Pre-expanded Anterolateral Thigh Perforator Flap for Phalloplasty




The anterolateral thigh (ALT) perforator flap for phalloplasty is gaining popularity because it avoids the well-known scars of the radial forearm flap. However, scars are not eliminated, just moved to a different location, the thigh, that can for some patients be of great sexual value. Preexpansion of the ALT flap allows primary donor site closure, thus avoiding not only the unsightly appearance of a skin grafted ALT donor site, but also the skin graft donor site scar. Preoperative perforator location by means of computed tomography angiography allows safe expander placement through 2 small remote incisions.


Key points







  • •

    The anterolateral thigh (ALT) perforator flap is a valuable alternative to the radial forearm flap for patients who do not wish to have the forearm scar.


  • •

    ALT flap phalloplasty leaves visible scarring in the thighs owing to skin grafting of its donor site.


  • •

    Pre-expansion of an ALT flap allows primary donor site closure.


  • •

    Preoperative perforator location with computed tomography angiography is crucial to the success of the procedure.






Introduction


Since the first description in 2005, phalloplasty with a free or pedicled anterolateral thigh (ALT) flap has gradually gained popularity for penile reconstruction as an alternative to the standard radial forearm flap (RFF).


The main advantage of the ALT flap in this indication is avoidance of the large forearm scar, which has become a recognizable sign of this operation because of the increasing attention received from the media. Very large flaps are needed for a phalloplasty and the donor site subsequently needs skin grafting. As a result, the donor site is quite noticeable because a hairless skin graft with a depression is left at the donor site. If the donor site is located in the forearm, it is not only quite visible and difficult to conceal unless long sleeves are worn, but also a recognizable sign of the operation performed ( Fig. 1 ).




Fig. 1


Postoperative result of a radial forearm flap (RFF) phalloplasty showing the typical scar at the donor site. Because this is the only application for use of such a large RFF, this scar has become a recognizable sign of the operation, which not all patients like to have. Scars in the thigh are also present due to harvest of STSGs for coverage of the RFF donor site.


If an ALT flap is used for phalloplasty, the RFF donor site scars are avoided. However, a donor site scar will be present in the thigh, combined with the scars needed for skin graft harvest ( Fig. 2 ). With the RFF and ALT, there is not only the flap donor site scar, but also the split thickness skin graft donor site, which is often more painful than the flap donor site itself.




Fig. 2


Postoperative result of an anterolateral thigh (ALT) and superficial circumflex iliac perforator flaps phalloplasty. Although concealable with regular clothing, when naked the scars in the thigh, owing to both ALT and split thickness skin graft harvest, are apparent.


There is a particular subset of patients who want to avoid both scars because, although the thigh scars can be easily concealed whit a pair of shorts while dressed, they cannot be concealed when naked and are very close to the genital area. These patients would rather avoid disfigurement of the area that is the center of their masculinity and intimacy. Pre-expansion of the ALT allows donor site scarring to be minimized in these patients ( Fig. 3 ).




Fig. 3


Expanded anterolateral thigh and superficial circumflex iliac perforator flaps phalloplasty donor site, 5 months postoperatively. For comparison, here is an early postoperative image of a phalloplasty after expansion. The donor site has been closed with an inverted “Y” scar and no skin graft donor site is present in the thigh. The scars are still red but already much less disfiguring than those in Fig. 2 .




Introduction


Since the first description in 2005, phalloplasty with a free or pedicled anterolateral thigh (ALT) flap has gradually gained popularity for penile reconstruction as an alternative to the standard radial forearm flap (RFF).


The main advantage of the ALT flap in this indication is avoidance of the large forearm scar, which has become a recognizable sign of this operation because of the increasing attention received from the media. Very large flaps are needed for a phalloplasty and the donor site subsequently needs skin grafting. As a result, the donor site is quite noticeable because a hairless skin graft with a depression is left at the donor site. If the donor site is located in the forearm, it is not only quite visible and difficult to conceal unless long sleeves are worn, but also a recognizable sign of the operation performed ( Fig. 1 ).




Fig. 1


Postoperative result of a radial forearm flap (RFF) phalloplasty showing the typical scar at the donor site. Because this is the only application for use of such a large RFF, this scar has become a recognizable sign of the operation, which not all patients like to have. Scars in the thigh are also present due to harvest of STSGs for coverage of the RFF donor site.


If an ALT flap is used for phalloplasty, the RFF donor site scars are avoided. However, a donor site scar will be present in the thigh, combined with the scars needed for skin graft harvest ( Fig. 2 ). With the RFF and ALT, there is not only the flap donor site scar, but also the split thickness skin graft donor site, which is often more painful than the flap donor site itself.




Fig. 2


Postoperative result of an anterolateral thigh (ALT) and superficial circumflex iliac perforator flaps phalloplasty. Although concealable with regular clothing, when naked the scars in the thigh, owing to both ALT and split thickness skin graft harvest, are apparent.


There is a particular subset of patients who want to avoid both scars because, although the thigh scars can be easily concealed whit a pair of shorts while dressed, they cannot be concealed when naked and are very close to the genital area. These patients would rather avoid disfigurement of the area that is the center of their masculinity and intimacy. Pre-expansion of the ALT allows donor site scarring to be minimized in these patients ( Fig. 3 ).




Fig. 3


Expanded anterolateral thigh and superficial circumflex iliac perforator flaps phalloplasty donor site, 5 months postoperatively. For comparison, here is an early postoperative image of a phalloplasty after expansion. The donor site has been closed with an inverted “Y” scar and no skin graft donor site is present in the thigh. The scars are still red but already much less disfiguring than those in Fig. 2 .




Treatment goals and planned outcomes


Pre-expansion of a conventional ALT flap has 3 main goals:



  • 1.

    Allowing primary donor site closure;


  • 2.

    Improving the perforator’s vascular territory;


  • 3.

    Thinning of the flap.



In this particular application, the goal of preoperative expansion of the ALT flap is achieving primary donor site closure. Improving the perforator’s vascular territory is not needed in this case. The flap measures 14 × 18 cm on average and survival is not an issue. Partial flap necrosis is a very uncommon occurrence, even without prior expansion. Selection of the largest perforator with the aid of a preoperative computed tomography (CT) angiography warrants complete flap survival.


Flap thinning would be extremely desirable and was one of the goals we planned of pursuing when we first started expanding the ALT. Unfortunately, for this particular flap 2 expanders need to be placed medially and laterally to the perforator and expansion only results in a peripheral thinning of the flap with the flap’s fat being squeezed toward the perforator in the middle of the flap. This kind of deformation is of little use in a phalloplasty because a lot of bulk is created in the middle of the flap, where it cannot be thinned out.


The planned outcome of preoperative ALT expansion in phalloplasty is to allow primary donor site closure, avoid the disfiguring scar and the painful skin graft donor site in the thigh.




Preoperative planning and preparation


Preoperative location of the perforator is crucial to flap planning. A CT angiography is used for this purpose. The CT angiography allows the most distal perforator with the largest caliber, the longest (to comfortably reach the pubis), with the best subcutaneous branching and the most convenient intramuscular or septal course, providing a preoperative navigation that cannot be obtained by simple Doppler location.


The radiologist provides distances from the anterior superior iliac spine based on an x–y axis ( Fig. 4 ) drawn on the thigh and the position of the perforator is marked on the patient’s skin. The flap is drawn accordingly with the perforator lying along its midline and close to its proximal margin. Then the expander’s base (20 × 7 cm) is drawn outside of the flap’s borders ( Fig. 5 ) because, as described, placing the expanders in the flap will squeeze the fat toward the midline, which is not desirable in this case.




Fig. 4


An example of a preoperative computed tomography angiography. The sagittal ( upper left ), coronal ( upper right ), and axial ( lower right ) views of the perforator course together with a 3-dimensional reconstruction of the skin with the projection on the skin of the point of emergency from the fascia of the perforator ( lower left ), are provided. In the upper right coronal view, the distances measured from the anterior superior iliac spine are provided. Thus in a single image information about the course and position of the perforator are provided.



Fig. 5


Same patient as Fig. 4 . A line is drawn connecting the anterior superior iliac spine (ASIS) to the upper lateral border of the patella. Using the angiographic computed tomography measurement in Fig. 4 , the projection on the skin of the perforator is marked with a black, circled X, exactly 222 mm below and 32 mm laterally from the ASIS. Afterward the flap is drawn ( black rectangle ). The skin projection of the 2 expander pockets is drawn just lateral and medial to the flap to have little overlapping with the flap once the expanders are inflated. The expander base and remote ports are drawn in green. The ports are placed in an easily reachable position when the patient is lying supine. The “W” incisions ( black ) are placed in between.




Patient positioning


The patient is placed in the supine position. The ipsilateral arm can be abducted or adducted based on the surgeon’s preference. Abduction will provide greater room for the placement of the lateral expander because the hand, with the arm adducted, comes in close proximity to the lateral incision and pocket.




Procedural approach


Expander Placement


Two remote “W” incisions are performed some centimeters caudal to the inguinal ligament (see Fig. 5 ) and deepened to the deep fascia. Then the 2 pockets are dissected, bluntly or with the cautery, with the aid of a lighted retractor to obtain hemostasis. Care must be taken not to deepen the plane too much because the sensory nerves lie on top of the fascia and they must not be damaged. Once the pocket is complete, a superficial (3–5 mm of fat left on the skin flap) pocket is dissected cranially to the incision to allow for remote port placement in a position that shall be as easily accessible as possible ( Fig. 6 ). Before expander placement, two 12-F suction drains are placed in the pocket. The air is emptied from the expanders and they are partially filled with methylene blue–tinted saline, which allows easy visualization of the fluid coming out of the expanders during ambulatory postoperative expansion. Partial inflation keeps the expander distended and allows easy placement without folding ( Fig. 7 ). Once the expander and ports are in position, easy accessibility of the ports is double checked before closure ( Figs. 8 and 9 ).




Fig. 6


Medial view of a right thigh (the knee is on the left hand side of the picture) at the time of expander placement. The pocket has already been dissected through the “W” incision, which allows wider exposure with the same length compared with a linear incision. The drain is in place. Saline (150 mL) colored with methylene blue is injected in the expander after all air has been removed. The expander is placed on the skin in the same position that it will eventually have inside the pocket.



Fig. 7


Same view as in Fig. 6 . The partial inflation of the expander facilitates insertion by keeping it distended and avoiding folding.



Fig. 8


Same view as in Figs. 6 and 7 . The remote port is inserted last. The pocket for the port is dissected in a different – more superficial – plane and with a bottleneck to prevent the port from slipping back toward the incision once inserted.



Fig. 9


Bird’s eye view, knee on the left hand side. The figure shows the 2 expanders with the procedure completed for the lateral one and to be completed for the medial one, to show the 2 moments of placement of the needle in the port. The syringe on the right is connected to the medial port before closure. At this point, the port is probed to verify easy access before closure, for eventual replacement. The syringe on the right has been used for a final inflation of the expander after closure, to ensure obliteration of dead space within the pocket to avoid fluid collection.

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Nov 17, 2017 | Posted by in General Surgery | Comments Off on Pre-expanded Anterolateral Thigh Perforator Flap for Phalloplasty

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