Phalloplasty in complete aphallia and ambiguous genitalia

Abstract

The most common indications for phalloplasty in children include aphallia, micropenis/severe penile inadequacy, ambiguous genitalia, phallic inadequacy associated with epispadias/bladder exstrophy and female to male gender reassignment in adolescents. There are many surgical options for phalloplasty; both local pedicled tissue as well as free tissue transfer. The advantages of local tissue include a more concealed donor site, less complex operation and potentially faster recovery. However, pedicled options are generally less sensate, making placement of a penile prosthesis more risky and many children with bladder exstrophy have been previously operated upon making the blood supply for local pedicled flaps less reliable. This Here the authors discuss free tissue transfer, including the radial forearm, the anterolateral thigh, the scapula and latissimus, and the fibula free flaps, as well as local rotational flaps from the abdomen, groin, and thigh. The goal of reconstruction should be an aesthetic and functional (ability to penetrate) phallus, which provides tactile and erogenous sensation, and the ability to urinate standing. Ideally, the operation should be completed in one to two operations with minimal donor site morbidity. There are advantages and disadvantages of each of flap and thus the choice of donor site should be a combination of the patient's preference and surgeon's ability to produce a consistent result.

Keywords: Phalloplasty; aphallia; children bladder exstrophy.

Figure 1

(A) A 6-month-old boy with epispadias. (B) An 8-month-old boy with bladder exstrophy.

Figure 2

A 12-month-old boy with cloacal exstrophy.

Figure 3

(A) the outline of the radial forearm phalloplasty flap on the arm. The lateral and medial antebrachial cutaneous nerves can be coapted to the ilioinguinal and dorsal penile nerves. The radial artery of the flap can be anastomosed to either the profunda femoris, lateral circumflex femoral, circumflex iliac, or the inferior epigastric artery. The venae comitantes and the cephalic vein of the flap can be anastomosed to branches of the greater saphenous vein. (B) Illustration of the flap following inset, anastomosis, and coaptation.

Figure 4

Incorporation of the native glans and urethra into the base of the ventral surface of the phalloplasty. These patients have a continent umbilical stoma and therefore do not void through the penis.

Figure 5

(A) The flap is divided into three sections, the outer skin envelope of the penis, the deepithelialized portion, which is used to separate the outer portion of the reconstructed penis from the urethra, and the ulnar-sided skin paddle used to create the urethra. (B) The entire flap is tubed around a 16-French Foley catheter.

Figure 6

To create a glans, the distal portion of the flap is deepithelialized and then curled under. A full thickness skin graft, harvested from the groin is then placed just below.

Figure 7

(A) Partial amputation of the penis following an explosion of an improvised explosive device. (B) After penile and urethral reconstruction and tattooing.

Figure 8

(A) A 16-year-old boy with severe micropenis and bladder exstrophy (B) who underwent radial forearm phalloplasty. Urethral reconstruction was not undertaken as the patient has a continent umbilical stoma.

Figure 9

(A) This is a 17-year-old patient with micropenis and bladder exstrophy who underwent a radial forearm phalloplasty. (B) Flap after tubularization and creation of the neoglans. Urethral reconstruction was not performed as the patient has a continent umbilical stoma. (C) Immediately following anastomosis. The corona is deliberately peaked on the ventral surface of the neophallus to simulate the natural shape of the glans-shaft junction. (D) Two months postop prior to tattooing.

Figure 10

This illustrates the design for the myocutaneous latissimus flap described by Perovic. The flap is centered over the pedicle and measures 17 × 15 cm, with a rectangular skin paddle for the shaft, an intervening 1-cm deepithelialized strip, and a distal circular component for glans reconstruction. Only a thin strip of muscle around the pedicle is harvested, allowing the flap to be easily tabularized.

Figure 11

Illustration of the prelamination of the neo-urethra in the fibula free flap using a full thickness skin graft tubed over a Foley catheter.

Figure 12

This drawing illustrates the vertically oriented flap. The distal skin paddle contains the fibula and the prelaminated urethra and is then folded to form the ventral side of the penis. The proximal skin paddle is more sensate and forms the dorsal side of the penis.