Clinical Presentation
A 14-year-old intersex White person had been born with ambiguous genitalia. The patient decided to be a male but unfortunately all male genital organs had been removed at a young age. The patient now strongly desired a transformation from female to male and was seen by the pediatric urology service for a total penile reconstruction ( Fig. 38.1 ). The plastic surgery service was asked to perform a microvascular penile reconstruction in conjunction with the patient’s entire surgical care for penile reconstruction.
Operative Plan and Special Considerations
There are several options with a microvascular flap for total penile reconstruction. Among them, free radial forearm flap or free fibular osteocutaneous flap is the common option. However, free fibular osteocutaneous flap can provide a total penile reconstruction without the need for a penile implant. In addition, urethral reconstruction can also be done within the flap to provide a more functional reconstructed penis. In this case, a two-stage reconstruction was planned. During the first stage, a prefabricated urethroplasty was designed and performed in the proposed free fibular osteocutaneous flap donor site so that urethral reconstruction could be accomplished first. The formal penile reconstruction was performed during the second stage and a free fibular osteocutaneous flap was dissected out and a reconstructed penis could be created. This type of penile reconstruction may prevent future implant extrusion that might be experienced after a free radial forearm flap for a total penile reconstruction. Preoperative arterial angiogram would be needed to make sure there was normal vascular anatomy of the selected lower leg for a free fibular osteocutaneous flap donor site.
Operative Procedures
For this patient, the total penile reconstruction was performed in two stages. During the first-stage procedure, a prefabricated urethroplasty was performed. Under general anesthesia with the patient in the supine position, a free fibular osteocutaneous flap was designed and marked in the left leg. Two perforators were identified by a handheld Doppler and marked. A 10 × 11 cm skin paddle was marked based on the location of the fibula and the two identified perforators. The location of the proposed new urethra was also marked ( Fig. 38.2 ). A 15 × 2 cm full thickness skin graft was designed in the left groin and then harvested ( Fig. 38.3 ). This full-thickness skin graft was sutured to form a tube over a rubber catheter with 3-0 Vicryl suture in a running fashion. This newly created urethra was buried under the skin within the skin paddle of the planned free fibular osteocutaneous flap ( Fig. 38.4 ). The catheter remained in place and acted as a stent for the prefabricated urethral reconstruction.
Eleven months later, the patient underwent the second-stage procedure where the total penile reconstruction was performed. A suprapubic catheter was placed for urinary drainage. Under general anesthesia with the patient in the supine position, the free fibular osteocutaneous flap was marked including two septocutaneous perforators that were confirmed by a handheld Doppler scan. A catheter was easily passed through the prefabricated and reconstructed new urethra with the flap. A 10 × 11 cm of the skin paddle was again designed ( Fig. 38.5 ).
