CLINICAL ARTICLE
Penile Reconstruction by Preexpanded Free Scapular Flap in Severely Burned Patient Liwei Dong, MD, Yulin Dong, MD, Lin He, MD, Chaohua Liu, MD, Zhaoxiang Zhang, MD, Bo Xiao, MD, Wei Xia, MD, and Wensen Xia, MD Background: Penile reconstruction or phalloplasty has always been one of the most challenging problems for plastic surgeons. In 1936, Bogoras performed the first phalloplasty by using traditional tubed pedicle flaps. Many other f laps and methods have been applied since, including lower abdominal f laps, pudendal-thigh f laps, parascapular f laps, paraumbilical flaps and, of course, radial forearm f laps. For each method, reports of both functional and esthetic successes abound. In this case, donor sites for phalloplasty were somewhat limited by the severe electric burn injury. After much consideration, we decided to preexpand the scapular f lap and to use this for phalloplasty, with satisfactory outcome. Our case is a 31-year-old patient who sustained a 19% total burn surface area by electrical burn in August 2011. The burn area involved both forearms, abdominal region, both femoral regions, and perineum including genitalia loss. Most of the burn wounds were skin grafted shortly after the injury. Due to the nature of the burn, regular donor sites for penile reconstruction were unavailable. Before surgery, we went through a detailed plan for phalloplasty with the patient and his family. The patient consented to the 2-stage surgery for the penile reconstruction. The first stage was insertion of a 600-mL soft tissue expander in the scapular region. After 4 months of expansion, the second stage of free scapular flap transfer was performed in March 2012. Results: The reconstruction was successful with good appearance and patient satisfaction, complicated by urethral fistula. Eight months later, the urinary fistula was repaired successfully. Conclusions: The free scapular flap proved to be an ideal solution to this patient’s dilemma. The f lap has adequate amount of tissue and a reliable blood supply. Its amenability to be expanded allows better donor-site primary closure. Tissue bulk resulted in adequate stiffness without artificial prosthesis for the phallus to be functional. Key Words: penile reconstruction, phalloplasty, preexpanded free scapular flap (Ann Plast Surg 2014;73: S27YS30)
P
enile reconstruction is indicated in patients with congenital deformities, gender dysphoria, and penis loss caused by trauma, selfmutilation, or tumor resection. In 1936, Bogoras1 performed the first penile reconstruction by using traditional tubed pedicle f laps. Many other types of flaps have been applied since. These include lower abdominal flaps, pudendal-thigh flaps, scapular flaps, paraumbilical flaps, and the radial forearm f lap.2 Each method has advantages and Received April 28, 2014, and accepted for publication, after revision, May 5, 2014. From the Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi People’s Republic of China. Conflicts of interest and sources of funding: none declared. The authors contributed equally for this manuscript. Reprints: Wei Xia, MD, Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, 15 West Changle Road, Xi’an, Shaanxi 710032. E-mail: [email protected]; and Wensen Xia, MD, Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, 15 West Changle Road, Xi’an, Shaanxi 710032. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7301-S027 DOI: 10.1097/SAP.0000000000000282
Annals of Plastic Surgery
disadvantages. Thus, flap selection is based on patient factors, patient requests, and surgeon preferences. In our patient, the free scapular flap was used with good functional and esthetic outcome.
Clinical Anatomy The first successful surgical application of the microsurgical scapular f lap was performed in Paris in October 1979. This f lap is based on the circumf lex scapular branch of the subscapular artery and is a versatile and reliable f lap. The length of vascular pedicle and its diameter are suitable for microsurgical anastomosis.3Y5 The circumf lex scapular artery, a branch of the subscapular artery, has a constant location. It emerges from the trilateral foramen, on the lateral border of the scapular. The artery divides into 2 branches. The superficial one is a cutaneous branch, which is known as the cutaneous scapular artery. This branch courses horizontally to the cutaneous territory of the dorsal region of the scapular, gives out 2 or more small branches, distributed to the teres major and teres minor muscles, the interspace fascia, and overlying skin. The length of the cutaneous scapular artery is approximately 4 to 6 cm, and the diameter of the artery ranges from 1.5 to 2.5 mm.6 Also, it is approximately 0.98 mm larger in diameters than in women. Both circumflex scapular artery and cutaneous scapular artery have venae comitantes with good size diameters. Researchers believe that there is no large single nerve furnishing the f lap, and the cutaneous innervation is through branches of the cervical and brachial plexuses. The f lap dermis is of intermediate thickness with hairless skin in Asians. Functional deficit and distortion of the axillary contours are minimal with this flap site.7
METHODS The surgical procedure can be divided into 2 stages. First is the expansion phase followed by the second stage of penile reconstruction performed 4 months later. At the first surgery, we implanted a rectangular 600-mL soft tissue expander at the scapular region. Before surgery, using the ultrasound Doppler survey, the pedicle is mapped out on the skin surface (Fig. 1). The pocket for implantation should be determined by the size of expander and the location of vasculature. The appropriate tissue layer is dissected out. The pocket is created parallel to the scapular spine and the lateral border being 4 cm away from the pedicle. An 8-cm incision was made 3 cm away from the medial border of the pocket. The expander was implanted deep to the deep fascial layer, whereas the filling port was placed in a separate pocket lateral to the expander. During surgery, the expander was prefilled with 100-mL saline. Serial expansion was started 10 days after surgery at the interval of 3 to 4 days for 4 months, reaching a final volume of 800 mL. At the second stage of reconstruction, the f lap was designed in 5 parts (Fig. 2), 15 cm in length and 18.5 cm in width. Vasculature was once again determined by ultrasound Doppler. The emerging point of the circumf lex scapular vessel from the trilateral space along the lateral border of the scapular as well as distribution of its 3 major branches is mapped on the skin. Flap parts A and C were
& Volume 73, Supplement 1, September 2014
www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S27
Annals of Plastic Surgery
Dong et al
& Volume 73, Supplement 1, September 2014
FIGURE 1. A, The area of implantation pocket was determined by the size of expander. B, The surface markings of the scapular cutaneous vessels. The top one was not included in the f lap planning because of its inappropriate distribution. Another 2 branches were contained by the area of implant pocket. C, Four months after expansion.
FIGURE 2. Flap planning. A, Five parts of the f lap marked out. Vascular anatomy is mapped out yet again. B, Flap after dissection and deepithelialization. C, Formation of neourethra. D, The reconstructed penis.
planned for reconstructing the body of penis, whereas parts D and E for glans penis. Flap part B is to be curled inward around a folly’s catheter placed inside, and the 2 small deepithelialized gaps by both sides of part B were sutured together, to form the new urethra. The side of the neourethra was designed to be the ventral surface side of the reconstructed penis. Another deepithelialized gap perpendicular to the macroaxis of the f lap is also curled inward and sutured
together to form the corona of the glans penis, whereas the other 2 deepithelialized gaps with ‘‘V’’ shape used for external orifice of neourethra. When the new urethra was completed, f lap parts A and C were rotated backward and sutured together to form the dorsal side of the penis. The recipient site is prepared by a second group of surgeons at the same time. Both vascular pedicle and urethra should be prepared.
FIGURE 3. A to C, Perineum region before surgery. D to F, Reconstructed penis 8 months later. Urinary fistula repair and lipectomy were also performed. S28
www.annalsplasticsurgery.com
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 73, Supplement 1, September 2014
First, the urethral opening was completely released from the scar tissue, and mucosa mobilized to anastomose it to the proximal end of neourethra using 5-0 Vicryl suture, reducing tension on the anastomosis as much as possible. Afterward, the body of reconstructed penis must be well fixed to provide a stable and clear operation field for vascular anastomosis. The recipient inferior epigastric vessels were identified for anastomosis to the f lap pedicle. After careful dissection, the length of circumf lex scapular vessels was 6 cm, including 1 artery and 2 venae comitantes. The donor and recipient vessels are well matched for end-to-end anastomosis. The same measure was also adapted for external orifice of neourethra. The donor site of the f lap was covered by split-thickness skin graft. Postoperative care includes the following8: 1) complete bed rest, 2) indwelling urinary catheter for 1 week, and 3) using external frame for elevation and fixation of penis. Antibiotics and anticoagulation were also highly recommended for at least 3 days. Frequent inspection was another important aspect, to detect any complications at early stage and take effective measure.
FIGURE 4. A, Donor site of f lap after expansion. B, Donor site covered by split-skin graft 8 months later after reconstruction. * 2014 Lippincott Williams & Wilkins
Phalloplasty by Preexpanded Free Scapular Flap
RESULT The reconstructed penis achieved good esthetic appearance and satisfactory stiffness. However, a urinary fistula developed. The fistula was repaired 8 months later. The final appearance and function were quite satisfying, with the donor site of the flap also undergoing good recovery (Figs. 3 and 4).
DISCUSSION Compared with other classic methods for phalloplasty the free scapular f lap provided adequate amount of tissue, reliable vascularity. The donor site is well concealed compared to radial forearm f laps. Preexpansion of the scapular f lap in this case obviated the excessive donor-site defect and reduced the area for skin graft. The large defect of the donor site can potentially cause a large deformity on the back. Soft tissue expansion of free f laps before transfer have been used for a long time, to increase the size of the transferred tissue and some time allow primary closure of the donor site, which is especially important in burns when there is a lack of healthy tissue, or in children when there is a relative lack of tissue.9 The introduction of the preexpansion technique into free scapular f lap penile reconstruction achieved a satisfying result. The stage of preexpansion was also prefabrication for the f lap. During the expansion, the subdermal vascular network improved even further, which also increases the safety of f lap transfer than 1-stage surgery. By the clinical observation, we noticed the reconstructed penis had very satisfying stiffness after surgery. The probable reason was that f lap preexpansion resulted in dermal layer thickening from the capsule relayed to the expander. This obviated the need for any other prosthesis, whether artificial or autologous costal cartilage, which introduces more complications, such as exposure of prosthetics, chronic infection, or mechanical problem of prosthetics.10 At the year of 1984, Gao11 reported a 1-stage reconstruction of the penis with free skin f lap from the forearm. This method still remains the gold standard for phalloplasty. In this case, both forearm of the patient were ruled out as donor sites. Besides the ideal thickness and reliable vascularity, the forearm f lap is relatively easy for molding and can be transferred with a sensory nerve. But the disadvantage is also significant. It leaves an unsightly donor site,12 and loss of both radial artery and radial nerve of the forearm, which lead to impaired appearance and reduction of sensitivity to the distal forearm.2,8 Thin subcutaneous tissue and less tissue for transfer of free forearm f lap result in thin reconstructed phallus. When penile prostheses are implanted at the same time, it is more likely to erode the soft and thin f laps with the final result of prostheses exposure.2,10 The most common complications of penile reconstruction are related to the neourethra, including urethral fistula and urethral stricture as the top 2 problems.13 The major reason of fistula is closely associated with the blood supply of the neourethra. Biemer14 in 1988 redesign the phalloplasty f lap, making the neourethra located at the central part to the reconstructed phallus, with the axis parallel to the f lap and radial artery, to improve the blood supply. Semple et al15 suggested avoiding contact between neourethra and suture material to protect the tissue. For the urethral stricture, Gottlieb and Levine16 designed a small f lap at the distal end of neourethra to prevent straight scar formation and stricturing. Good f lap design is of most important in preventing urethral complications. The reported complication rates are still high and many factors were identified in different studies, such as patient factors and skill or experience of surgeons. Overall complication rate of urethral fistula rate was 40.9%, needing fistula repair surgery, whereas urethral stricture was noted in 13.7% of all the subjects.17 In our case, urethral fistula occurred necessitating a secondary urethroplasty. Song et al18 in their publication showed much lower rates of fistula formation www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S29
Annals of Plastic Surgery
Dong et al
using modifications of the radial forearm f lap. They demonstrated that using a randomly based muscle flap harvested from the perineal floor juxtaposed to the neophallus to encuff the urethral anastomosis resulted in a water tight seal.
& Volume 73, Supplement 1, September 2014
7. Hamilton SG, Morrison WA. The scapular free flap. Br J Plast Surg. 1982; 35:2Y7. 8. Yang M, Zhao M, Li S, et al. Penile reconstruction by the free scapular flap and malleable penis prosthesis. Ann Plast Surg. 2007;59:95Y101. 9. Acarturk TO, Glaser DP, Newton ED. Reconstruction of difficult wounds with tissue-expanded free flaps. Ann Plast Surg. 2004;52:493Y499; discussion 500.
CONCLUSIONS The introduction of preexpansion technique is an effective modification for the traditional free scapular f lap penile reconstruction. This adds value to the scapular f lap as a donor site, with reliable vascularity, adequate amount of tissue, as well as stiffness of the reconstructed penis. In conclusion, the preexpanded free scapular f lap is a useful choice for penile reconstruction. REFERENCES 1. Bogoras N. Plastic construction of penis capable of accomplishing coitus. Zentralbl Chir. 1936;63:1271Y1276. 2. Babaei A, Safarinejad MR, Farrokhi F, et al. Penile reconstruction: evaluation of the most accepted techniques. Urol J. 2010;7:71Y78. 3. Dos Santos LF. The vascular anatomy and dissection of the free scapular flap. Plast Reconstr Surg. 1984;73:599Y604. 4. Barwick WJ, Goodkind DJ, Serafin D. The free scapular flap. Plast Reconstr Surg. 1982;69:779Y787. 5. Gahhos FN, Tross RB, Salomon JC. Scapular free-flap dissection made easier. Plast Reconstr Surg. 1985;75:115Y118. 6. Urbaniak JR, Koman LA, Goldner RD, et al. The vascularized cutaneous scapular flap. Plast Reconstr Surg. 1982;69:772Y778.
S30
www.annalsplasticsurgery.com
10. Sengezer M, Ozturk S, Deveci M, et al. Long-term follow-up of total penile reconstruction with sensate osteocutaneous free fibula flap in 18 biological male patients. Plast Reconstr Surg. 2004;114:439Y450; discussion 451-432. 11. Gao XS. [One-stage reconstruction of the penis with free skin flap from the forearmVreport of 5 cases]. Zhonghua Yi Xue Za Zhi. 1984;64:470Y473. 12. Wang H, Li SK, Yang MY, et al. A free scapular skin flap for penile reconstruction. J Plast Reconstr Aesthet Surg. 2007;60:1200Y1203. 13. Levine LA, Elterman L. Urethroplasty following total phallic reconstruction. J Urol. 1998;160:378Y382. 14. Biemer E. Penile construction by the radial arm flap. Clin Plast Surg. 1988; 15:425Y430. 15. Semple JL, Boyd JB, Farrow GA, et al. The ‘‘cricket bat’’ flap: a one-stage free forearm flap phalloplasty. Plast Reconstr Surg. 1991;88:514Y519. 16. Gottlieb LJ, Levine LA. A new design for the radial forearm free-flap phallic construction. Plast Reconstr Surg. 1993;92:276Y283; discussion 284. 17. Fang RH, Kao YS, Ma S, et al. Phalloplasty in female-to-male transsexuals using free radial osteocutaneous flap: a series of 22 cases. Br J Plast Surg. 1999;52:217Y222. 18. Song C, Wong MZ, Wong CH, et al. Modifications of the radial forearm flap phalloplasty for female to male gender reassignment. J Reconstr Microsurg. 2011;27:115Y121.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Penile Reconstruction by Preexpanded Free Scapular Flap in Severely Burned Patient Liwei Dong, MD, Yulin Dong, MD, Lin He, MD, Chaohua Liu, MD, Zhaoxiang Zhang, MD, Bo Xiao, MD, Wei Xia, MD, and Wensen Xia, MD Background: Penile reconstruction or phalloplasty has always been one of the most challenging problems for plastic surgeons. In 1936, Bogoras performed the first phalloplasty by using traditional tubed pedicle flaps. Many other f laps and methods have been applied since, including lower abdominal f laps, pudendal-thigh f laps, parascapular f laps, paraumbilical flaps and, of course, radial forearm f laps. For each method, reports of both functional and esthetic successes abound. In this case, donor sites for phalloplasty were somewhat limited by the severe electric burn injury. After much consideration, we decided to preexpand the scapular f lap and to use this for phalloplasty, with satisfactory outcome. Our case is a 31-year-old patient who sustained a 19% total burn surface area by electrical burn in August 2011. The burn area involved both forearms, abdominal region, both femoral regions, and perineum including genitalia loss. Most of the burn wounds were skin grafted shortly after the injury. Due to the nature of the burn, regular donor sites for penile reconstruction were unavailable. Before surgery, we went through a detailed plan for phalloplasty with the patient and his family. The patient consented to the 2-stage surgery for the penile reconstruction. The first stage was insertion of a 600-mL soft tissue expander in the scapular region. After 4 months of expansion, the second stage of free scapular flap transfer was performed in March 2012. Results: The reconstruction was successful with good appearance and patient satisfaction, complicated by urethral fistula. Eight months later, the urinary fistula was repaired successfully. Conclusions: The free scapular flap proved to be an ideal solution to this patient’s dilemma. The f lap has adequate amount of tissue and a reliable blood supply. Its amenability to be expanded allows better donor-site primary closure. Tissue bulk resulted in adequate stiffness without artificial prosthesis for the phallus to be functional. Key Words: penile reconstruction, phalloplasty, preexpanded free scapular flap (Ann Plast Surg 2014;73: S27YS30)
P
enile reconstruction is indicated in patients with congenital deformities, gender dysphoria, and penis loss caused by trauma, selfmutilation, or tumor resection. In 1936, Bogoras1 performed the first penile reconstruction by using traditional tubed pedicle f laps. Many other types of flaps have been applied since. These include lower abdominal flaps, pudendal-thigh flaps, scapular flaps, paraumbilical flaps, and the radial forearm f lap.2 Each method has advantages and Received April 28, 2014, and accepted for publication, after revision, May 5, 2014. From the Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi People’s Republic of China. Conflicts of interest and sources of funding: none declared. The authors contributed equally for this manuscript. Reprints: Wei Xia, MD, Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, 15 West Changle Road, Xi’an, Shaanxi 710032. E-mail: [email protected]; and Wensen Xia, MD, Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, 15 West Changle Road, Xi’an, Shaanxi 710032. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7301-S027 DOI: 10.1097/SAP.0000000000000282
Annals of Plastic Surgery
disadvantages. Thus, flap selection is based on patient factors, patient requests, and surgeon preferences. In our patient, the free scapular flap was used with good functional and esthetic outcome.
Clinical Anatomy The first successful surgical application of the microsurgical scapular f lap was performed in Paris in October 1979. This f lap is based on the circumf lex scapular branch of the subscapular artery and is a versatile and reliable f lap. The length of vascular pedicle and its diameter are suitable for microsurgical anastomosis.3Y5 The circumf lex scapular artery, a branch of the subscapular artery, has a constant location. It emerges from the trilateral foramen, on the lateral border of the scapular. The artery divides into 2 branches. The superficial one is a cutaneous branch, which is known as the cutaneous scapular artery. This branch courses horizontally to the cutaneous territory of the dorsal region of the scapular, gives out 2 or more small branches, distributed to the teres major and teres minor muscles, the interspace fascia, and overlying skin. The length of the cutaneous scapular artery is approximately 4 to 6 cm, and the diameter of the artery ranges from 1.5 to 2.5 mm.6 Also, it is approximately 0.98 mm larger in diameters than in women. Both circumflex scapular artery and cutaneous scapular artery have venae comitantes with good size diameters. Researchers believe that there is no large single nerve furnishing the f lap, and the cutaneous innervation is through branches of the cervical and brachial plexuses. The f lap dermis is of intermediate thickness with hairless skin in Asians. Functional deficit and distortion of the axillary contours are minimal with this flap site.7
METHODS The surgical procedure can be divided into 2 stages. First is the expansion phase followed by the second stage of penile reconstruction performed 4 months later. At the first surgery, we implanted a rectangular 600-mL soft tissue expander at the scapular region. Before surgery, using the ultrasound Doppler survey, the pedicle is mapped out on the skin surface (Fig. 1). The pocket for implantation should be determined by the size of expander and the location of vasculature. The appropriate tissue layer is dissected out. The pocket is created parallel to the scapular spine and the lateral border being 4 cm away from the pedicle. An 8-cm incision was made 3 cm away from the medial border of the pocket. The expander was implanted deep to the deep fascial layer, whereas the filling port was placed in a separate pocket lateral to the expander. During surgery, the expander was prefilled with 100-mL saline. Serial expansion was started 10 days after surgery at the interval of 3 to 4 days for 4 months, reaching a final volume of 800 mL. At the second stage of reconstruction, the f lap was designed in 5 parts (Fig. 2), 15 cm in length and 18.5 cm in width. Vasculature was once again determined by ultrasound Doppler. The emerging point of the circumf lex scapular vessel from the trilateral space along the lateral border of the scapular as well as distribution of its 3 major branches is mapped on the skin. Flap parts A and C were
& Volume 73, Supplement 1, September 2014
www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S27
Annals of Plastic Surgery
Dong et al
& Volume 73, Supplement 1, September 2014
FIGURE 1. A, The area of implantation pocket was determined by the size of expander. B, The surface markings of the scapular cutaneous vessels. The top one was not included in the f lap planning because of its inappropriate distribution. Another 2 branches were contained by the area of implant pocket. C, Four months after expansion.
FIGURE 2. Flap planning. A, Five parts of the f lap marked out. Vascular anatomy is mapped out yet again. B, Flap after dissection and deepithelialization. C, Formation of neourethra. D, The reconstructed penis.
planned for reconstructing the body of penis, whereas parts D and E for glans penis. Flap part B is to be curled inward around a folly’s catheter placed inside, and the 2 small deepithelialized gaps by both sides of part B were sutured together, to form the new urethra. The side of the neourethra was designed to be the ventral surface side of the reconstructed penis. Another deepithelialized gap perpendicular to the macroaxis of the f lap is also curled inward and sutured
together to form the corona of the glans penis, whereas the other 2 deepithelialized gaps with ‘‘V’’ shape used for external orifice of neourethra. When the new urethra was completed, f lap parts A and C were rotated backward and sutured together to form the dorsal side of the penis. The recipient site is prepared by a second group of surgeons at the same time. Both vascular pedicle and urethra should be prepared.
FIGURE 3. A to C, Perineum region before surgery. D to F, Reconstructed penis 8 months later. Urinary fistula repair and lipectomy were also performed. S28
www.annalsplasticsurgery.com
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 73, Supplement 1, September 2014
First, the urethral opening was completely released from the scar tissue, and mucosa mobilized to anastomose it to the proximal end of neourethra using 5-0 Vicryl suture, reducing tension on the anastomosis as much as possible. Afterward, the body of reconstructed penis must be well fixed to provide a stable and clear operation field for vascular anastomosis. The recipient inferior epigastric vessels were identified for anastomosis to the f lap pedicle. After careful dissection, the length of circumf lex scapular vessels was 6 cm, including 1 artery and 2 venae comitantes. The donor and recipient vessels are well matched for end-to-end anastomosis. The same measure was also adapted for external orifice of neourethra. The donor site of the f lap was covered by split-thickness skin graft. Postoperative care includes the following8: 1) complete bed rest, 2) indwelling urinary catheter for 1 week, and 3) using external frame for elevation and fixation of penis. Antibiotics and anticoagulation were also highly recommended for at least 3 days. Frequent inspection was another important aspect, to detect any complications at early stage and take effective measure.
FIGURE 4. A, Donor site of f lap after expansion. B, Donor site covered by split-skin graft 8 months later after reconstruction. * 2014 Lippincott Williams & Wilkins
Phalloplasty by Preexpanded Free Scapular Flap
RESULT The reconstructed penis achieved good esthetic appearance and satisfactory stiffness. However, a urinary fistula developed. The fistula was repaired 8 months later. The final appearance and function were quite satisfying, with the donor site of the flap also undergoing good recovery (Figs. 3 and 4).
DISCUSSION Compared with other classic methods for phalloplasty the free scapular f lap provided adequate amount of tissue, reliable vascularity. The donor site is well concealed compared to radial forearm f laps. Preexpansion of the scapular f lap in this case obviated the excessive donor-site defect and reduced the area for skin graft. The large defect of the donor site can potentially cause a large deformity on the back. Soft tissue expansion of free f laps before transfer have been used for a long time, to increase the size of the transferred tissue and some time allow primary closure of the donor site, which is especially important in burns when there is a lack of healthy tissue, or in children when there is a relative lack of tissue.9 The introduction of the preexpansion technique into free scapular f lap penile reconstruction achieved a satisfying result. The stage of preexpansion was also prefabrication for the f lap. During the expansion, the subdermal vascular network improved even further, which also increases the safety of f lap transfer than 1-stage surgery. By the clinical observation, we noticed the reconstructed penis had very satisfying stiffness after surgery. The probable reason was that f lap preexpansion resulted in dermal layer thickening from the capsule relayed to the expander. This obviated the need for any other prosthesis, whether artificial or autologous costal cartilage, which introduces more complications, such as exposure of prosthetics, chronic infection, or mechanical problem of prosthetics.10 At the year of 1984, Gao11 reported a 1-stage reconstruction of the penis with free skin f lap from the forearm. This method still remains the gold standard for phalloplasty. In this case, both forearm of the patient were ruled out as donor sites. Besides the ideal thickness and reliable vascularity, the forearm f lap is relatively easy for molding and can be transferred with a sensory nerve. But the disadvantage is also significant. It leaves an unsightly donor site,12 and loss of both radial artery and radial nerve of the forearm, which lead to impaired appearance and reduction of sensitivity to the distal forearm.2,8 Thin subcutaneous tissue and less tissue for transfer of free forearm f lap result in thin reconstructed phallus. When penile prostheses are implanted at the same time, it is more likely to erode the soft and thin f laps with the final result of prostheses exposure.2,10 The most common complications of penile reconstruction are related to the neourethra, including urethral fistula and urethral stricture as the top 2 problems.13 The major reason of fistula is closely associated with the blood supply of the neourethra. Biemer14 in 1988 redesign the phalloplasty f lap, making the neourethra located at the central part to the reconstructed phallus, with the axis parallel to the f lap and radial artery, to improve the blood supply. Semple et al15 suggested avoiding contact between neourethra and suture material to protect the tissue. For the urethral stricture, Gottlieb and Levine16 designed a small f lap at the distal end of neourethra to prevent straight scar formation and stricturing. Good f lap design is of most important in preventing urethral complications. The reported complication rates are still high and many factors were identified in different studies, such as patient factors and skill or experience of surgeons. Overall complication rate of urethral fistula rate was 40.9%, needing fistula repair surgery, whereas urethral stricture was noted in 13.7% of all the subjects.17 In our case, urethral fistula occurred necessitating a secondary urethroplasty. Song et al18 in their publication showed much lower rates of fistula formation www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S29
Annals of Plastic Surgery
Dong et al
using modifications of the radial forearm f lap. They demonstrated that using a randomly based muscle flap harvested from the perineal floor juxtaposed to the neophallus to encuff the urethral anastomosis resulted in a water tight seal.
& Volume 73, Supplement 1, September 2014
7. Hamilton SG, Morrison WA. The scapular free flap. Br J Plast Surg. 1982; 35:2Y7. 8. Yang M, Zhao M, Li S, et al. Penile reconstruction by the free scapular flap and malleable penis prosthesis. Ann Plast Surg. 2007;59:95Y101. 9. Acarturk TO, Glaser DP, Newton ED. Reconstruction of difficult wounds with tissue-expanded free flaps. Ann Plast Surg. 2004;52:493Y499; discussion 500.
CONCLUSIONS The introduction of preexpansion technique is an effective modification for the traditional free scapular f lap penile reconstruction. This adds value to the scapular f lap as a donor site, with reliable vascularity, adequate amount of tissue, as well as stiffness of the reconstructed penis. In conclusion, the preexpanded free scapular f lap is a useful choice for penile reconstruction. REFERENCES 1. Bogoras N. Plastic construction of penis capable of accomplishing coitus. Zentralbl Chir. 1936;63:1271Y1276. 2. Babaei A, Safarinejad MR, Farrokhi F, et al. Penile reconstruction: evaluation of the most accepted techniques. Urol J. 2010;7:71Y78. 3. Dos Santos LF. The vascular anatomy and dissection of the free scapular flap. Plast Reconstr Surg. 1984;73:599Y604. 4. Barwick WJ, Goodkind DJ, Serafin D. The free scapular flap. Plast Reconstr Surg. 1982;69:779Y787. 5. Gahhos FN, Tross RB, Salomon JC. Scapular free-flap dissection made easier. Plast Reconstr Surg. 1985;75:115Y118. 6. Urbaniak JR, Koman LA, Goldner RD, et al. The vascularized cutaneous scapular flap. Plast Reconstr Surg. 1982;69:772Y778.
S30
www.annalsplasticsurgery.com
10. Sengezer M, Ozturk S, Deveci M, et al. Long-term follow-up of total penile reconstruction with sensate osteocutaneous free fibula flap in 18 biological male patients. Plast Reconstr Surg. 2004;114:439Y450; discussion 451-432. 11. Gao XS. [One-stage reconstruction of the penis with free skin flap from the forearmVreport of 5 cases]. Zhonghua Yi Xue Za Zhi. 1984;64:470Y473. 12. Wang H, Li SK, Yang MY, et al. A free scapular skin flap for penile reconstruction. J Plast Reconstr Aesthet Surg. 2007;60:1200Y1203. 13. Levine LA, Elterman L. Urethroplasty following total phallic reconstruction. J Urol. 1998;160:378Y382. 14. Biemer E. Penile construction by the radial arm flap. Clin Plast Surg. 1988; 15:425Y430. 15. Semple JL, Boyd JB, Farrow GA, et al. The ‘‘cricket bat’’ flap: a one-stage free forearm flap phalloplasty. Plast Reconstr Surg. 1991;88:514Y519. 16. Gottlieb LJ, Levine LA. A new design for the radial forearm free-flap phallic construction. Plast Reconstr Surg. 1993;92:276Y283; discussion 284. 17. Fang RH, Kao YS, Ma S, et al. Phalloplasty in female-to-male transsexuals using free radial osteocutaneous flap: a series of 22 cases. Br J Plast Surg. 1999;52:217Y222. 18. Song C, Wong MZ, Wong CH, et al. Modifications of the radial forearm flap phalloplasty for female to male gender reassignment. J Reconstr Microsurg. 2011;27:115Y121.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
