British Journal ofPlustic Surgery (1990), 43,21l-222 0 1990The Trustees of British Association of Plastic Surgeons
Reconstruction T. HARASHINA,
of penis with free deltoid flap
T. INOUE, I. TANAKA,
K. IMAI and M. HATOKO
Department of Plastic and Reconstructive Surgery, Saitama Medical Center, Saitama, Japan
Summary-Two cases of reconstruction urethra was reconstructed with part of the the remainder. In one case an autogenous as a strut. Postoperatively both patients cartilage graft was used sexual intercourse protective sensation in their reconstructed
of the penis with a free deltoid flap are described. The flap and external coverage of the penis was provided with rib cartilage graft was inserted in the reconstructed penis can urinate standing up, and for the one in which a rib is possible. Both cases have good recovery of tactile and penis.
Loss of the penis, either from trauma or malignancy, poses a serious and distressing impact and is regarded almost as loss of masculinity. Microvascular free tissue transfers, which have brought revolutionary changes to the field of reconstructive plastic surgery, also benefit the difficult problem of penile reconstruction. We have reconstructed the penis in two cases using a free deltoid flap. Operative procedure
The surgery is performed under general anaesthesia by two teams. While one team elevates the deltoid flap, the other team prepares the recipient site to accept the constructed penis and, if required, obtains a costal cartilage graft. The design of the deltoid flap is accurately drawn the day before surgery (Fig. 2A). First, the intervening portion between A and B (Figs 2B and 3) is de-epithelialised and the flap elevated. Dissection of the neurovascular pedicle of the flap is not straightforward due to numerous and complex branchings of the vessels, and liberal use of haemoclips makes it much easier and faster. After the neurovascular pedicle is completely freed, the flap is temporarily fixed with sutures at the original site. The urethra is constructed by suturing flap B around a No. 14 or 16 Foley catheter with absorbable sutures (Fig. 4). After preparation of the recipient site is completed, the neurovascular pedicle is divided and the neopenis is formed by enveloping the constructed urethra and, if desired, the costal cartilage graft with flap A (Fig. 5). The cartilage graft is obtained from the 8th or 9th rib and should be as straight as possible, with a length of 10 cm and diameter of 1.5 cm.
Preparation of the recipient site consists of dissecting out the penile and urethral stump and dissection of inferior epigastric vessels and pudendal nerve through appropriate skin incisions. The pudendal nerve is located just distal to Alcock’s canal along the medial border of the inferior pubic ramus where the nerve runs with its accompanying artery. The nerve is easiest to locate by elevating the underlying pubic periosteum and dissecting the overlying soft tissue until it is found (Gilbert et al., 1987). Transfer is begun by nerve anastomosis between the pudendal nerve and the cutaneous nerve of the deltoid flap. The pudendal nerve is located deep in the wound and if the neopenis is fixed first, the nerve anastomosis becomes extremely difficult because the two nerves to be anastomosed run almost vertically. The stump of the remaining urethra is anastomosed to the newly constructed urethra with absorbable sutures in zig-zag fashion to prevent possible later stricture at the suture line. The dermis of the flap and the inserted rib cartilage are sutured to the stump of the penile fascias with heavy, non-absorbable sutures. After the penis is fixed securely to the proposed site, vascular anastomoses are performed. Patency of the anastomoses is observed for 30 minutes and all the wounds are closed with appropriate drains. The donor site of the deltoid flap is split skin grafted. Case reports Case I (Figs l-7) A 54-year-old male had had his penis amputated due to malignancy at the age of 39. He was divorced when he
217
BRITISH JOURNAL OF PLASTIC SURGERY It is now 3 years after the reconstruction and he can urinate in a standing position with a strong stream and can enjoy sexual intercourse. He has a good sensory recovery all over his reconstructed penis but the quality of it is not an erogenous one and there is no measurable two-point discrimination.
Discussion The aims of penile reconstruction are (1) to enable urination in the standing position, (2) to enable sexual intercourse and (3) to reconstruct an aesthetically acceptable penis. For these purposes a reconstructed penis should have a urethra lined with epithelium without stricture, should be stiff enough to allow for successful sexual penetration and should have adequate tactile and protective sensation or, ideally, erogenous sensation.
Fig. 1 Figure I-Case
1. Preoperative view.
was 44. Reconstruction of the penis was performed in October 1986. At reconstruction the pudendal nerve, which was identified with difficulty, was extremely small. The lateral femoral cutaneous nerve was used instead as a recipient nerve. After reconstruction part of the groin skin which was elevated as a skin flap necrosed and it was allowed to heal spontaneously. Two years after reconstruction the patient can urinate in a standing position (Fig. 6) and has good sensory recovery in the flap but there is no measurable two-point discrimination.
Case 2 (Figs 8-11) A 26-year-old lorry driver, married 3 months before, met with a traffic accident in which his penis was severely crushed between the steering wheel and his pubic bone. After several unsuccessful attempts at reconstruction in a local hospital, he was referred to us 15 months after the accident. When first seen by us the penis was almost completely absent, leaving a small remnant of skin under which the urethraopened (Fig. 8). Urination in a standing position was impossible. Reconstruction of the penis using a free deltoid flap was performed in December 1985, as described above. The patient seemed to have an uneventful recovery but about 4 weeks after reconstruction pus discharged and, subsequently, a small fistula formed with urinary leakage at the root of the reconstructed penis. This healed spontaneously in a few days. One year after reconstruction, surgery to reduce the size ofthe penis was performed.
Choice of reconstructive method For reconstruction of the penis pedicled skin flaps such as abdominal or groin flaps, or muscle or musculocutaneous flaps such as gracilis or rectus abdominis have been used. However, most of these are multi-staged procedures and do not fully meet the criteria mentioned above for penile reconstruction. There is now general agreement that the method of choice for penile reconstruction is microsurgical. Choice offree neurosensoryflap For reconstruction of the penis a free flap should be thin, durable, adequately large in size, as hairless as possible, have consistent and reliable vascular and neural anatomy with a long and large neurovascular pedicle, and should be capable of sensory reinnervation. Many neurosensory free flaps have been developed (Russell et al., 1985) and among them the forearm flap (Song et al., 1982) and the deltoid flap (Franklin, 1984) seem to fulfil the criteria mentioned above. It is certain that a forearm flap is the most frequently used donor site for this purpose but its disadvantages for penile reconstruction are that the flap is often too hairy, especially in Caucasians, and the donor site deformity cannot be ignored. If a hair-bearing skin flap is used for urethral reconstruction, it can cause severe trouble. The only report of a deltoid flap being used for penile reconstruction is a single case by Gilbert et al. (1987) but they give no precise description of the case. The deltoid flap, in our hands, seems to be the best donor site for this purpose. Its biggest and
RECONSTRUCTION
OF PENIS WITH FREE DELTOID
219
FLAP
Fig. 2
Fig. 3
Fig. 5
Fig. 4
Fig. 6
Fig. 7
Figure 2-Case I. (A) Design of the deltoid flap. The dot indicates the point where the nemovascular pedicle is located (confirmed by Doppler flowmetry). (B) Flap A is used for external coverage and flap B for urethra. The shaded area between the flaps is deepithelialised. Figure &The elevated flap. Figure GA urethra is constructed by suturing flap B round a Foley catheter. Figure 5A constructed penis. A neurovascular bundle is seen in the right lower corner. Figure wne year 3 months after reconstruction. Figure 7- A donor site was mesh skin grafted.
BRITISH JOURNAL
Fig. 8
Fig. 10
OF PLASTIC SURGE :RY
Fig. 9
Fig. 11
Figure (I-Case 2. Preoperative view. The penis is almost completely absent except for a small remnant of skin. The urethra is open under the skin remnant. Figure %Two years 7 months after reconstruction. Figure l&Xerogram.of the reconstructed penis. A shadow of the inserted cartilage is seen on the upper half of the penis. Figure ll-Donor site was split skin grafted.
maybe only disadvantage is that in obese patients the flap can be too thick. Our Case 2 is a moderately obese young man (166 cm, 72 kg) and the flap was thick; moreover, the addition of the cartilage graft made it a little too big and later reduction was
necessary (the diameter was reduced from 5.4 cm to 4.5 cm). However, if a patient is normally developed or thin, the thickness of the flap is almost ideal, as seen in Case 1. When the flap is too thick because of obesity, it can be thinned by skin
FLAP
221
expansion (Shenaq, 1988) or the reconstructed penis could be reduced in size by liposuction. As for hair growth, the deltoid region is one of the least hairy areas of the body. We have observed the deltoid region in Caucasians on Waikiki beach and found that about 10% of the population have hair growth in that area. Sensory recovery of the deltoid flap was very good in our two cases. Russell et al. (1985) also reported that sensory recovery of the deltoid flap was excellent when it was used for resurfacing the extremities, but there was no sensory recovery in the single case of Gilbert ef al. (1987). At present there is no report comparing the relative quality of sensory return between a forearm flap and a deltoid flap and this question should be examined in the future.
tion and the other part for external coverage. We have used a similar technique. To prevent late stricture of the reconstructed urethra, it should be adequately large in diameter and the suture line between the remaining and the new urethra should be zig-zag and not a straight line.
RECONSTRUCTION
OF PENIS WITH FREE DELTOID
Donor site deformity One reason why the deltoid flap has failed to become more popular is its donor site deformity. However, in our two cases it was not as bad as expected (Figs 7 and 11). We have used more than 50 forearm flaps for head and neck reconstruction, mostly in elderly patients, and noticed that most of them continue to conceal the forearm flap donor site with bandages. So this may be unacceptable, especially to those young transsexual patients who seek penile reconstruction and consider external appearance of the body of great importance. We believe that a deltoid flap is far superior than a forearm flap in regard to donor site deformity. Construction of urethra Construction of a urethra is one of the main goals of penile reconstruction, to enable urination in the standing position. We believe that if it is constructed with a skin graft, the incidence of fistula and urethral stricture is quite high. It is better to use a skin flap, and the concept of “a tube within a tube” (Gillies and Harrison, 1948) should be highly respected. When free flaps are used for penile reconstruction there are two ways in which a urethra is constructed, with either a part or the whole of the flap. Some authors use small free flaps to construct the urethra only, or urethra and glans penis, and external coverage of the penis is provided from other sources (Gilbert et al., 1987; Hentz et al., 1987). Chang and Hwang (1984) reported an ingenious method of using part of a forearm flap for urethral reconstruc-
Penile stlj&ener To enable sexual intercourse, the insertion of a stiffener into a reconstructed penis is necessary. Several authors do not use stiffeners but do not say why. Our Case 2 met with the accident at the age of 26 and only 3 months after marriage. Autogenous rib cartilage was inserted and the patient is quite satisfied with his sexual ability in spite of considerable inconvenience due to his permanently erect penis. In Case 1 it was not used considering that the patient was 54 years old, single and psychologically unstable. When a penis is reconstructed using an autogenous rib cartilage, it should be made a little shorter than ideal to cause less inconvenience in daily life. There is no report of good results obtained with a prosthetic stiffener because of the potential problem of erosion or extrusion. As for autogenous material, a rib cartilage is most commonly used (Chang and Hwang, 1984; Meyer et al., 1986). There are also scattered reports of using part of the radius incorporated with a forearm skin flap (Koshima et al., 1986; Biemer, 1988). A revascularised radius may resist infection, exposure or absorption but donor site deformity, fracture or functional disability in the donor limb may be subsequent problems. As for absorption of rib cartilage graft, Chang reported (personal communication, 1988) that in more than 50 cases of penile reconstruction using this material, absorption of the grafts was not a problem in any patient. Choice of recipient nerve Various nerves, such as the ilio-inguinal, iliopudendal, saphenous, lateral femoral cutaneous or pudendal, have been used as recipient nerves. The pudendal nerve is that which supplies the penis with erogenous sensibility and correct cortical localisation (Gilbert et al., 1987). These authors used the pudendal nerve as the recipient nerve in 10 cases of penile reconstruction and most patients reported the return of erogenous sensibility and the ability to masturbate. It may therefore be most logical to use this nerve as a recipient nerve.
222
BRITISH JOURNAL
Unfortunately, in our single case in which the pudendal nerve was used, no erogenous sensibility was obtained in spite of fairly good recovery of tactile and protective sensation. This is a one-stage reconstruction but a lengthy procedure. Our two cases lasted 9+ and 99 hours respectively. The most time-consuming part of the operation was dissection of the pudendal nerve, so the operating time could be reduced with increasing experience in dissecting this nerve. Choice of recipient vessels
There are abundant recipient vessels available in this region. We believe that inferior epigastric vessels are the best choice to accept a constructed penis because they are rarely injured by previous operation, trauma or irradiation, and have a good diameter with long pedicles. Matti et al. (1988) reported loss of 3 out of 5 cases of penile reconstruction in transsexual patients. Two were lost due to late arterial thrombosis which occurred 3 and 6 weeks after surgery. They reasoned that the loss of the flaps might have been due to atherosclerosis following prolonged high hormonal ingestion by these patients. However, in their cases vein grafts were used to interpose arterial shortages and this might have increased the incidence of late arterial thrombosis. When the inferior epigastric vessels are used there is no need for the use of vein grafts. Acknowledgement These operations were performed University Hospital, Tokyo.
when the authors
were at Keio
References Biemer, E. (1988). Results and complications of penile construction by free tissue transfer. Paper read at the Ninth Symposium of the International Society of Reconstructive Microsurgery, Japan.
OF PLASTIC SURGERY
Chang, T. and Hwang, W. (1984). Forearm flap in one-stage reconstruction of the penis. Plusric and Reconstructice Surgery, 74,251. Franklin, J. D. (1984). The deltoid flap: anatomy and applications. In Buncke. H. J. and Fumas, D. W. (Eds) Symposium on Clinical Frontiers in Reconstructive Microsurgery. St Louis: C.V. Mosby Co. Gilbert, D. A., Horton, C. E., Terzis, J. K., Devine, C. J. Jr, Winslow, B. H. and Devine, P. C. (1987). New concepts in phallic reconstruction. AnnnlsojPlustic Surgerv. 18, 128. Gillies, H. D. and Harrison, R. J. (1948). Congenital absence of the penis. British Journalof Plastic Surgery, 1,s. Hentz, V. R., Pearl, R. M., Grossman, J. A. I., Wood, M. B. and Cooney, W. P. (1987). The radial forearm flap: a versatile source of composite tissue. Annuls ofPlastic Surgery, 19,485. Koshima, I., Tai, T. and Yamazaki, M. (1986). One-stage reconstruction of the penis using an innervated radial forearm osteocutaneous flap. Journal of Reconstructive Microsurgery, 3, 19. Matti, B. A., Matthews, R. N. and Davies, D. M. (1988). Phalloplasty using the free radial forearm flap. Brmsh Journal ofPlastic Surgery. 41. 160. Meyer, R., Deverio, P. J. and Dequesne, J. (1986). One-stage phalloplasty in transsexuals. AnnalsofPlustic Surgery, 16,472. Russell, R. C., Guy, R. J., Zook, E. C. and MerrelI, J. C. (1985). Extremity reconstruction using the free deltoid flap. Plastic and Reconstructive Surgery, 76,586. Shenaq, S. (1988). An expanded sensate lateral arm free flap for total penile and urethral reconstruction. Paper read at the Ninth Symposium of the International Society of Reconstructive Microsurgery, Japan. Song, R., Gao, Y., Song, Y., Yu, Y. and Song, Y. (1982). The forearm flap. Clinics in Plastic Surgery, 9,21_
The Authors Takao Harashina, MD, Professor Takeo Inoue, MD, Assistant Professor ichiro Tanaka, MD, Lecturer Keisuke Imai, MD, Resident Mitsuo Hatoko, MD, Resident Department of Plastic and Reconstructive Medical Center. Saitama Medical School, moda, Kawagoe, Saitama 350, Japan. Requests
for reprints
to Dr Harashina
Paper received 9 February Accepted 8 May 1989.
1989.
Surgery. Saitama 1981 Tsujido. Ka-
at the above address
Reconstruction T. HARASHINA,
of penis with free deltoid flap
T. INOUE, I. TANAKA,
K. IMAI and M. HATOKO
Department of Plastic and Reconstructive Surgery, Saitama Medical Center, Saitama, Japan
Summary-Two cases of reconstruction urethra was reconstructed with part of the the remainder. In one case an autogenous as a strut. Postoperatively both patients cartilage graft was used sexual intercourse protective sensation in their reconstructed
of the penis with a free deltoid flap are described. The flap and external coverage of the penis was provided with rib cartilage graft was inserted in the reconstructed penis can urinate standing up, and for the one in which a rib is possible. Both cases have good recovery of tactile and penis.
Loss of the penis, either from trauma or malignancy, poses a serious and distressing impact and is regarded almost as loss of masculinity. Microvascular free tissue transfers, which have brought revolutionary changes to the field of reconstructive plastic surgery, also benefit the difficult problem of penile reconstruction. We have reconstructed the penis in two cases using a free deltoid flap. Operative procedure
The surgery is performed under general anaesthesia by two teams. While one team elevates the deltoid flap, the other team prepares the recipient site to accept the constructed penis and, if required, obtains a costal cartilage graft. The design of the deltoid flap is accurately drawn the day before surgery (Fig. 2A). First, the intervening portion between A and B (Figs 2B and 3) is de-epithelialised and the flap elevated. Dissection of the neurovascular pedicle of the flap is not straightforward due to numerous and complex branchings of the vessels, and liberal use of haemoclips makes it much easier and faster. After the neurovascular pedicle is completely freed, the flap is temporarily fixed with sutures at the original site. The urethra is constructed by suturing flap B around a No. 14 or 16 Foley catheter with absorbable sutures (Fig. 4). After preparation of the recipient site is completed, the neurovascular pedicle is divided and the neopenis is formed by enveloping the constructed urethra and, if desired, the costal cartilage graft with flap A (Fig. 5). The cartilage graft is obtained from the 8th or 9th rib and should be as straight as possible, with a length of 10 cm and diameter of 1.5 cm.
Preparation of the recipient site consists of dissecting out the penile and urethral stump and dissection of inferior epigastric vessels and pudendal nerve through appropriate skin incisions. The pudendal nerve is located just distal to Alcock’s canal along the medial border of the inferior pubic ramus where the nerve runs with its accompanying artery. The nerve is easiest to locate by elevating the underlying pubic periosteum and dissecting the overlying soft tissue until it is found (Gilbert et al., 1987). Transfer is begun by nerve anastomosis between the pudendal nerve and the cutaneous nerve of the deltoid flap. The pudendal nerve is located deep in the wound and if the neopenis is fixed first, the nerve anastomosis becomes extremely difficult because the two nerves to be anastomosed run almost vertically. The stump of the remaining urethra is anastomosed to the newly constructed urethra with absorbable sutures in zig-zag fashion to prevent possible later stricture at the suture line. The dermis of the flap and the inserted rib cartilage are sutured to the stump of the penile fascias with heavy, non-absorbable sutures. After the penis is fixed securely to the proposed site, vascular anastomoses are performed. Patency of the anastomoses is observed for 30 minutes and all the wounds are closed with appropriate drains. The donor site of the deltoid flap is split skin grafted. Case reports Case I (Figs l-7) A 54-year-old male had had his penis amputated due to malignancy at the age of 39. He was divorced when he
217
BRITISH JOURNAL OF PLASTIC SURGERY It is now 3 years after the reconstruction and he can urinate in a standing position with a strong stream and can enjoy sexual intercourse. He has a good sensory recovery all over his reconstructed penis but the quality of it is not an erogenous one and there is no measurable two-point discrimination.
Discussion The aims of penile reconstruction are (1) to enable urination in the standing position, (2) to enable sexual intercourse and (3) to reconstruct an aesthetically acceptable penis. For these purposes a reconstructed penis should have a urethra lined with epithelium without stricture, should be stiff enough to allow for successful sexual penetration and should have adequate tactile and protective sensation or, ideally, erogenous sensation.
Fig. 1 Figure I-Case
1. Preoperative view.
was 44. Reconstruction of the penis was performed in October 1986. At reconstruction the pudendal nerve, which was identified with difficulty, was extremely small. The lateral femoral cutaneous nerve was used instead as a recipient nerve. After reconstruction part of the groin skin which was elevated as a skin flap necrosed and it was allowed to heal spontaneously. Two years after reconstruction the patient can urinate in a standing position (Fig. 6) and has good sensory recovery in the flap but there is no measurable two-point discrimination.
Case 2 (Figs 8-11) A 26-year-old lorry driver, married 3 months before, met with a traffic accident in which his penis was severely crushed between the steering wheel and his pubic bone. After several unsuccessful attempts at reconstruction in a local hospital, he was referred to us 15 months after the accident. When first seen by us the penis was almost completely absent, leaving a small remnant of skin under which the urethraopened (Fig. 8). Urination in a standing position was impossible. Reconstruction of the penis using a free deltoid flap was performed in December 1985, as described above. The patient seemed to have an uneventful recovery but about 4 weeks after reconstruction pus discharged and, subsequently, a small fistula formed with urinary leakage at the root of the reconstructed penis. This healed spontaneously in a few days. One year after reconstruction, surgery to reduce the size ofthe penis was performed.
Choice of reconstructive method For reconstruction of the penis pedicled skin flaps such as abdominal or groin flaps, or muscle or musculocutaneous flaps such as gracilis or rectus abdominis have been used. However, most of these are multi-staged procedures and do not fully meet the criteria mentioned above for penile reconstruction. There is now general agreement that the method of choice for penile reconstruction is microsurgical. Choice offree neurosensoryflap For reconstruction of the penis a free flap should be thin, durable, adequately large in size, as hairless as possible, have consistent and reliable vascular and neural anatomy with a long and large neurovascular pedicle, and should be capable of sensory reinnervation. Many neurosensory free flaps have been developed (Russell et al., 1985) and among them the forearm flap (Song et al., 1982) and the deltoid flap (Franklin, 1984) seem to fulfil the criteria mentioned above. It is certain that a forearm flap is the most frequently used donor site for this purpose but its disadvantages for penile reconstruction are that the flap is often too hairy, especially in Caucasians, and the donor site deformity cannot be ignored. If a hair-bearing skin flap is used for urethral reconstruction, it can cause severe trouble. The only report of a deltoid flap being used for penile reconstruction is a single case by Gilbert et al. (1987) but they give no precise description of the case. The deltoid flap, in our hands, seems to be the best donor site for this purpose. Its biggest and
RECONSTRUCTION
OF PENIS WITH FREE DELTOID
219
FLAP
Fig. 2
Fig. 3
Fig. 5
Fig. 4
Fig. 6
Fig. 7
Figure 2-Case I. (A) Design of the deltoid flap. The dot indicates the point where the nemovascular pedicle is located (confirmed by Doppler flowmetry). (B) Flap A is used for external coverage and flap B for urethra. The shaded area between the flaps is deepithelialised. Figure &The elevated flap. Figure GA urethra is constructed by suturing flap B round a Foley catheter. Figure 5A constructed penis. A neurovascular bundle is seen in the right lower corner. Figure wne year 3 months after reconstruction. Figure 7- A donor site was mesh skin grafted.
BRITISH JOURNAL
Fig. 8
Fig. 10
OF PLASTIC SURGE :RY
Fig. 9
Fig. 11
Figure (I-Case 2. Preoperative view. The penis is almost completely absent except for a small remnant of skin. The urethra is open under the skin remnant. Figure %Two years 7 months after reconstruction. Figure l&Xerogram.of the reconstructed penis. A shadow of the inserted cartilage is seen on the upper half of the penis. Figure ll-Donor site was split skin grafted.
maybe only disadvantage is that in obese patients the flap can be too thick. Our Case 2 is a moderately obese young man (166 cm, 72 kg) and the flap was thick; moreover, the addition of the cartilage graft made it a little too big and later reduction was
necessary (the diameter was reduced from 5.4 cm to 4.5 cm). However, if a patient is normally developed or thin, the thickness of the flap is almost ideal, as seen in Case 1. When the flap is too thick because of obesity, it can be thinned by skin
FLAP
221
expansion (Shenaq, 1988) or the reconstructed penis could be reduced in size by liposuction. As for hair growth, the deltoid region is one of the least hairy areas of the body. We have observed the deltoid region in Caucasians on Waikiki beach and found that about 10% of the population have hair growth in that area. Sensory recovery of the deltoid flap was very good in our two cases. Russell et al. (1985) also reported that sensory recovery of the deltoid flap was excellent when it was used for resurfacing the extremities, but there was no sensory recovery in the single case of Gilbert ef al. (1987). At present there is no report comparing the relative quality of sensory return between a forearm flap and a deltoid flap and this question should be examined in the future.
tion and the other part for external coverage. We have used a similar technique. To prevent late stricture of the reconstructed urethra, it should be adequately large in diameter and the suture line between the remaining and the new urethra should be zig-zag and not a straight line.
RECONSTRUCTION
OF PENIS WITH FREE DELTOID
Donor site deformity One reason why the deltoid flap has failed to become more popular is its donor site deformity. However, in our two cases it was not as bad as expected (Figs 7 and 11). We have used more than 50 forearm flaps for head and neck reconstruction, mostly in elderly patients, and noticed that most of them continue to conceal the forearm flap donor site with bandages. So this may be unacceptable, especially to those young transsexual patients who seek penile reconstruction and consider external appearance of the body of great importance. We believe that a deltoid flap is far superior than a forearm flap in regard to donor site deformity. Construction of urethra Construction of a urethra is one of the main goals of penile reconstruction, to enable urination in the standing position. We believe that if it is constructed with a skin graft, the incidence of fistula and urethral stricture is quite high. It is better to use a skin flap, and the concept of “a tube within a tube” (Gillies and Harrison, 1948) should be highly respected. When free flaps are used for penile reconstruction there are two ways in which a urethra is constructed, with either a part or the whole of the flap. Some authors use small free flaps to construct the urethra only, or urethra and glans penis, and external coverage of the penis is provided from other sources (Gilbert et al., 1987; Hentz et al., 1987). Chang and Hwang (1984) reported an ingenious method of using part of a forearm flap for urethral reconstruc-
Penile stlj&ener To enable sexual intercourse, the insertion of a stiffener into a reconstructed penis is necessary. Several authors do not use stiffeners but do not say why. Our Case 2 met with the accident at the age of 26 and only 3 months after marriage. Autogenous rib cartilage was inserted and the patient is quite satisfied with his sexual ability in spite of considerable inconvenience due to his permanently erect penis. In Case 1 it was not used considering that the patient was 54 years old, single and psychologically unstable. When a penis is reconstructed using an autogenous rib cartilage, it should be made a little shorter than ideal to cause less inconvenience in daily life. There is no report of good results obtained with a prosthetic stiffener because of the potential problem of erosion or extrusion. As for autogenous material, a rib cartilage is most commonly used (Chang and Hwang, 1984; Meyer et al., 1986). There are also scattered reports of using part of the radius incorporated with a forearm skin flap (Koshima et al., 1986; Biemer, 1988). A revascularised radius may resist infection, exposure or absorption but donor site deformity, fracture or functional disability in the donor limb may be subsequent problems. As for absorption of rib cartilage graft, Chang reported (personal communication, 1988) that in more than 50 cases of penile reconstruction using this material, absorption of the grafts was not a problem in any patient. Choice of recipient nerve Various nerves, such as the ilio-inguinal, iliopudendal, saphenous, lateral femoral cutaneous or pudendal, have been used as recipient nerves. The pudendal nerve is that which supplies the penis with erogenous sensibility and correct cortical localisation (Gilbert et al., 1987). These authors used the pudendal nerve as the recipient nerve in 10 cases of penile reconstruction and most patients reported the return of erogenous sensibility and the ability to masturbate. It may therefore be most logical to use this nerve as a recipient nerve.
222
BRITISH JOURNAL
Unfortunately, in our single case in which the pudendal nerve was used, no erogenous sensibility was obtained in spite of fairly good recovery of tactile and protective sensation. This is a one-stage reconstruction but a lengthy procedure. Our two cases lasted 9+ and 99 hours respectively. The most time-consuming part of the operation was dissection of the pudendal nerve, so the operating time could be reduced with increasing experience in dissecting this nerve. Choice of recipient vessels
There are abundant recipient vessels available in this region. We believe that inferior epigastric vessels are the best choice to accept a constructed penis because they are rarely injured by previous operation, trauma or irradiation, and have a good diameter with long pedicles. Matti et al. (1988) reported loss of 3 out of 5 cases of penile reconstruction in transsexual patients. Two were lost due to late arterial thrombosis which occurred 3 and 6 weeks after surgery. They reasoned that the loss of the flaps might have been due to atherosclerosis following prolonged high hormonal ingestion by these patients. However, in their cases vein grafts were used to interpose arterial shortages and this might have increased the incidence of late arterial thrombosis. When the inferior epigastric vessels are used there is no need for the use of vein grafts. Acknowledgement These operations were performed University Hospital, Tokyo.
when the authors
were at Keio
References Biemer, E. (1988). Results and complications of penile construction by free tissue transfer. Paper read at the Ninth Symposium of the International Society of Reconstructive Microsurgery, Japan.
OF PLASTIC SURGERY
Chang, T. and Hwang, W. (1984). Forearm flap in one-stage reconstruction of the penis. Plusric and Reconstructice Surgery, 74,251. Franklin, J. D. (1984). The deltoid flap: anatomy and applications. In Buncke. H. J. and Fumas, D. W. (Eds) Symposium on Clinical Frontiers in Reconstructive Microsurgery. St Louis: C.V. Mosby Co. Gilbert, D. A., Horton, C. E., Terzis, J. K., Devine, C. J. Jr, Winslow, B. H. and Devine, P. C. (1987). New concepts in phallic reconstruction. AnnnlsojPlustic Surgerv. 18, 128. Gillies, H. D. and Harrison, R. J. (1948). Congenital absence of the penis. British Journalof Plastic Surgery, 1,s. Hentz, V. R., Pearl, R. M., Grossman, J. A. I., Wood, M. B. and Cooney, W. P. (1987). The radial forearm flap: a versatile source of composite tissue. Annuls ofPlastic Surgery, 19,485. Koshima, I., Tai, T. and Yamazaki, M. (1986). One-stage reconstruction of the penis using an innervated radial forearm osteocutaneous flap. Journal of Reconstructive Microsurgery, 3, 19. Matti, B. A., Matthews, R. N. and Davies, D. M. (1988). Phalloplasty using the free radial forearm flap. Brmsh Journal ofPlastic Surgery. 41. 160. Meyer, R., Deverio, P. J. and Dequesne, J. (1986). One-stage phalloplasty in transsexuals. AnnalsofPlustic Surgery, 16,472. Russell, R. C., Guy, R. J., Zook, E. C. and MerrelI, J. C. (1985). Extremity reconstruction using the free deltoid flap. Plastic and Reconstructive Surgery, 76,586. Shenaq, S. (1988). An expanded sensate lateral arm free flap for total penile and urethral reconstruction. Paper read at the Ninth Symposium of the International Society of Reconstructive Microsurgery, Japan. Song, R., Gao, Y., Song, Y., Yu, Y. and Song, Y. (1982). The forearm flap. Clinics in Plastic Surgery, 9,21_
The Authors Takao Harashina, MD, Professor Takeo Inoue, MD, Assistant Professor ichiro Tanaka, MD, Lecturer Keisuke Imai, MD, Resident Mitsuo Hatoko, MD, Resident Department of Plastic and Reconstructive Medical Center. Saitama Medical School, moda, Kawagoe, Saitama 350, Japan. Requests
for reprints
to Dr Harashina
Paper received 9 February Accepted 8 May 1989.
1989.
Surgery. Saitama 1981 Tsujido. Ka-
at the above address
