The anatomy of the musculocutaneous latissimus dorsi flap for neophalloplasty

Abstract

In transgender surgery, the ideal neophallus is one that: (a) is constructed using a reproducible procedure, (b) possesses tactile and erogenous sensation, (c) is large and rigid enough (naturally, or using a prosthesis) to permit penetrative intercourse, (d) leaves acceptable donor site morbidity, (e) results in esthetically satisfactory appearance, and (f) allows for voiding while standing. The musculocutaneous latissimus dorsi (MLD) flap has favorable results in the area of neophalloplasty. Among its advantages are acceptable donor site appearance, stiffness sufficient for intercourse, and esthetically satisfactory genital appearance. The anatomy of the MLD flap supports the creation of a neophallus for transsexual anatomy revision. Herein, we give an overview of the advantages and disadvantages of the procedure, and the anatomical details and surgical steps involved. Novel illustrations were created from standard surgical text descriptions to clarify this topic for surgical training and patient understanding and decision making. A review of the relevant literature regarding the anatomy, procedure development, and outcomes is presented. The MLD flap uses part of the latissimus dorsi muscle with branches of the thoracodorsal vessels and nerve to construct a neophallus. A thin strip of muscle around the pedicle is harvested, resulting in a slightly curvilinear scar. The blood supply is connected to the femoral artery and saphenous vein or the deep inferior epigastric artery and vein, while the nerve is connected to the ilioinguinal nerve or the obturator nerve. The MLD flap for neophalloplasty is a reliable graft with a well concealed scar and low donor site morbidity. Clin. Anat. 31:152-159, 2018. © 2017 Wiley Periodicals, Inc.

Keywords: gender affirmation surgery; latissimus dorsi flap; neophallus; phalloplasty.