transsexuals).32
VOIDING WHILE STANDING
For biological males as well as for FTM transsexuals undergoing a phalloplasty, the ability to void while standing is a high priority.33 Unfortunately, the reported incidences of urological complications, such as urethrocutaneous fistulas, stenoses, strictures, and hairy urethras are extremely high in all series of phalloplasties, as high as 80%.34 For this reason, certain (well-intentioned) surgeons have even stopped reconstructing a complete neo-urethra.35,36
In their series of radial forearm phalloplasties, Hoebeke and Monstrey still reported a urological complication rate of 41% (119/287), but the majority of these early fistulas closed spontaneously and ultimately all patients were able to void through the newly reconstructed penis.37 Because it is unknown how the new urethra—a 16-cm skin tube—will affect bladder function in the long term, lifelong urologic follow-up was strongly recommended for all these patients.
Complications following phalloplasty include the general complications attendant to any surgical intervention such as minor wound healing problems in the groin area or a few patients with a (minor) pulmonary embolism despite adequate prevention (interrupting hormonal therapy, fractioned heparin subcutaneously, elastic stockings). A vaginectomy is usually considered a particularly difficult operation with a high risk of postoperative bleeding, but in their series no major bleedings were seen.30 Two early patients displayed symptoms of nerve compression in the lower leg, but after reducing the length of the gynecological positioning to under 2 hours, this complication never occurred again. Apart from the urinary fistulas and/or stenoses, most complications of the radial forearm phalloplasty are related to the free tissue transfer. The total flap failure in their series was very low (<1%, 2/287) despite a somewhat higher anastomotic revision rate (12% or 34/287). About 7 (3%) of the patients demonstrated some degree of skin slough or partial flap necrosis. This was more often the case in smokers, in those who insisted on a large-sized penis requiring a larger flap, and also in patients having undergone anastomotic revision.
With smoking being a significant risk factor, under our current policy, we no longer operate on patients who fail to quit smoking one year prior to their surgery.
NO FUNCTIONAL LOSS AND MINIMAL SCARRING IN THE DONOR AREA
The major drawback of the radial forearm flap has always been the unattractive donor site scar on the forearm (Fig. 10). Selvaggi et al conducted a long-term follow-up study38 of 125 radial forearm phalloplasties to assess the degree of functional loss and aesthetic impairment after harvesting such a large forearm flap. An increased donor site morbidity was expected, but the early and late complications did not differ from the rates reported in the literature for the smaller flaps as used in head and neck reconstruction.38 No major or long-term problems (such as functional limitation, nerve injury, chronic pain/edema, or cold intolerance) were identified. Finally, with regard to the aesthetic outcome of the donor site, they found that the patients were very accepting of the donor site scar, viewing it as a worthwhile trade-off for the creation of a phallus (Fig. 10).38 Suprafascial flap dissection, full thickness skin grafts, and the use of dermal substitutes may contribute to a better forearm scar.
(A,B) Aspect of the donor site after a phalloplasty with a radial forearm flap.
For the FTM patient, the goal of creating natural-appearing genitals also applies to the scrotum. As the labia majora are the embryological counterpart of the scrotum, many previous scrotoplasty techniques left the hair-bearing labia majora in situ, with midline closure and prosthetic implant filling, or brought the scrotum in front of the legs using a V-Y plasty. These techniques were aesthetically unappealing and reminiscent of the female genitalia. Selvaggi in 2009 reported on a novel scrotoplasty technique, which combines a V-Y plasty with a 90-degree turning of the labial flaps resulting in an anterior transposition of labial skin (Fig. 11). The excellent aesthetic outcome of this male-looking (anteriorly located) scrotum, the functional advantage of fewer urological complications and the easier implantation of testicular prostheses make this the technique of choice.39
Reconstruction of a lateral looking scrotum with two transposition flaps: (A) before and (B) after implantation of testicular prostheses.
In a radial forearm phalloplasty, the insertion of erection prosthesis is required to engage in sexual intercourse. In the past, attempts have been made to use bone or cartilage, but no good long-term results are described. The rigid and semirigid prostheses seem to have a high perforation rate and therefore were never used in our patients. Hoebeke, in the largest series to date on erection prostheses after penile reconstruction, only used the hydraulic systems available for impotent men. A recent long-term follow-up study showed an explantation rate of 44% in 130 patients, mainly due to malpositioning, technical failure, or infection. Still, more than 80% of the patients were able to have normal sexual intercourse with penetration.37 In another study, it was demonstrated that patients with an erection prosthesis were more able to attain their sexual expectations than those without prosthesis (Fig. 12).32
(A,B) Phalloplasty after implantation of an erection prosthesis.
A major concern regarding erectile prostheses is long-term follow-up. These devices were developed for impotent (older) men who have a shorter life expectancy and who are sexually less active than the mostly younger FTM patients.
Alternative Phalloplasty Techniques
A metoidioplasty uses the (hypertrophied) clitoris to reconstruct the microphallus in a way comparable to the correction of chordee and lengthening of a urethra in cases of severe hypospadias. Eichner40 prefers to call this intervention “the clitoris penoid.” In metoidioplasty, the clitoral hood is lifted and the suspensory ligament of the clitoris is detached from the pubic bone, allowing the clitoris to extend out further. An embryonic urethral plate is divided from the underside of the clitoris to permit outward extension and a visible erection. Then the urethra is advanced to the tip of the new penis. The technique is very similar to the reconstruction of the horizontal part of the urethra in a normal phalloplasty procedure. During the same procedure, a scrotal reconstruction, with a transposition flap of the labia majora (as previously described) is performed combined with a vaginectomy.
FTM patients interested in this procedure should be informed preoperatively that voiding while standing cannot be guaranteed, and that sexual intercourse will not be possible (Fig. 13).
Results of a metoidioplasty procedure.
The major advantage of metoidioplasty is the complete lack of scarring outside the genital area. Another advantage is that its cost is substantially lower than that of phalloplasty. Complications of this procedure also include urethral obstruction and/or urethral fistula.
It is always possible to perform a regular phalloplasty (e.g., with a radial forearm flap) at a later stage, and with substantially less risk of complications and operation time.
There have been several reports on penile reconstruction with the fibular flap based on the peroneal artery and the peroneal vein.27,41,42 It consists of a piece of fibula that is vascularized by its periosteal blood supply and connected through perforating (septal) vessels to an overlying skin island at the lateral site of the lower leg. The advantage of the fibular flap is that it makes sexual intercourse possible without a penile prosthesis. The disadvantages are a pointed deformity to the distal part of the penis when the extra skin can glide around the end of fibular bone, and that a permanently erected phallus is impractical.
Many authors seem to agree that the fibular osteocutaneous flap is an optimal solution for penile reconstruction in a natal male.42
NEW SURGICAL DEVELOPMENTS: THE PERFORATOR FLAPS
Perforator flaps are considered the ultimate form of tissue transfer. Donor site morbidity is reduced to an absolute minimum, and the usually large vascular pedicles provide an additional range of motion or an easier vascular anastomosis. At present, the most promising perforator flap for penile reconstruction is the anterolateral thigh (ALT) flap. This flap is a skin flap based on a perforator from the descending branch of the lateral circumflex femoral artery, which is a branch from the femoral artery. It can be used both as a free flap43 and as a pedicled flap44 then avoiding the problems related to microsurgical free flap transfer. The problem related to this flap is the (usually) thick layer of subcutaneous fat making it difficult to reconstruct the urethra as a vascularized tube within a tube. This flap might be more indicated for phallic reconstruction in the so-called boys without a penis, like in cases of vesical exstrophy (Fig. 14). However, in the future, this flap may become an interesting alternative to the radial forearm flap, particularly as a pedicled flap. If a solution could be found for a well-vascularized urethra, use of the ALT flap could be an attractive alternative to the radial forearm phalloplasty. The donor site is less conspicuous, and secondary corrections at that site are easier to make. Other perforator flaps include the thoracodorsal perforator artery flap (TAP) and the deep inferior epigastric perforator artery flap (DIEP). The latter might be an especially good solution for FTM patients who have been pregnant in the past. Using the perforator flap as a pedicled flap can be very attractive, both financially and technically.
Penile reconstruction with a pedicled anterolateral thigh flap. (A) Preoperative and (B) postoperative results.
Sex reassignment surgery female to male includes a variety of surgical procedures for transgender people that alter female anatomical traits to provide physical traits more appropriate to the trans man's male identity and functioning.
Many trans men considering the option do not opt for genital reassignment surgery; more frequent surgical options include bilateral mastectomy (removal of the breasts) and chest contouring (providing a more typically male chest shape), and hysterectomy (the removal of internal sex organs).
Sex reassignment surgery is usually preceded by beginning hormone treatment with testosterone.
Many trans men seek bilateral mastectomy, also called "top surgery", the removal of the breasts and the shaping of a male contoured chest.
Trans men with moderate to large breasts usually require a formal bilateral mastectomy with grafting and reconstruction of the nipple-areola. This will result in two horizontal scars on the lower edge of the pectoralis muscle, but allows for easier resizing of the nipple and placement in a typically male position.
By some doctors, the surgery is done in two steps, first the contents of the breast are removed through either a cut inside the areola or around it, and then let the skin retract for about a year, where in a second surgery the excess skin is removed. This technique results in far less scarring, and the nipple-areola doesn't need to be removed and grafted. Completely removing and grafting often results in a loss of sensation of that area that may take months to over a year to return, or may never return at all; and in rare cases in the complete loss of this tissue. In these rare cases, a nipple can be reconstructed as it is for surgical candidates whose nipples are removed as part of treatment for breast cancer.
For trans men with smaller breasts, a peri-areolar or "keyhole" procedure may be done where the mastectomy is performed through an incision made around the areola. This avoids the larger scars of a traditional mastectomy, but the nipples may be larger and may not be in a perfectly male orientation on the chest wall. In addition, there is less denervation (damage to the nerves supplying the skin) of the chest wall with a peri-areolar mastectomy, and less time is required for sensation to return. See Male Chest Reconstruction.
Hysterectomy and bilateral salpingo-oophorectomy
Hysterectomy is the removal of the uterus. Bilateral salpingo-oophorectomy (BSO) is the removal of both ovaries and fallopian tubes. Hysterectomy without BSO in women is sometimes erroneously referred to as a 'partial hysterectomy' and is done to treat uterine disease while maintaining the female hormonal milieu until natural menopause occurs. A 'partial hysterectomy' is actually when the uterus is removed, but the cervix is left intact. If the cervix is removed, it is called a 'total hysterectomy.'
Some trans men desire to have a hysterectomy/BSO because of a discomfort with having internal female reproductive organs despite the fact that menses usually cease with hormonal therapy. Some undergo this as their only gender-identity confirming 'bottom surgery'.
For many trans men however, hysterectomy/BSO is done to decrease the risk of developing cervical, endometrial, and ovarian cancer. (Though like breast cancer, the risk does not become zero, but is drastically decreased.) It is unknown whether the risk of ovarian cancer is increased, decreased, or unchanged in transgender men. The risk will probably never be known since the overall population of transgender men is very small;[improper synthesis?] even within the population of transgender men on hormone therapy, many patients are at significantly decreased risk due to prior oophorectomy (removal of the ovaries). While the rates of endometrial and cervical cancer are overall higher than ovarian cancer, and these malignancies occur in younger people, it is still highly unlikely that this question will ever be definitively answered.[improper synthesis?]
Decreasing cancer risk is however, particularly important as trans men often feel uncomfortable seeking gynecologic care, and many do not have access to adequate and culturally sensitive treatment. Though ideally, even after hysterectomy/BSO, trans men should see a gynecologist for a check-up at least every three years. This is particularly the case for trans men who:
- retain their vagina (whether before or after further genital reconstruction,)
- have a strong family history or cancers of the breast, ovary, or uterus (endometrium,)
- have a personal history of gynecological cancer or significant dysplasia on a Pap smear.
One important consideration is that any trans man who develops vaginal bleeding after successfully ceasing menses on testosterone, must be evaluated by a gynecologist. This is equivalent to post-menopausal bleeding in a woman and may herald the development of a gynecologic cancer.
Further information: Metoidioplasty and Phalloplasty
Genital reconstructive procedures (GRT) use either the clitoris, which is enlarged by androgenic hormones (metoidioplasty), or rely on free tissue grafts from the arm, the thigh or stomach and an erectile prosthetic (phalloplasty). In either case, the urethra can be rerouted through the phallus to allow urination through the newly constructed penis. The labia majora are united to form a scrotum, where prosthetic testicles can be inserted.