The pedicled Antero lateral thigh flap for gender affirming surgery: what is different? First case series outcomes of a single center from Turkey
Colgajo anterolateral del muslo regional para cirugía genital transgénero. ¿Qué tiene de diferente? Primer reporte de serie de casos en un centro hospitalario de Turquía

2.1 Study design and ethics details

A cross-sectional study, comprising all adult cases who underwent pedicled ALTf phalloplasty for female to male (FtM) GAS in our clinic, between January 2015 and December 2019, was designed. Examination of all cases prior to surgery was performed by both surgeons (urologist and plastic surgeon) simultaneously at the outpatient clinic. Demographic data including case characteristics, medical history and previous surgery details were recorded with the patient follow-up chart. In addition, intraoperative findings, early postoperative alterations and complications detected during follow-up examinations were classified and recorded to the same patient follow-up chart.

2.2 Inclusion and exclusion criteria

Our inclusion criteria for FtM GAS were (i) Gender Incongruence (GI) diagnosis by at least two psychiatrists; (ii) to be over 18 years of age; (iii) two years of real-life experiences in accordance with GI accompanied by psychotherapy; (iv) one year of hormone therapy; and (v) differential diagnosis of clinically identical disorders (psychotic disorder, physical intersex conditions, etc.). Patients who had underwent any surgical step or management of complications in another center were excluded.

2.3 Patient evaluation and outcomes

Depending on the technique that is used and the potential complications that can be observed, FtM GAS is commonly performed in two or three stages. In our routine practice, we prefer and offer a three staged surgical transition, in which early and late first follow-up examinations are done approx. 2 weeks and 3 months after discharge, at each surgical stage.

Assessment of complications that might occur after phalloplasty are made via clinical application and/or, for those who could not show up due to traveling issues, via telephone and/or electronic images. Most common complications are reviewed with a short checklist, but if necessary, opportunity has been given to explain them more detailed. In addition, cases who had to apply and were treated due to any complication elsewhere, were informed to provide feedback about their duration. Thus, no matter how minor or temporary, all complications are included in the study.

Since there is no defined standard evaluation protocol for the postoperative follow-up examination of transgender cases, a non-validated satisfaction inquiry consisting of 10 questions was adapted to evaluate general mental, social and physical conditions and to optimize our clinical process. In this inquiry, each question was designed with five choices of response resulting in a minimum of zero (definitely no) and a maximum of eight points (definitely yes) (Table 1). At the end of the inquiry, the total score between 0–80 points was calculated for each patient, which 80 points indicate 100% satisfaction rate and the mean value of all patients’ scores, were designated as percentages, to evaluate satisfaction rates that included mental, physical and social health in general.

2.4 Surgical technique; description of pedicled ALTf phalloplasty

As mentioned before, FtM GAS is usually performed in a multi-staged fashion of which our surgical steps could be summarized as;

Stage 1: Creation of the neo-phallus by harvesting the ALTf, and midline repositioning at the level of the symphysis pubis;

Stage 2: (approx. 3–6 months later) Vaginal closure, urethral reconstruction (elongation of the urethra to the level of the clitoral hood or trans-positioning to the tip of the neo-phallus), glansplasty and/or scrotoplasty;

Stage 3: (approx. 6 months later) Implementation of penile and/or scrotal prostheses.

However, due to the limited number of cases who passed the third stage and were followed up adequately, only the first two stages are defined in this study. Each stage, of all cases, was carried out in collaboration of a plastic surgeon and urologist, who are experienced in FtM GAS.

2.4.1 Stage one

Just before the surgery, ALTf perforators are determined with an 8 MHz portable hand-held doppler ultrasonography (USG) again, and marked on the skin (Fig. 1). The flap is centered along a line, representing the intermuscular septum, between the rectus femoris and vastus lateralis muscle joining proximally the anterior superior iliac crest and distally the upper lateral border of the patella. The ALTf is formed, in a trapezoidal rectangular shape varying between 14 × 16 × 12 cm and 12 × 14 × 10 cm of dimensions, and is harvested in standard supine position. Mainly, the donor limb is chosen according to the person’s preference, if not the non-dominant limb is used.

Fig. 1.Determination of Antero Lateral Thigh flap perforators with doppler ultrasonography and marking on the skin.

In order to define the lateral femoral cutaneous nerve, the dissection of the flap starts proximally and is lifted through the suprafascial plane, medial to lateral, over the rectus femoris. The rectus femoris fascia is then cut, and dissection continues to the subfascial plane launching the gap between the rectus femoris and vastus lateralis. After perforating vessels are freely dissected through the fascial and intramuscular course, the remainder of the dissection can be completed suprafascially. Considering the size of the flap, no matter how meticulously it is harvested, thinning is not recommended as it may impair perfusion. After complete isolation of perforator vessels, the pedicle is pursued proximally. Meanwhile, the dissection of arteria profunda femoris is important to allow the flap to reach the pubic midline. Therefore, pedicular dissection should be up to the depth of the femoral vascular branches. Subsequently, rectus femoris and sartorius muscles are elevated to allow the flap and accompanying vascular structures to pass underneath without causing any compression (Fig. 2A,B).

Fig. 2.Elevating the rectus femoris and sartorius muscles. (A) Flap and accompanying vascular structures. (B) Rectus femoris and sartorius muscles.

For an easy and a secure positioning of the neo-phallus, the recipient area should be created at the lower border of the symphysis pubis, under the guidance of the existing genital structures, by a large enough and arc shaped incision which is carried out directly to the suprapubic fascia. Eventually, after the prepared thigh flap is shaped as “tube-in-tube” or folded on itself and passed smoothly underneath the muscles, it is fixed to the recipient area (Fig. 3).

Fig. 3.Fixation the thigh flap in the shape of “tube in tube” to the recipient area.

2.4.2 Stage two

The most important part of this stage includes the urethral reconstruction.

Formation of the neo-urethra in ALTf phalloplasty is planned according to the “Pinch test” [4]. If subcutaneous fatty tissue thickness of the thigh is <1.5 cm, the urethra is marked on the donor site and prepared directly during flap harvesting to form a “tube-in-tube” shaped neo-phallus. However, if it is >1.5 cm, additional flap or graft substitution from other donor sites is required for urethral trans-positioning.

The surgery mainly begins with the vaginal closure, in which it is carefully dissected from surrounding tissues, i.e., the rectum, proximal urethra and bladder neck, and excised as proximal as possible.

Urethral reconstruction, in our cases, is carried out in two ways. In cases not requesting the meatus to the tip of the neo-phallus, a urethral elongation was performed (Fig. 4). Therefore, the peri-clitorideal mucosal area is prepared to obtain an approx. 4–5 cm vascular bed, which is afterwards tubularized and proximally anastomosed to the urethral meatus and distally fixed near to the radix of the neo-phallus. In all our cases, who requested their urethra to the tip and refused an additional visible donor site had a “Pinch test” >1.5 cm, therefore an inguinal full thickness skin graft was taken to create the neo-urethra. After the graft is tubularized on an 18ch Foley catheter (Fig. 5) it is placed through the created neo-meatal opening into the neo-phallus and anastomosed with the elongated neo-urethra.

Fig. 4.Urethral elongation.

Fig. 5.Tubularization of the graft on the 18ch Foley catheter.

The clitoris, on the other hand, is released after desepithelization to allow trans-positioning of its volar and dorsal attachments to the recipient site. After the clitoral nerve is located and isolated, on the adjacent side of the flap donor, the clitoral hood is fixed onto the neo-urethral anastomosis below the level of the symphysis pubis (Fig. 6). Hereby, besides providing an additional vascular supply to the neo-urethral anastomosis, stimulation from the radix of the neo-phallus can maintain erogenous sensation even in cases with weak or absent cutaneous nerve healing.

Fig. 6.Fixation of the clitoral hood onto the neourethral anastomosis.

2.5 Statistics

Descriptive statistical analysis was performed with the IBM Statistical Package for Social Sciences 23.0 (SPSS, Chicago, IL, USA) package program. Considering the sample size, the Shapiro-Wilk test was used to decide on the normality assessment of the data and it was found that it was not normally distributed. Thus, continuous data were expressed as median and interquartile range, and categorical variables were expressed as numbers (n) and percentage (%).

4.1 Patient satisfaction

The vast majority of current information, on the results obtained in FtM GAS regarding case satisfaction, is considered to be of low-quality of evidence. Due to the lack of controlled/prospective studies, low response rates in long-term studies, and standard nomograms consisting of components such as cosmetic, sexual, functional, social and psychological status, available outcomes of postoperative case satisfaction during follow-up is inadequate [10, 16].

In a previously published study in this regard, it was reported that, 72% of cases were accepted by their family, friends and other people, and 86% were mainly satisfied with their new lives [17]. In the study of De Cuypere et al. [18], in which the physical, emotional and social levels of satisfaction were questioned and determined as 81.5%, 94.4% and 90.7%, respectively; common sexual satisfaction levels, after a six-year follow-up period, was reported as 76% for transwomen and 89% for transmen.

Considering our results, with a mean follow-up period of 44.1 ± 15.7 months, satisfaction levels of transmen with 77.14%, have shown correlation with the literature (Table 2).

4.2 Complications

Most detected postoperative complications in cases undergoing FtM GAS are related to the neo-urethra, such as strictures and fistulas, which can be mostly managed by open and/or endoscopic techniques [10, 11, 16].

Use of a second donor site for urethral reconstruction has been reported in cases not eligible for a “tube-in-tube” shaped phalloplasty [5, 7, 19, 20, 21, 22]. None of our cases preferred the use of a second donor site for various reasons: radial forearm flap (RFF) because of donor site visibility, superficial circumflex iliac artery flap (SCIAF) because of relatively high loss rates, and buccal mucosal graft because of the necessity for multiple stages as well as the potential use for revisions rather than primary cases [19, 20, 22].

Reviewing the literature, less information is available about the results of skin grafts used for neo-urethral reconstruction in transmen. Studies using free skin grafts in ALTf phalloplasty were reported by Felici et al. [7], with no urethral complications; and Darpa et al. [20], showing no fistula whereas stenosis was observed in seven out of eight cases. Although the location and length of the stenotic segments were not specified, D’Arpa et al. [20] noted that all cases were able to void upright, after adequate treatment [7, 14]. With a mean follow-up of 44.1 ± 15.7 months, neo-urethral complications were observed in seven (27%) of our cases of which four were able to void upright after multiple endoscopic and/or open surgical interventions. Despite that, due to some personal matters described before, three cases demanded to re-substitute their neo-urethra back to the previous proximal elongated segment, to confront less complications.

The most important and non-urethral complication in FtM GAS is flap loss. In a systematic review comparing multiple techniques, published in 2016, it has been shown that pedicled ALTf phalloplasty has lower flap loss rates compared to all other techniques, with no total and only one partial flap loss [10]. Similarly, no flap loss was experienced in our cases at the first two stages. However, in one case (3.84%) whose first two stages were completed, a 4–5 cm distal segmental flap necrosis, at postoperative day four, after buccal mucosa graft substitution for distal neo-urethral stenosis occurred.

Eventually, some main limitations of our study have to be addressed which were:

(i) the retrospective nature; (ii) the small sample size; (iii) urethral complications that could not be compared between elongation and trans-positioning cases; (iv) incomplete results/data of cases who passed the third stage and, as in all previously conducted studies, (v) the lack of a validated standard satisfaction assessment.