Grabb’s Encyclopedia of Flaps Upper Extremities, Torso, Pelvis, and Lower Extremities

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FIGURE 447.3 A: Perineal fistula accounting for loss of urethra segment. B: Design of the inguinal flap. C:
Tubed urethral flap with skin surface on the inside. D: Tubed flap anastomosed to proximal urethra, with a
Foley catheter in place. Donor area of tube closed by direct approximation. (Continued)
FIGURE 447.3 (Continued) E: Design for second stage. F: Intraoperative view of distal urethral
anastomosis. G: Final perineal appearance. H: Patient during micturition.
References
1. Johanson B. Reconstruction of the male urethra in stricture. Acta Chir Scand [Suppl.] 1953:176.
2. Pressman D, Greenfield LD. Reconstruction of the perineal urethra with a free full-thickness skin graft from
the prepuce. J Urol 1953;69:677.
3. Marshall VF, Spellman RM. Construction of urethra in humans by free grafts of mucosa from urinary
bladder. Plast Reconstr Surg 1957;20:423.
4. Lapidas J. Simplified modification of Johanson urethroplasty of deep bulbous urethra. J Urol 1959;82:115.
5. Turner-Warwick RT. A technique for posterior urethroplasty. J Urol 1960;83:416.
6. Webb H, Campbell J, Grindley J, Erich J. Use of the Z-plastic procedure in urethra-urethral anastomosis.
Ann Surg 1963;157:579.
7. Wood-Smith DP. Hypospadias: some historical aspects and the evolution of methods of treatment. In:
Converse JM, ed. Reconstructive plastic surgery. Philadelphia: Saunders, 1964;2010.
8. Kishev S. Surgical restoration of the penile urethra. Plast Reconstr Surg 1964;33:47.

9. Ardelyi R. Substitution of a total traumatic defect of urethra. Acta Chir Orthop Trauma (Czech)
1966;33:364.
10. Cowan RJ, Sullivan LD. Experiences with perineal urethroplasty for stricture. Plast Reconstr Surg
1968;41:137.
11. Zenteno Alanis S. An innovation in total penis reconstruction. Plast Reconstr Surg 1969;43:418.

Chapter 448
Tubed Abdominal Skin Flap for Penile Reconstruction
J. M. NOE
EDITORIAL COMMENT
Although supplanted by microvascular techniques, this is still an excellent flap for reconstruction of the
penis.
The use of a vertical midline lower abdominal tubed flap turned inside out so that the abdominal skin forms an
internal tunnel, with a split-thickness skin graft used for the exterior of the inverted tube, allows a phallus-like
structure to be constructed in only two stages without excessive morbidity and with cosmetic and psychologic
objectives achieved (1, 2).
INDICATIONS
Historically, the major methods for reconstructing a penis have developed largely from war injuries (3, 4, 5,
6, 7, 8, 9, 10, 11, 12, 13, 14, 15). Other causes of loss or absence of the penis have been burns, cancer,
infections, metabolic or vascular derangement, punitive ablation, or congenital abnormality. The flap
described in this chapter has been used almost exclusively for the construction of male genitalia for the
female-to-male transsexual.
The object of any method of reconstruction is a penis that is satisfactory psychologically, cosmetically, and
physiologically. No attempt was made to meet all these reconstructive objectives, but only the psychologic
and cosmetic objectives and that part of the physiologic objective concerned with producing a rigid penis,
so that coitus is possible with a temporary implant (1). No attempt was made to construct a urethra in the
transsexual, because the difficulties and complications outweigh the benefits of being able to stand while
urinating.
In this situation, there is little place for a permanent prosthesis in the construction of a penis. In a movable
organ without sensation that is obtained when an abdominal tubed flap is used, extrusion of any permanent
implant is likely (16). Therefore, a removable prosthesis, inserted at the time of intercourse, best overcomes
the problem.
No claim is made of providing an organ that serves as an area of genital stimulation. Because the tubed flap
has a very coarse, tough sensation, the clitoris is neither amputated nor is its sensibility compromised; it
continues to serve its sexual function.
ANATOMY (17)
The midline tubed abdominal flap is largely supplied by musculocutaneous perforating vessels from the deep
inferior epigastric artery, except for the base of the flap, which is supplied by the external pudendal artery (Fig.
448.1). When the flap is raised, the perforating vessels from the deep inferior epigastric artery are divided. In the
second stage, when the superior pedicle is cut free, all the blood supply is from the external pudendal system;
the flap is then a random flap based on this blood supply.

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OPERATIVE TECHNIQUE
There are two stages to the procedure: (1) a bipedicle vertical midline lower abdominal tubed flap is constructed,
and (2) the upper end of this tube is cut loose and the glans penis is constructed. At this second stage, a
hysterectomy and bilateral salpingo-oophorectomy can be performed. A hysterectomy should not be done prior to
the first stage, to prevent either the midline or the Pfannenstiel incision from interfering with the blood supply to
the tubed flap.
First Stage
Two incisions are made 8 to 9 cm apart, extending from the umbilicus to the area of the pubic symphysis, to
create a vertical tube (Fig. 448.2). These incisions are carried down through the skin and subcutaneous tissue
until Camper's areolar fascia is identified. Camper's fascia is then undermined (after it is incised in a vertical
direction parallel to the incisions on the skin), and a tubed flap is then created with the abdominal skin inside.
Camper's fascia is sutured together around the outside of this tube.
FIGURE 448.1 The blood supply of the tubed abdominal flap.

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FIGURE 448.2 A: Flap outlined in lower abdomen. B: Incisions down to Camper's fascia. C: Healed flap. Note
that the split-thickness skin graft was placed in spiral fashion. D: Incision for second stage. E: Representative
example. (From Noe et al., ref. 1, with permission.)
A split-thickness skin graft taken from a hairless area is wound around the tube. The skin graft is placed in a
spiral fashion, so that no longitudinal scars are created. A thick, potentially hair growing split-thickness skin graft
(to simulate pubic hair) is also placed at the base of the inferior pedicle to provide extra skin for use in the
second stage and to allow the tube to bend downward 180 degrees to the genital area.
The flap donor site is closed under tension. Scrub sponges “cored” out have been used as part of the dressing
to support the tubed flap in its new position.
When all the wounds are well healed and the blood supply is sufficient to nourish the tube from its lower pedicle,
the second stage is done.
Second Stage
Releasing the upper end of the tube, fashioning the tip to construct a glans and corona, and fusing the labia
majora (as needed to create a scrotal appearance) are accomplished during the second stage. A hysterectomy
and bilateral salpingo-oophorectomy also can be performed, going through the midline scar created when the
donor site of the flap was closed.
A transverse elliptical incision is made around the upper pedicle of the tube, going through it to release that end
of the tube from the abdomen. The glans penis is then constructed, after removing excess subcutaneous tissue.
The corona is fashioned by using epidermal-to-dermal stitches to create an overlap of local skin.

By leaving the lining skin tube open at both the proximal and distal ends, it is possible to maintain better hygiene
within this tunnel. The tunnel within the tube also facilitates the use of a temporary, custom-made T-shaped
baculum, which is inserted through the proximal opening of the tunnel (at the base of the constructed penis) (Fig.
448.3). It provides rigidity for intercourse. The insert rests on the pubic symphysis, so that an “erection” can be
transmitted from this bony area outward through the penis. Conversely, external pressure on the tip can be
transmitted back to the clitoral area, affording some stimulation there.
FIGURE 448.3 Baculum in place in inner tube.
The labia majora are fused in the midline to create a scrotum. Each labium is incised in its midline, hemostasis is
obtained, and then a three-layer closure from side to side (consisting of the posterior epithelium, the
subcutaneous tissue, and the anterior epithelium) is performed. The inferior end is left open to facilitate hygiene
and permit urination.
No attempt is made to amputate the clitoris nor to interfere in any way with its sensibility.
Third Stage (Optional)
An optional third stage in phalloplasty for transsexuals is the placement of testicular prostheses into the labia (17,
18). Hairbearing labial flaps have been transposed to the suprapubic area to accomplish additional release of the
phallus and more closely to simulate the male escutcheon (19).
CLINICAL RESULTS
Between 1966 and 1978, 48 female-to-male transsexual patients underwent surgery with the midline
abdominal tubed method at the Stanford Gender Dysphoria Program (19, 20). There were 154 operative
procedures performed on 48 patients. Fifty-eight percent of these patients had one or more complications.
Obesity, previous abdominal surgery with abdominal scars, and acne were frequently associated with these
complications. Forty-two percent of the complications were in the first stage, 19 percent in the second
stage, and 30 percent in the third stage. Graft loss requiring regrafting was the largest complication in the
first stage, followed by tube dehiscence.
SUMMARY
The vertical midline lower abdominal tubed flap, used with a split-thickness skin graft, allows a phallus-like

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structure to be constructed in only two stages.
References
1. Noe JM, Birdsell D, Laub DR. The surgical construction of male genitalia for female-to-male transsexuals.
Plast Reconstr Surg 1974;53:511.
2. Noe TM, Sato R, Coleman C, Laub DR. Construction of male genitalia: the Stanford experience. Arch Sex
Behav 1978;7:297.
3. Bogaras N. Ueber die voile plastische Wiederherstellung eines zum Koitus faehigen Penis. Zentralbl Chir
1936;63:1271.
4. Blum V. A case of plastic restoration of the penis. J Mt Sinai Hosp 1938; 4:506.
5. Frumkin AP. Reconstruction of the male genitalia. Annu Rev Soviet Med 1944;2:214.
6. Gillies HD, Millard DR. Congenital absence of the penis. Br J Plast Surg 1948;1:8.
7. McIndoe A. Deformities of the male urethra. Br J Plast Surg 1948;1:29.
8. Farina R, Frier EG. Total reconstruction of the penis. Plast Reconstr Surg 1954;14:351.
9. Morales PA, O'Connor JJ, Hotchkiss RS. Plastic reconstructive surgery after total loss of the penis. Am J
Surg 1956;92:403.
10. Munawar A. Surgical treatment of the male genitalia. J Int Coll Surg 1957; 27:352.
11. Gelb J, Malament M, LoVerme S. Total reconstruction of the penis. Plast Reconstr Surg 1959;24:62.
12. Fleming JP. Reconstruction of the penis. J Urol 1970;104:213.
13. Orticochea M. A new method of total reconstruction of the penis. Br J Plast Surg 1972;25:347.
14. Hoopes JE. Surgical correction of the male external genitalia. Clin Plast Surg 1975;1:325.
15. Puckett CL, Montie JE. Construction of male genitalia in the transsexual using a tubed groin flap for the
penis and a hydraulic inflation device. Plast Reconstr Surg 1978;61:523.
16. Evans AT. Buried-skin-strip urethra in tube pedicle phalloplasty. Br J Plast Surg 1963;16:280.
17. Rea CE. The use of testicular prosthesis made of Lucite with a note concerning the size of the testis at
different ages. J Urol 1943;49:727.

18. Noe TM, Laub DR, Schulz W. The external male genitalia: the interplay of surgery and mechanical
prosthesis. In: Meyer J, ed. Clinical management of sexual disorders. Philadelphia: Williams & Wilkins,
1976.
19. Dubin BJ, Sato RM, Laub DR. Results of phalloplasty. Plast Reconstr Surg 1979;64:163.
20. Laub DR, Dubin BJ. Gender dysphoria. In: Grabb WC, Smith JW, eds. Plastic surgery, 3rd ed. Boston:
Little, Brown, 1979;883.

Chapter 449
Tubed Groin Skin Flap and Microvascular Free Flap Pha Lloplasty
C. L. PUCKETT
A dissatisfaction with the existing techniques of phalloplasty led to the use of the groin flap for penis construction.
It continues to be my flap of choice for this procedure, and in the absence of injury to the superficial circumflex
iliac artery, this is a most reliable and predictable flap (1, 2).
INDICATIONS
The advantages of the groin flap in phalloplasty are its proximity to the pubic area, relatively hairless skin,
good color and texture for penis construction, and an easily concealed donor scar. In the transsexual patient
in whom aesthetic appearance and sexual function are major concerns, the procedure has been quite
satisfactory. From a cosmetic standpoint, this technique compares favorably with the bulkier
musculocutaneous flaps that have been proposed. I feel that the natural skin of the groin flap is preferable
to grafted skin (2). However, this method of phalloplasty is by no means free of problems, and many
complications have occurred with the Brantly-Scott prosthesis as well.
Although the multistaged groin flap has been quite satisfactory from an aesthetic and functional standpoint
for penis construction, the multiple delay procedures that are intended to decrease the likelihood of tip
necrosis at the time of final division of the primary pedicle are cumbersome. Therefore, to ensure a more
reliable blood supply and to decrease the amount of time necessary for penis construction, I have also
performed a microvascular free transfer of the groin flap in several patients (1).
FLAP DESIGN AND DIMENSIONS
Depending on the patient's body build and subcutaneous fat content, the dimensions of the tubed groin skin flap
vary slightly. However, 23 cm long and 11 or 12 cm wide are average dimensions.
OPERATIVE TECHNIQUE
Tubed Groin Skin Flap
The flap is elevated with care taken to preserve the superficial circumflex iliac artery, although I do not feel it is
mandatory to visualize the artery. Following elevation, the flap is tubed and the distal portion is deepithelialized
and split into two tails that are inserted into the midline of the mons (Fig. 449.1). These tails are delivered into
tunnels dissected into each of the labia majora. The insertion of this deepithelialized portion mimics the position
of the corporal bodies of the penis and also provides a greater surface area for revascularization. Each tip of the
two tails is secured with a suture that is brought out over a cotton bolus on the labia.
The donor site has been closed primarily in all patients. However, it is under considerable tension, and most of
the scars have widened significantly with time.
At 3 weeks, a delay procedure is accomplished with division of the superficial circumflex iliac artery and
approximately one-third of the skin circumference at the base of the flap. Usually, three delay procedures have
been necessary, each separated by 7- to 10-day intervals.
After the penile shaft has been constructed (Fig. 449.2A), a single-stage sculpturing is done to create the glans.
This is accomplished by excising a series of diamond-shaped ellipses spaced circumferentially to form a coronal

sulcus (Fig. 449.3). Maintenance of this sulcus has been aided by the incorporation of a buried 5-0 nylon
subcuticular stitch to “purse string” the area (Fig. 449.3B).
Four to six weeks after this stage, the final procedure can be done. This includes the clitoroplasty, scrotoplasty,
and insertion of the testicular prostheses and the Brantly-Scott inflation device. In the clitoroplasty, the clitoris is
bivalved and inserted into the base of the penile shaft by reorienting it 180 degrees. After most of the labia
minora are resected, the labia majora are approximated in the midline to create the scrotum. This technique
retropositions the vaginal orifice and makes it less apparent. Urethral reconstruction has not been done in any of
my patients. Testicular prostheses are inserted from above deeply into each of the labia majora. The Brantly-
Scott pump is placed on the right or the left side, depending on patient preference. Two inflation cylinders have
been used in my recent patients, and the reservoir is put extraperitoneally behind the rectus muscle. Test
inflation at the time of surgery ensures that the hydraulic system is working properly.
Free Flap
The inset of the flap is similar to that described above for the standard groin-flap transfer. I simply use the
proximal end of the flap, rather than the distal end, to insert into the mons area. This is deepithelialized and split
into two tails in the same manner previously described (Fig. 449.4). I have not found suitable recipient vessels in
the mons area. Therefore, an interpositional vein graft is used to elongate the superficial circumflex iliac artery of
the flap and attach it to a larger branch of the femoral artery. The saphenous vein is detached lower in the leg
and rotated into position through the same tunnel made for the arterial vein graft. Thus only one venous
anastomosis is necessary—the one between the superficial circumflex iliac vein and the saphenous vein. The
remainder of the procedure is identical to that done for the multistaged transfer.
FIGURE 449.1 The tubed groin flap has been rotated from the right groin into the mons area. The distal 3 to 4
cm have been deepithelialized, split into two tails, and inserted into tunnels in the labia majora. A suture is placed
to secure the tip of the tail to the skin of the labia majora.

FIGURE 449.2 A: Patient following completion of the penile shaft construction. B: The same patient following
single-stage glans sculpturing.
CLINICAL RESULTS
Since 1976, I have used the tubed groin skin flap in over 15 phalloplasty procedures (1). I have had no
instances of even partial flap necrosis with primary elevation and transfer. However, using three delay
procedures, division of the flap has produced tip necrosis of some degree in approximately 30 percent of
patients. I have responded to this incidence of tip necrosis by adding more delays and increasing the time
before final division. However, even this has not always prevented some necrosis. It has been necessary to
abandon the existing flap and start over with a new flap from the opposite groin in only one patient. In the
other patients, resection and revision of the tip of the shaft have still resulted in a penis of adequate length.
FIGURE 449.3 Glans sculpturing. A: Asymmetrical diamond-shaped ellipses of skin are drawn to create a
coronal sulcus. Usually three are necessary. B: The ellipses have now been excised and closed. The
dashed line indicates the placement of a monofilament nylon dermal purse-string stitch to help maintain the
sulcus.

FIGURE 449.4 A: Free-flap transfer of the groin for phalloplasty. The flap has been elevated and tubed.
The proximal end has to be deepithelialized and split into two tails for insertion into the labia majora. At this
point, the superficial circumflex iliac artery and vein are still intact. B: A free-flap phalloplasty patient at the
time of final surgery. Scrotoplasty, clitoroplasty, and insertion of testicular and inflation prostheses have
been done. This patient has had only two previous procedures—the free-flap transfer and the glans
sculpturing.
Disadvantages of the groin flap have been (1) the need for a multistaged transfer, (2) some degree of
fragility when ultimately divided from its original pedicle, and (3) the propensity to gain bulk (but not lose it)
with fluctuations in the patient's body weight.
To 1982, I used the microvascular free transfer of the groin flap in three patients (1) (Fig. 449.4). There was
one flap failure that could not be salvaged following venous thrombosis. In this patient, a multistaged
transfer of the opposite groin flap was done. The remaining two patients were completely without incident.
SUMMARY
The groin flap can be used either as a staged pedicled flap or as a free flap to construct a cosmetically
acceptable penis.
References
1. Puckett CL, Reinisch JF, Montie JE. Free-flap phalloplasty. J Urol 1982;128:294.
2. Puckett CL, Montie JE. Construction of the male genitalia in the transsexual using a tubed groin flap for
the penis and a hydraulic inflation device. Plast Reconstr Surg 1978;61:523.
3. Noe JM, Birdsell D, Laub DR. The surgical construction of the male genitalia for the female-to-male
transsexual. Plast Reconstr Surg 1974;53:511.

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Chapter 450
Pedicled Anterolateral Thigh Flap for Total Penis Reconstruction
R. S. NAZERALI
A. GURJALA
G. K. LEE
EDITORIAL COMMENT
The pedicled anterolateral thigh (PAT) flap allows for pedicled and sensate penile reconstruction. This
avoids microsurgical involvement.
INDICATIONS
Phalloplasty construction is a challenging endeavor. Previously reports have mostly focus on gender
reassignment. However, traumatic and postoncologic reconstructions are also important indications.
Phalloplasty should ideally be performed in one stage. Reconstruction should allow for a competent
neourethra
permitting voiding while standing. Return of tactile and erogenous sensibility, adequate bulk for penetration,
and aesthetic acceptability are important considerations. Finally, the procedure should cause minimal
scarring and minimal functional loss in the donor area.
Due to several distinct advantages, the pedicled anterolateral thigh flap has increased in popularity for
neophallus construction: it requires no need for a microsurgical technique, results in an easily hidden donor
scar with no functional loss, can be sensate, and does not sacrifice major blood vessels. Additionally, the
flap is bulky permitting penetration without a stiffener.
ANATOMY
The anterolateral thigh neophallus reconstruction is based on the standard anterolateral thigh flap. The
descending branch of the lateral femoral circumflex artery, arising off of the profunda femoris, supplies inflow.
The descending branch travels on the surface of the vastus intermedius, between the rectus femoris and the
vastus lateralis muscles.
Perforators that supply the flap penetrate through the deep intermuscular septum of the lateral thigh or through
the vastus lateralis as described by Koshima et al. (1) The artery is generally 1.5 to 2.5 mm in diameter, and the
vein is slightly larger than the artery at the origin. Pedicle length can reach up to 7 cm, depending on where the
perforators enter.
FLAP DESIGN AND DIMENSIONS
The flap is centered over the perforators located by pencil Doppler, halfway between the anterior superior iliac
spine, and the superolateral border of the patella. Flap markings are based on a tube-within-a-tube design as
described by Chang and Hwang (2). The thigh is marked approximately 7 cm wide on each half of the shaft, 4 cm
wide for a tubularized urethra, a 1-cm area of de-epithelialization on either side of the urethra approximately 12

cm long, and an additional 3-cm portion for the neoglans (see Fig. 450.1) (3).
The neoglans is shaped as a semicircular extension, resembling the head of a mushroom. When tubularized, the
neoglans has the anatomic landmarks of a circumcised penis. This construct permits single stage reconstruction
of the neophallus, neoglans, and neourethra (4).
FIGURE 450.1 Schematic representation of the tube-in-tube design with the mushroom flap incorporated. Note
that the inner conduit becomes the neourethra, the outer tube becomes the penile shaft, and the distal portion
becomes the neoglans.
OPERATIVE TECHNIQUE
General anesthesia is typically employed due to the extent and length of surgery. The dissection is carried along
the medial aspect of the thigh through the skin to the muscular fascia, and the flap is elevated in a medial to
lateral direction in a subfascial plane. The perforators penetrating the flap are identified and preserved.
Care must also be taken to identify the sensory nerves of the thigh. Depending upon the region, it is possible to
isolate both the lateral and medial femoral cutaneous nerves, tracking them for a distance of at least 6 cm for
nerve coaptation.
Dissection is then performed on the lateral aspect of the leg after ensuring the perforators are centered. The flap
is elevated subfascially over the vastus lateralis and the perforators isolated. The dissection is tracked proximally
towards the origin of the lateral femoral circumflex vessels. Dissection near the origin of the vessel is tedious with
multiple branches, which must be ligated and cut to ensure maximal length, permitting tension-free transposition
(Fig. 450.2).
A submuscular tunnel below the rectus femoris and sartorius four fingerbreadths wide is dissected. A second
tunnel of the same caliber is created subcutaneously towards the perineum. Utilizing primarily blunt dissection
and spreading, care must be taken to preserve the motor branches of the femoral nerve.
The flap is then passed towards the groin area. It is critical to evaluate the pedicle to ensure minimal tension,
kinking, and compression (Fig. 450.3).
Construction of the neophallus is then performed, beginning with de-epithelialization of the edges of the
demarcated region of neourethra. To ensure patency, the urethral portion of the flap is then tabularized over a
capped 16-French silastic Foley, and skin layers are approximated with deep dermal sutures and running
intracuticular stitches. The shaft is formed by tubularizing the remaining tissue over the neourethral tube and
sutured with dermal 5-0 Monocryl and 4-0 Monocryl intracuticular sutures.
The distal portion of the flap is rolled and trimmed to recreate a neoglans. This is secured with half-buried 5-0
chromic mattress sutures.
The lateral femoral cutaneous nerve harvested with the flap is coapted to the dorsal pudendal nerves at the

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penile shaft base utilizing an operating microscope and 8-0 nylon sutures.
FIGURE 450.2 Elevated flap with pedicle shown running between under rectus femoris and over vastus
intermedius.
FIGURE 450.3 Flap transposed through a submuscular tunnel (under the rectus femoris and sartorius muscle)
and being tunneled subcutaneously towards the groin.
Next, a urethroplasty is performed. Triangular flaps are used to interdigitate the urethral stump of the native
urethra to break up the circular scar to minimize risk of strictures. This is sutured together using simple
interrupted 5-0 Monocryl.
A deep intramuscular 15-French drain is placed at the donor site. The ipsilateral thigh is covered with a split-
thickness skin graft harvested from the contralateral thigh.
Two 1/4-inch Penrose drains are placed around the construct. A normal saline plastic bottle cylindrical protective
silo, nonstick gauze, and cotton fluff rolls are used to pad the reconstruction (Fig. 450.4).
CLINICAL RESULTS
Seromas or hematomas can form at the donor site. Closed suction drains should be maintained until the
patient is ambulatory and output is less than 30 mL/d for 2 consecutive days.

FIGURE 450.4 Postoperative result of neophallus reconstruction using the innervated mushroom design
anterolateral thigh pedicled flap.
Due to stress placed on the flap when performing the tubein-tube design, partial necrosis has been reported
secondary to thinning of the flap. It is important to minimize flap thinning during the first stage of the
procedure and perform liposuction or direct excision more safely on subsequent operations.
Transient femoral motor nerve palsy can be encountered due to traction or from direct injury. This can be
avoided by ensuring direct visualization during dissection. Unless direct surgical damage has been inflicted,
lower extremity quadriceps strength should return within several weeks.
SUMMARY
The innervated, pedicled anterolateral thigh flap can be a one-stage tubularized solution for the
reconstruction of the phallus allowing patients to micturate in a standing position, retain tactile and
erogenous sensation, and allow for penetrative sexual intercourse.
References
1. Koshima I, Fukuda H, Utunomiya R, et al. The anterolateral thigh flap: variations in its vascular pedicle. Br
J Plast Surg 1989;42:260-262.
2. Chang TS, Hwang WY. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg
1984;74:251-258.
3. Lee GK, Lim AF, Bird ET. A novel single-flap technique for total penile re- construction: the pedicled
anterolateral thigh flap. Plast Reconstr Surg 2009;124:163-166.
4. Morrison SD, Son J, Song J, et al. Modification of the tube-in-tube pedicled anterolateral thigh flap for total
phalloplasty: the mushroom flap. Ann Plast Surg 2014;72(suppl 1):S22-S26.

Chapter 451
Radial Forearm Free Flap for Penile Reconstruction
C. K. HERMAN
A. S. HOSCHANDER
B. STRAUCH
EDITORIAL COMMENT
This is an excellent and most elegant method for penile reconstruction, providing the ability to micturate
standing up, return of erogenous sensibility, and the possibility of stiffness, usually done as a second
operative procedure approximately 1 year later. The editors recommend the use of a temporary
arteriovenous fistula between the saphenous vein and the femoral artery, which will facilitate
revascularization of the forearm flap. For patients who have a considerable amount of hair on the forearm,
one should consider laser hair removal for two or three sessions to prevent a hairy neourethra.
The radial forearm free flap has been successfully used for single- operation total penile reconstruction for more
than two decades. First described as an alternative to nonmicrosurgical procedures by Chang and Hwang in
1984 (1), this fasciocutaneous flap has evolved into the most effective method of near-total or total phallic
reconstruction. A number of modifications have led to improved functionality and cosmesis (2, 3, 4, 5, 6, 7).
Historical methods of reconstruction, including local tube flaps and myocutaneous flaps, have demonstrated
significant drawbacks, including absent or minimal sensation. The radial forearm free flap allows a sensate (both
erogenous and tactile) reconstruction, with a non- or minimally hair-bearing neophallus, and potential for the
addition of an erectile or semirigid prosthesis to enable coitus.
INDICATIONS
Major deformities of the penis requiring phallic reconstruction can occur secondary to trauma, neoplasm, or
infection. Congenital absence of the penis is seen in male patients with micropenis and male
pseudohermaphroditism, as well as in female patients with gender dysphoria. The goals of phalloplasty
include a reliable and durable reconstruction, a sensate neophallus, urethral integrity to allow voiding while
standing, and adequate rigidity or erectile function to allow penetration. The radial forearm free flap is one
of many microsurgical and nonmicrosurgical options available for total phallic reconstruction. Use of the
radial forearm free flap should be reserved for cases in which total or near-total phallic reconstruction is
required.
The radial forearm flap is based on a neurovascular pedicle with adequate length to reconstruct the penis.
The fasciocutaneous radial forearm free flap receives its blood supply from the radial artery, a branch of the
brachial artery. The radial forearm free flap may be considered among the first-line surgical therapies for
total penile reconstruction.
ANATOMY
As noted, the fasciocutaneous radial forearm free flap receives its blood supply from the radial artery, a branch of
the brachial artery. The radial artery vascular supply perfuses the fasciocutaneous flap via cutaneous perforating

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vessels that course through a thin intermuscular septum and the antebrachial fascia. These perforating vessels
most commonly arise from the proximal and distal thirds of the radial artery; the middle third rarely contributes
perforating branches. The cephalic vein or basilic vein or both provide venous drainage of the flap. The medial
and lateral antebrachial cutaneous nerves constitute the neurosensory component of the flap, with enhanced
dermatomal sensation in the distal forearm corresponding to the glans component of the reconstruction. The
structural component of the flap includes the volar forearm skin, subcutaneous adipose tissue, and deep fascia.
FLAP DESIGN AND DIMENSIONS
Several modifications of the original design by Chang and Hwang (1) have been described (3, 4, 6, 7). The
central concept pervades all techniques: a radial forearm fasciocutaneous flap that is relatively hairless along its
ulnar border. The radial forearm free flap is created with a width of approximately 13 cm and a length of
approximately 12 cm. The basic flap design consists of three separate areas: the neourethral area, the external
skin covering, and an intervening deepithelialized area. The neourethra is located along the ulnar portion (area
A) (Fig. 451.1). The neourethra should be 2 to 3 cm in width
and is positioned on the ulnar side of the flap, which is generally less hair-bearing. Bordering the neourethra
radially is a segment of tissue measuring 0.5 to 1 cm (area B) that will require deepithelialization. Lateral to area
B is an area measuring 8 to 10 cm that will become the outer surface of the neophallus (area C). A small tongue
flap, centered at the distal end of this segment, will form the orifice of the distal urethra.
FIGURE 451.1 Elevation of flap and deepithelialization of Area B. 1. Area (A); 2. area (B); 3. area (C); 4. radial
artery and veins; 5. cephalic vein and lateral cutaneous nerve of the forearm; 6. basilic vein and medial
cutaneous nerve of the forearm.
OPERATIVE TECHNIQUE
The flap is first outlined on the patient's nondominant forearm (2). The perfusion of the superficial palmar arch by
the ulnar artery should be assessed with a preoperative Allen test, by ultrasonic Doppler flowmeter testing, or by
arteriography. The Allen test is generally considered sufficient for this purpose.

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A pneumatic tourniquet is applied with elevation exsanguination. Initially, the area radial to the neourethra (area
B) is deepithelialized. The radial vascular bundle, found at the lateral edge of the flexor carpi radialis tendon, is
then identified at the distal lateral portion of the flap and dissected. Laterally, at the edge of the flap, the cephalic
vein is isolated and ligated. The ulnar incision is then made and carried down deep to the fascia. The dissection
continues radially until it reaches the thin intermuscular septum, which contains the septocutaneous perforating
vessels of the radial artery. This dissection is carried out from distal to proximal. The basilic vein and the medial
cutaneous nerve of the forearm are located at the proximal medial border of the flap and can be ligated and
raised with the flap. Next, the radial portion of the flap is raised from the brachioradialis medially. The muscle is
retracted laterally, and the radial vascular bundle connected to the flap is dissected from the distal edge of the
flap to its origin from the brachial artery.
Again, the septocutaneous perforators are preserved in the intermuscular septum. During this dissection, it is
important to identify and preserve the superficial branch of the radial nerve. This nerve can be found as it
courses with the cephalic vein and pierces through or travels beneath the brachioradialis tendon. The cephalic
vein and lateral cutaneous nerve of the forearm are identified in the groove between the brachioradialis and
biceps muscles. At this point, the vein and nerve are isolated and ligated. The cephalic vein may be dissected
proximally for additional length, if necessary. Once the flap is completely raised and is being perfused and
drained only by the radial artery and its venae comitantes, the tourniquet is released, and the distal radial artery
is clamped while perfusion of the hand is assessed. When adequate perfusion of the hand is confirmed, the
distal radial vascular bundle can be ligated (Fig. 451.1).
The creation of the neophallus begins with rolling of the neourethra (area A) over a urinary catheter, with the
epidermis positioned internally, and suturing it to the medial side of the deepithelialized portion of the flap (area
B) (Fig. 451.2).
The shaft of the neourethra is then created by wrapping the lateral area (area C) around the neourethra with the
epidermis positioned externally. The lateral, radial border of the flap is sutured to the lateral portion of the
deepithelialized area (Fig. 451.3). The distal edges of areas A and C are sutured to each other to create the
orifice of the neourethra (Fig. 451.4).

FIGURE 451.2 Creation of neourethra over a catheter. 1. Area (A); 2. area (B) 3. area (C); 4. radial artery and
veins; 5. cephalic vein and lateral cutaneous nerve of the forearm; 6. basilic vein and medial cutaneous nerve of
the forearm.
FIGURE 451.3 Cross-sectional view. 1. Area (A) 2. area (B) 3. area (C) 4. radial artery and veins; 5. cephalic
vein and lateral cutaneous nerve of the forearm; 6. basilic vein and medial cutaneous nerve of the forearm.
The recipient site may be prepared by a separate team during flap elevation. Recipient-vessel preferences may
vary, including the inferior epigastric vessels, vein grafts to the femoral vessels, and saphenous vein. Our
preferred technique is as follows. The saphenous vein is dissected in the thigh, and approximately 20 cm of vein
is harvested. The saphenous vein is left attached to the femoral vein, and the free end is anastomosed to the
femoral artery. creating a temporary loop arteriovenous fistula. The site of attachment should be prepared at the
site of the native phallus, but if no native phallus exists, an incision should be made over the pubic symphysis.
The recipient nerves should be located at this time. It is preferable to isolate the dorsal penile (or clitoral)
branches of the pudendal nerve; if these are not found, the pudendal nerves may be used. The thigh incision
may be extended medially to the recipient bed to improve blood flow from the vein grafts to the neophallus.
The neophallus is now detached from its radial vascular pedicle in the forearm and transferred to its new
location. The neophallus should be secured to the recipient bed with tacking sutures. The catheter is now
inserted into the bladder, and a primary anastomosis between the flap's neourethra and the native urethra is
made. The saphenous vein loop is now bisected. The venous limb is anastomosed to the cephalic vein, and the
arterial limb is anastomosed to the radial artery. The paired pudendal nerves are anastomosed to the medial and
lateral cutaneous nerves of the forearm. The neophallus is now completely sutured to the recipient bed, and the
remainder of the incisions are closed. Finally, a suprapubic catheter is placed to divert urine away from the
healing urethral anastomosis. The urinary catheter is left in place from 10 days to 4 weeks, at which point a
retrograde urethrogram or a voiding trial may be performed.

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FIGURE 451.4 Radial forearm flap prepared for transfer to recipient area. 1. Area (A) 2. area (B) 3. area (C); 4.
radial artery and veins; 5. cephalic vein and lateral cutaneous nerve of the forearm; 6. basilic vein and medial
cutaneous nerve of the forearm.
The donor site is closed by approximating the forearm muscle to cover any exposed tendons. A split-thickness
skin graft is then used to cover the donor site. Flap viability should be assessed hourly, by using standard
assessment techniques, such as capillary refill, color, turgor, and pulse checks via palpation or Doppler analysis.
Many modifications to this flap have been made since its original design in 1984. Some of these modifications
have created the possibility of increasing the length of the phallus and the ability to add a prosthesis, as well as
different designs for a more aesthetically pleasing corona. It is our preference to provide rigidity to the shaft by
incorporating an irradiated human costal cartilage graft. This operation generally is performed at least 1 year
after the initial reconstruction, when adequate protective sensation is present. Other techniques to achieve
rigidity also can be used, including various inflatable penile prosthetic devices.
CLINICAL RESULTS
Reconstruction of the penis has been accomplished by many methods, including both microsurgical and
local flaps, with the radial forearm free flap providing the most reliable results. Cheng et al. (5) studied 136
patients who had undergone various methods of penile reconstruction. Of these patients, 93 had
penile reconstruction by using the radial forearm flap, with 13 (14%) patients experiencing a major
complication. The main complications of this flap are the formation of fistulae (10%) and urethral strictures
(3%), as well as partial flap necrosis (6.5%). Complete flap loss occurred in one case and required a new
flap from the contralateral forearm. The radial forearm flap was described as having an appropriate
thickness and texture as well as having hairless skin. Additionally, the flap is reported as having good
erogenous and tactile sensation, with tactile sensation returning to the flap within 6 months for those who
underwent nerve coaptation. Erogenous sensation returned in 81% of patients, allowing generation of an
orgasm in the majority of cases. The appearance of the neophallus is acceptable, and micturition can be

achieved while standing. The major disadvantage of this flap is the donor-site deformity, but this is usually
tolerated well under the circumstances that warrant a total penile reconstruction.
SUMMARY
The construction and reconstruction of a neophallus by using the radial forearm free flap is aesthetically
acceptable and widely functional. This technique can achieve both protective and erogenous sensation, as
well as the ability to micturate while standing. Many congenitally male patients will regain the ability to
achieve orgasm and ejaculate with appropriate stimulation. The addition of a penile prosthesis allows
pleasurable and successful coitus.
References
1. Chang TS, Hwang WY. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg
1984;74:251.
2. Strauch B, Yu HL. Atlas of microvascular surgery: anatomy and operative approaches. Stuttgart: Thieme,
1993;318.
3. Gottlieb LJ, Levine LA. A new design for the radial forearm free-flap phallic construction. Plast Reconstr
Surg 1993;92:276.
4. Gilbert DA, Williams MW, Horton CE, et al. Phallic innervation via the pudendal nerve. J Urol 1988;41:160.
5. Cheng KX, Hwang WY, Aie AE, et al. Analysis of 136 cases of reconstructed penis using various methods.
Plast Reconstr Surg 1995;95:1070.
6. Hu ZQ, Hyakusoku H, Gao JH, et al. Penis reconstruction using three different operative methods. Br J
Plast Surg 2005;58:487.
7. Rashid M, Sarwar SU. Avulsion injuries of the male external genitalia: classification and reconstruction
with the customised radial forearm free flap. Br J Plast Surg 2005;58:585.

P.1222
Chapter 452
Ulnar Forearm Flap for Phallic Reconstruction
D. A. GILBERT
EDITORIAL COMMENT
There are now multiple methods of reliable canal reconstructions utilizing microvascular techniques
(Chapters 452-455). Each of the authors claims significant advantages for each of their own techniques,
and they are probably all correct. All of these flaps work for reconstruction of the penis. However, the
biggest problem is the location of the recipient vessels. A solution to this problem of recipient vessels is the
use of the saphenous vein plugged info the femoral artery, creating a temporary A-V fistula. The fistula is
then brought into the perineal area, divided, and a large artery and vein are available for attachment to the
penile reconstruction.
The microsurgical free forearm flap has become the mainstay of modern phallic reconstruction (1, 2). Such
reconstructions have classically depended on the radial forearm flap. However, the flap may also be based on
the ulnar artery (3), providing a thin, malleable, non-hirsute, sensate flap that can be sculpted to the patient's
needs.
INDICATIONS
Phallic reconstruction should ideally: (1) be a one-stage microsurgical procedure that can be reliably
reproduced; (2) have both tactile and erogenous sensibility; (3) be created with a competent neourethra that
allows voiding while standing; (4)
have enough bulk to tolerate insertion of a prosthetic stiffener to allow for successful intromission; (5) be
aesthetically acceptable to the patient and his partner; (6) grow through childhood to an acceptable adult
size; and (7) be associated with acceptable donor-site morbidity.
Early reconstructions often failed because of the multiple procedures involved or because of fistulae,
strictures, or hair in the urethra. More important, the final product lacked sensation and had a poor aesthetic
appearance. The development of microsurgical techniques allowed for selection of distant flaps, the transfer
of free tissue, and the coaptation of nerves from the donor flap to recipient nerves in the perineum.
Indications for total phallic reconstruction include posttraumatic loss, female-to-male transsexual surgery,
developmental micropenis, exstrophy/epispadias deformities, and sickle cell disease.
Drawbacks of the ulnar forearm flap include the obvious donor-site deformity on the forearm, possible cold
intolerance in the ipsilateral hand, potential loss of function, and hirsutism in many patients (including
female-to-male transsexuals on testosterone therapy). Although the ulnar aspect of the forearm is often
relatively hairless and can be used to construct the urethra, subsequent hair growth inside the neourethra is
not only unsightly but, more serious, excess hair possibly promotes bacterial colonization and calculus
formation. To date, we have not had any patients who have experienced complications with postoperative
cold intolerance or permanent ulnar nerve injury in the donor hand.

P.1223
ANATOMY
The ulnar forearm flap is vascularized by the ulnar artery and its paired venae comitantes (Fig. 452.1). The
caliber and length of the ulnar artery are superior to those of the radial artery. The ulnar artery arises as a
continuation of the brachial artery, and then runs distally to the ulnar wrist. The artery is covered proximally by
the long flexors, and distally by skin, subcutaneous tissue, and the flexor carpi ulnaris. Within the distal forearm,
two predictable vascular pedicles from the ulnar artery to the flap are identified. The largest one is usually found
at the mid-forearm level, where the ulnar artery lies deep between the flexor digitorum superficialis and the flexor
carpi ulnaris. The second perforator is located distally between the proximal perforator and the wrist.
FIGURE 452.1 “Cricket bat” centered over the ulnar aspect of the forearm. (From Gilbert et al., ref. 6, with
permission.)
The antebrachial fascia invests the forearm musculature and the ulnar artery in a firm sheet that separates the
muscles from each other and from overlying veins and nerves. The proximal forearm fascia is pierced by nerves,
arteries, and veins that run superficially through the premuscular fascia to the overlying skin. The veins include
the cephalic, basilic, and medial antebrachial. The cephalic vein runs proximally from the wrist over the radial
side of the forearm, collecting tributaries from the volar and dorsal forearm. The basilic vein begins over the
dorsal-ulnar wrist, and runs proximally to the ulnar side of the elbow. The medial antebrachial vein runs from the
volar-ulnar wrist to the side of the elbow. All these veins communicate with or receive tributaries from the median
cubital vein.
The lateral antebrachial nerve is the anatomic continuation of the musculocutaneous nerve arising at the elbow,
entering the antebrachial fascia deep to the cephalic vein, and dividing into anterior and dorsal branches that
provide sensation to the radial-volar and dorsal areas of the forearm.
The medial antebrachial nerve lies medial to the brachial artery in the upper arm, and then pierces the
antebrachial fascia, to run distally and superficially with the basilic and other antebrachial veins. This nerve
divides into anterior and ulnar branches, to innervate the ulnar-volar and dorsal-ulnar forearm.
FLAP DESIGN AND DIMENSIONS
All prospective patients undergo a standard preoperative assessment that includes an Allen's test, to evaluate
and confirm “two-vessel patency” in the upper extremity. Should there be any doubt concerning the vascular
integrity of either forearm vessel, patients undergo upper-extremity angiography.

Inherent to candidacy for surgery is the ability to tolerate an extended microvascular procedure.
Phallic flap dimensions are planned to accommodate each patient's specific anatomic needs regarding the
urethral and outer-shaft width and length. In preteen and adolescent patients, the phallus assumes a somatic
growth rate—not a “genital growth rate”—following transfer, and phallic size must be planned to accommodate
the disparity (4).
The quality of subcutaneous fat is also assessed in the forearm of each patient. Those with thicker
subcutaneous fat have a larger diameter reconstruction that requires added width for outer-shaft coverage, in
which there is a great deal of subcutaneous adipose tissue. In some cases, we achieved shaft coverage using a
split-thickness skin graft; the cosmetic results were amazingly good.
Our present design incorporates the original Biemer triple skin design and includes a fourth distal island
“neoglans” (5, 6). This island, a distal continuation of the neourethral island, is rotated proximally over
deepithelialized distal shaft skin, to create a pseudoglans and palpable step-off at the coronal sulcus. The
urethral component is at least 3.5 cm wide.
OPERATIVE TECHNIQUE
Deepithelialization is completed on the urethral borders between the urethra and the lateral skin flaps, and over
the distal skin flaps adjacent to the neoglans. Elevation of the forearm flap is begun after the ulnar artery is
determined to be anatomically normal by Doppler examination.
The ulnar artery and its venae comitantes are identified and ligated distally. The ulnar nerve is identified and left
in its bed. From laboratory dissections and clinical experience, we have found that the forearm fascia can be
dissected into two layers. The thicker deep antebrachial fascia is left intact on the forearm musculature, while a
thinner superficial layer is elevated within the flap. Over the vascular pedicle, the plane of dissection is directed
through the deep investing muscle fascia, to incorporate the ulnar artery and venous branches. During dissection
of the vascular pedicle, the ulnar artery is gently separated from the ulnar nerve along its length. The dorsal
sensory branches of the ulnar nerve are preserved (Fig. 452.2).
The ulnar artery is then dissected proximally to its origin from the brachial artery. When the full length of the ulnar
artery is required, a counterincision in the deep fascia between the brachial radialis or the flexor superficialis
provides exposure of the bifurcation of the brachial artery. It is important to identify the anterior interosseous
nerve when dissecting the ulnar artery beneath the flexor superficialis muscles. Transient loss of “pinch” can
occur, if traction is placed on this nerve.
FIGURE 452.2 Flap elevated on ulnar vessels. (From Gilbert et al., ref. 6, with permission.)
Numerous veins are often encountered at the proximal forearm, but we favor the basilic and cephalic veins for
anastomosis. Their diameter is similar to the recipient saphenous vein. If additional vascular egress is required,

P.1224
we anastomose the donor vena comitans and the recipient inferior epigastric vena comitans. Depending on the
flap design, we try to preserve one of the major superficial veins in the forearm. Although the flap donor site has
transient postoperative swelling, we have not experienced any chronic postoperative edema.
The lateral and medial antebrachial nerves are dissected in the forearm, usually close to the cephalic and basilic
veins, respectively.
Construction of the neophallus is begun while the flap is still perfusing on the forearm. The neourethra is tubed
with a two-layer closure, usually with a running locked suture, to achieve a more watertight seal (Figs. 452.3 and
452.4). The phallic shaft is crafted by suturing the lateral flaps to each other in a “clam-shell” fashion. Finally, the
neoglans is formed by rotating the glans paddle proximally, to create an appropriate conically- shaped neoglans
configuration (Figs. 452.5 and 452.6).
Prior to the microsurgical transfer, the length and diameter of the donor and recipient vessels are estimated. The
recipient inferior epigastric artery is anastomosed to the donor artery. If the epigastric artery is absent, a venous
fistula is created, using a saphenous-vein interposition graft between the femoral artery and the adjacent
saphenous vein. This fistula is cut in half, thereby creating a saphenous-vein interposition graft that serves as a
conduit between the “recipient” femoral and “donor” ulnar arteries, as well as venous egress.
A urethral anastomosis is then carried out between the neourethra and native urethra. Where possible, this
anastomosis is completed with a two-layer closure of long-term absorbable suture. A gracilis muscle is often
elevated and rotated over the urethral anastomosis for added vascularity at the anastomotic site. The gracilis
can be modified and, where necessary, skin grafted to mimic a neoscrotum.
The venous anastomoses and nerve coaptation are then completed.
When distal branches of the pudendal nerve cannot be located, dissection is carried out to identify the pudendal
nerve
more proximally (at the exit from Alcock's canal). Alternatively, a nonerogenous recipient nerve can be used. We
have used the ilioinguinal, genitofemoral, saphenous, hypogastric, and gracilis nerves to achieve phallic
sensation.
FIGURE 452.3 Neourethra planned closure. (From Gilbert et al., ref. 6, with permission.)
The final step is to cover the forearm flap donor site with a split-thickness skin graft. Some advancement of the
surrounding skin interface is attempted, to diminish the size of the donor site. A thick (20/1000 to 25/1000 of an
inch) split-thickness skin graft is harvested from the thigh and applied to the forearm. By preserving the forearm
antebrachial fascia, we find the donor site is smooth and bloodless, and readily accepts the skin graft. More
recently, we have used full-thickness skin grafts harvested from the groin bilaterally, to cover the donor site. A
nonadherent dressing and custom splint are then placed on the forearm.
Postoperatively, a custom splint is constructed to shield the penis. The splint encircles the phallus and rests on
the pubis. It is secured, so that no pressure can be applied from the sides or from the top. The penis is kept in an
erect position.

CLINICAL RESULTS
We have gradually modified our approach to phalloplasty, with the goals of improved function and aesthetic
results. Over the past 2 years, we have completed 21 ulnar-based forearm microsurgical phalloplasties, with
no failures. The youngest patient in this group was 6 years of age, and the oldest was 40 years of age
(mean age: 24.3 years). Of the 21 phalloplasties, three patients required reoperation to relieve arterial
thrombi. All of these arterial thrombi occurred in cases where a saphenous-vein interposition graft was used
between the recipient femoral artery and the donor ulnar artery. One thrombus occurred 12 days after
phallic reconstruction. All thrombi were successfully removed, and the flaps survived with a combination of
surgical thrombectomies, injection of intraarterial urokinase, and replacement of the saphenous-vein
interposition grafts.
FIGURE 452.4 Skin closure over neourethra. (From Gilbert et al., ref. 6, with permission.)
FIGURE 452.5 Over surface closed and glans planned to be closed. (From Gilbert et al., ref. 6, with
permission.)
Three patients had postoperative urethral stenosis that required internal urethrotomy to correct. Four
patients had postoperative urethrocutaneous fistulae, of which one resolved spontaneously, one was
successfully closed with an intraoral mucosal graft, and the two others await fistula repair.
Fourteen of the 18 patients had nerve coaptation to branches of the pudendal nerve. Two patients had
coaptation to genitofemoral nerves, one to the ilioinguinal nerve, and one patient awaits nerve coaptation.
Fourteen patients claim a return of postoperative sensibility. Five patients have had successful insertion of
a penile prosthesis.
SUMMARY
Recent modifications in forearm phalloplasty with ulnar forearm flaps have been described. These
modifications have improved overall phallic function and aesthetic results, and have provided acceptable

P.1225
outcomes at the forearm donor site.
FIGURE 452.6 All wounds are sutured anteriorly and posteriorly. (From Gilbert et al., ref. 6, with
permission.)
References
1. Chang TS, Hwang WY. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg
1984;74:251.
2. Gilbert DA, Horton CE, Terzis JK, et al. New concepts in phallic reconstruction. Ann Plast Surg
1987;18:128.
3. Lovie MJ, Duncan GM, Glasson DW. The ulnar artery forearm flap. Br J Plast Surg 1984;37:486.
4. Gilbert DA, Jordan GH, Devine CJ Jr, et al. Microsurgical forearm “cricket- bat-transformer” phalloplasty.
Plast Reconstr Surg 1992;90:711.
5. Beimer E. Penile construction by the radial arm flap. Clin Plast Surg 1988;15:425.
6. Gilbert DA, Schlossberg SM, Jordan GH. Ulnar forearm phallic construction and penile reconstruction.
Microsurgery 1995;16:314.

P.1226
Chapter 453
Prefabricated Lateral Arm Flap for Penile Reconstruction
R. K. KHOURI
P. PELISSIER
V. M. CASOLI
Excellent long-term results in penile reconstruction have been achieved with a prefabricated free flap, using a
lateral arm/proximal forearm donor site. The procedure consists of prefabricating a neourethra by inserting a
tubed, full-thickness skin graft in the lateral arm flap a few months prior to phalloplasty reconstruction.
INDICATIONS
One of the primary goals of phalloplasty is the creation of a urinary conduit that will allow the patient to void
in a standing position. However, for the neophallus to be fully functional, it must look like a phallus, be rigid
enough to allow sexual intercourse, and have ample sensation for protection and erotic stimulation. These
goals have been achieved with a prefabricated lateral arm free flap (1). The lateral arm, with an extension to
the proximal forearm (see chapter on the proximal forearm flap), is preferred, because it has a greater bulk
when the flap is tubed. It can recover excellent sensibility, and it leaves a less conspicuous donor-site scar
than the radial forearm flap.
ANATOMY
Excellent erogenous and protective sensation can be achieved by coapting the easily identified posterior
cutaneous nerves of the arm and forearm to the clitoral or penile nerves. The constant anatomy of the lateral arm
makes flap elevation quite straightforward (2, 3). The upper arm has a moderately thick subcutaneous tissue
layer and, consequently, its use results in greater bulk when the flap is tubed.
FLAP DESIGN AND DIMENSIONS AND OPERATIVE TECHNIQUE
The lateral arm allows for a substantial tissue length of up to 30 cm, and 10 to 12 cm in circumference, making it
the best option for simultaneously incorporating a neourethra alongside a permanent inflatable prosthesis. When
compared to flaps that incorporate bone or a rigid implant, the inflatable prosthesis allows a patient to control the
degree of rigidity in the neophallus. In addition, it is much easier to repair a fistula while the tubed flap has no
functional role in the arm and has ample available surrounding tissue than when the tube is isolated as a penis
and must function as a urinary conduit. When compared with a radial forearm phalloplasty, the donor-site scar on
the lateral arm has less morbidity and is easier to hide with clothing.
The prefabrication requires two stages.
First Stage
A large, full-thickness skin graft is harvested from a hairless area, such as the flank or groin. This graft, which
should measure approximately 4 cm in width and 23 cm in length, is carefully tubed, epithelial side in, around a
#24 or #26 French Silastic catheter. We then embed this construct into the superficial subcutaneous tissue of the
lateral arm, along the axis of the intermuscular septum (Fig. 453.1). The graft remains in place for 3 to 5 months,
until it matures and contraction is

complete. The take of the graft is monitored with a flexible fiberoptic endoscope. If there is any breakdown, or if
there is less than complete take of the graft, additional grafting is performed under local anesthesia, and more
lateral arm tissue can be mobilized. During this period, the patient carries the Silastic catheter inside the lateral
arm as a stent for the graft and removes it daily, to irrigate the new embedded epithelial conduit with water.
FIGURE 453.1 A full-thickness skin graft is tubed around a #26 French Silastic catheter, with the epithelial
surface facing the catheter. The whole construct is buried subcutaneously along the longitudinal axis of the
lateral arm flap.
FIGURE 453.2 The lateral flap is planned: the proximal part of the flap will become the penile shaft, and the
distal part will be used to construct the glans.
Second Stage
The flap is elevated according to the design shown in Figure 453.2. After preparing the recipient site and dividing
the vascular pedicle of the flap, the neophallus is tubed around an inflatable permanent prosthesis, with the
prefabricated urethra oriented along the ventral surface. The distal quarter of the flap, which is 1 to 1.5 cm wider
than the portion used to form the penile shaft, is fashioned into a glans. This allows for the creation of a penis 18
cm long and 11 to 12 cm in circumference (Fig. 453.3).
To lengthen the native meatus in transsexuals, the prefabricated neourethra is anastomosed to a labia minora
flap tubed around a bladder catheter, and additional tissue from the labia minora is mobilized and drawn over the
anastomotic site, to provide extra padding.
We coapt the posterior cutaneous nerves of the arm and forearm to the left and right dorsal penile nerves (or
clitoral nerves in transsexuals). We anastomose the posterior radial collateral vessels with the inferiorly mobilized
inferior epigastric vessels. The reservoir of the permanent inflatable prosthesis is finally positioned in a pocket
beneath the rectus abdominis muscle, and the pump is placed in the scrotum (or inside the labia majora in
transsexuals). The lateral arm donor site is closed with a skin graft.

FIGURE 453.3 Prior to insert, the skin flap is tubed around an inflatable penile prosthesis; a #20 French Silastic
catheter is placed through the neourethra.
CLINICAL RESULTS
We have a minimum of 4 years' follow-up (range: 4 to 5 years) on four female-to-male transsexuals. The
same procedure was performed for each patient. Following the creation of an epithelialized conduit in the
upper arm, we confirmed good complete epithelialization with a fiberoptic laryngoscope in all but one
patient. This patient required turn-down local flaps to restore epithelial continuity of the tube. After the
second-stage transfer, primary healing occurred in all patients. The bladder catheter was removed in the
third postoperative week, and all patients were able to void in a standing position.
However, all patients developed fistulas and strictures in the perineal area. These were repaired with local
turn-over flaps from the perineal skin, and from the excess tissue brought down with the generous design of
the neophallus. All the fistulas healed promptly, following the local surgical procedures, and the patients
were able to void from a standing position without leakage and with a forceful stream.
Inflation of the prosthesis was allowed at 6 months. At 1 year, sensation had returned over the entire
neophallus, and intercourse was allowed. At a minimum of 4 years' follow-up, the patients were satisfied
with the function and cosmetic appearance of their penises, and all were free of complications.
SUMMARY
The prefabricated lateral arm free flap has provided excellent long-term results, with no exposure of the
inflatable prosthesis, and with all patients reporting sexual performance and the ability to void while
standing.
References
1. Young VL, Khouri RK, Lee G, Riolo Nemecek J. Advances in total phalloplasty and urethroplasty with
microvascular free flaps. Gun Plast Surg 1992;19:927.
2. Katsaros J, Schusterman M, Beppu M, et al. The lateral upper arm flap: anatomy and clinical applications.
Ann Plast Surg 1984;12:489.
3. Brandt KE, Khouri RK. The lateral arm/proximal forearm flap. Plast Reconstr Surg 1993;92:1137.

(Trang không có chữ)

Chapter 454
Radial Forearm Flap for Penile Reconstruction
L. J. GOTTLIEB
L. A. LEVINE
L. S. ZACHARY
The radial forearm free flap was initially selected for penile reconstruction, as it is a thin, potentially sensate,
minimally hair-bearing flap, with enough flexibility for its design to incorporate a vascularized urethra (1). Since its
initial description, several modifications in the flap technique have emerged (2, 3, 4, 5, 6, 7, 8), some of which
are described below.
INDICATIONS
Patients with severe penile deformities, regardless of cause (congenital or traumatically acquired, infection,
or malignancy), or those who have suffered penile loss or mutilation, are potential candidates for
reconstruction using the radial forearm free flap. Gender dysphoria patients may become candidates for
penile construction, if they meet the guidelines established by the Harry Benjamin International Gender
Dysphoria Association.
FIGURE 454.1 Anatomy of the fasciocutaneous radial forearm flap. (From Cohen, ref. 9, with permission.)
Attention must be given to the patient's level of expectation and the ability to deal with potential
complications and significant donor-site scars.
ANATOMY
The neurovascular fasciocutaneous radial forearm free flap includes the volar forearm skin with its underlying
adipose tissue, the medial and lateral antebrachial cutaneous sensory nerves, the basilic and cephalic veins,
and the deep fascia. All of these are connected to the radial artery and its venae comitantes by a thin,

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intermuscular septum that contains cutaneous perforating vessels. A set of four or five perforating vessels
emerges from the proximal and distal thirds of the radial artery. Rarely are significant perforators found in the
middle third of the artery (Fig. 454.1).
FLAP DESIGN AND DIMENSIONS
The flap is designed with a centrally-located neourethra in continuity with a neoglans. This design avoids a
circumferential meatal suture line without sacrificing length and leads to an improved result.
The dimensions of the flap depend on the patient's needs and desires, as well as the size of the forearm and
amount of subcutaneous tissue present. The width of the flap should vary directly with the amount of
subcutaneous tissue present. While a width of 13 cm was initially described for penile reconstruction, we have
found this to be inadequate for tubing the flap and allowing closure without tension. Additionally, the flap length
of 10 cm initially described is generally unsatisfactory for successful intromission. In most cases, our flap
dimensions are a minimum of 15 × 17 cm. The size of the wrist may limit flap width distally, where it must be
tapered to 13-14 cm (Fig. 454.2). In situations in which the native urethra ends in the perineum, the length of the
neourethra may be safely increased to 25 cm, by designing a proximal extension just above the elbow.
OPERATIVE TECHNIQUE
The non-dominant arm is generally chosen as the donor site. A preoperative Allen test should be performed on
all patients for whom a radial forearm flap is being considered. Arteriograms are unnecessary. The patient is
placed supine on the operating table, with the non-dominant arm extended on an arm board. Transsexuals and
men with perineal urethrostomies are placed in the lithotomy position during the “recipient-site preparation”
portion of the case. Other patients may be positioned supine in a “frog-leg” position.
The design of the flap is outlined on the volar aspect of the forearm. The arm should not be shaved. This allows
markings for the planned neourethra to be made reliably on the portion of the volar forearm with the least amount
of hair. At this time, it is helpful to outline the course of the radial artery and the major veins. After the extremity is
moderately exsanguinated with an Esmarch bandage, a sterile tourniquet is inflated to 250 mmHg.
Two strips of skin, each 1 cm wide, on either side of the planned centrally-positioned neourethra, are
deepithelialized from the proximal edge of the flap to within 2.5 to 3 cm of the distal portion. Deepithelialization
should be continued around the proximal end of the planned neourethra (not shown in the diagram in Fig. 454.2).
The ulnar side of each of these strips is incised into the subcutaneous layer. The most distal portion of the flap,
which overlies the radial artery, is then incised. The radial artery and its venae comitantes are identified at the
wrist and isolated with vessel loops.
FIGURE 454.2 Flap design and dimensions. (From Cohen, ref. 9, with permission.)

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FIGURE 454.3 Sensory branch of the radial nerve at the wrist after it passes beneath the brachioradialis tendon.
(From Cohen, ref. 9, with permission.)
An incision is made along the radial border of the flap and carried down through the deep fascia. The dissection
then proceeds ulnarly beneath this layer and stops at the thin intermuscular septum, which contains the
septocutaneous perforating vessels. The surgeon must be careful to identify and preserve the superficial branch
of the radial nerve as it pierces through or beneath the brachioradialis tendon and courses close to the cephalic
vein at the wrist (Fig. 454.3).
The proximal incision is now made, care being taken to identify and preserve the cephalic vein. The medial and
lateral antebrachial cutaneous nerves are identified, dissected an additional 3 to 4 cm proximal to the skin
paddle, tagged with 7-0 Prolene, and divided.
Next, the ulnar border of the flap is incised and elevated radially beneath the deep fascia. The cutaneous
perforating vessels of the ulnar artery should be ligated and divided. This dissection is continued until the ulnar
side of the intramuscular septum containing the septocutaneous perforators of the radial artery is encountered.
At this time, the radial artery and its venae comitantes are elevated from their bed from distal to proximal, with
careful mobilization of the ulnar edge of the brachioradialis muscle radially. Muscular branches are ligated or
coagulated with a bipolar electrocautery. The arterial dissection is continued proximally until the bifurcation of the
brachial artery is reached.
The dissection of the proximal venae comitantes proceeds until the two veins coalesce into one. If this dissection
is continued more proximally (this often requires an incision in the antecubital fossa skin overlying the cephalic
vein), the venae comitantes (which have now coalesced) join the cephalic vein via the profundus cubitalis vein.
This extra dissection makes it possible for one large vein to drain not only the superficial cephalic system, but
also the venae comitantes (10) (Fig. 454.4). At this point, full-thickness transverse incisions are made connecting
the distal portion of the centrally-placed neourethral skin with the radial and ulnar edges of the flap (Fig. 454.5).
FIGURE 454.4 Venous anatomy of the flap. Note coalescence of venae comitantes (hemostat), which then join

the cephalic vein via the profundus cubitalis vein (arrow), crossing above the lateral antebrachial nerve. (From
Cohen, ref. 9, with permission.)
The tourniquet is released, the flap is perfused, and hemostasis is achieved. The flap is now attached only by
the radial vascular bundle. Small vascular clamps are applied to the distal radial vascular bundle, and the
perfusion of the hand is examined. Only after an adequate ulnar blood supply to the hand has been assured is
the distal radial vascular bundle clamped, ligated, and divided.
The portion of the flap forming the central neourethra is then tubed over a 12-French Silastic urinary catheter.
This is a four-layer closure. Initially, neourethral skin is secured to neourethral skin centrally. The free edge of
the ulnar deepithelialized strip is flipped over and secured over this suture line. The radial deepithelialized strip is
then advanced and secured, and the volar shaft skin is then closed (Fig. 454.6). The flap is now turned over and
the dorsal skin closure is performed.
FIGURE 454.5 Flap elevated, ready to be tubed.
FIGURE 454.6 Four-layer closure of neourethral tube. A: Neourethral skin edges. B: Ulnar deepithelialized edge
closed over layer A. C: Radial deepithelialized edge closed over layer B. D: Closure of volar shaft skin. E:
Closure of dorsal skin. (From Cohen, ref. 9, with permission.)
The “wings” of the neoglans are trimmed to the appropriate shape and rolled back on the shaft. The distal

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portion of the shaft that will be under the rolled-back neoglans is deepithelialized (Fig. 454.7A and B). The
neoglans is then secured in its rolled-back position with full-thickness nylon mattress sutures. The constructed
neophallus is left on the arm,
attached to its proximal vascular pedicle, until the recipient site has been prepared (Fig. 454.8).
FIGURE 454.7 Construction of neoglans. A: Arrowhead on unfolded extension of flap (“wings”) that will form the
neoglans. Distal shaft (between connected arrows) is deepithelialized. B: “Wings” that will form the neoglans
folded back over shaft. (From Cohen, ref. 9, with permission.)
During flap elevation, a separate team prepares the pubic site and the recipient vessels and nerves.
Approximately 20 cm of saphenous vein is harvested from the thigh and is left attached to the femoral vein at the
fossa ovalis. The divided end of this saphenous vein graft is then anastomosed to the femoral artery, using
microsurgical techniques and loupe magnification, to create a temporary loop arteriovenous fistula. This is
allowed to flow until the flap is ready for transfer.
If no penile remnant is present, an incision is made over the pubic symphysis. If a portion of the native phallus
exists, a degloving incision is designed. The dorsal penile (or clitoral in transsexuals) branches of the pudendal
nerve should be isolated. If no nerves are apparent, dissection is continued toward the perineum, and the
pudendal nerves are identified as they emerge from Alcock's canal and travel along the inferior ramus of the
pubis.
It is our practice to connect the incision used for the saphenous vein harvest to the flap recipient-bed incision,
thereby preventing compression, torquing, or kinking of the vein grafts.
The fully-constructed neophallus is detached from the arm, transferred to the pubic area, and secured in place
with tacking sutures. Before the proximal radial artery is ligated and divided, 5000 units of heparin are given
intravenously by the anesthesiologist.
FIGURE 454.8 Constructed neophallus attached to arm by vascular pedicle. (From Cohen, ref. 9, with
permission.)

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When a primary urethral anastomosis is possible, an end-to-end two-layered spatulated anastomosis with 4-0
absorbable sutures is performed, after the Foley catheter within the flap is passed through the native urethra into
the bladder. The sutures should not traverse the lumen, to reduce the possibility of fistula formation.
The saphenous vein loop is divided, and the cephalic vein is anastomosed end-to-end to the venous limb of the
saphenous loop with 8-0 nylon under the operating microscope. This is followed by end-to-end anastomosis of
the radial artery to the arterial limb of the saphenous loop with 8-0 nylon.
Epineural microneurorrhaphies between the paired pudendal nerves and the medial and lateral antebrachial
cutaneous nerves are performed with 9-0 nylon (Fig. 454.9).
The remaining wounds about the proximal shaft of the neophallus and femoral vessels are now closed (Fig.
454.10). A percutaneous suprapubic catheter is placed, to ensure adequate urine drainage away from the
healing neourethra. The postoperative dressing incorporates a large Styrofoam (coffee) cup to keep the
neophallus supported in the early postoperative period.
The ulnar artery is usually the dominant vessel supplying the palmar arch. The absence of postoperative
vascular compromise or cold intolerance has made vascular reconstruction of the radial artery unnecessary. The
forearm muscles in the bed of the flap donor site are approximated together and over any exposed tendons with
absorbable sutures, to minimize contour irregularities. A split-thickness skin graft, harvested from the hip or thigh,
is then applied to this muscular bed. A long arm splint is used to immobilize the elbow, wrist, and fingers.
Perioperative antibiotics and low-dose aspirin are used in all cases. Intravenous antibiotics are discontinued on
the second postoperative day, and suppressive oral antibiotic coverage is begun, which continues until the
urethral and suprapubic catheters are removed. Low-dose aspirin is continued indefinitely.
Flap viability is assessed by clinical examination, i.e., skin color, turgor, and capillary refill, as well as hourly
pulse checks by palpation or with a bedside Doppler probe.
Sequential pneumatic lower-extremity compression boots are used on the first few postoperative days when the
patient is confined to bed. Physical therapy for the donor upper extremity begins once the initial dressings are
removed on the 7th to 10th postoperative day. Xeroform is applied to the graft and an Ace wrap is applied to the
hand and forearm. A compressive garment
and wrist splint are then fashioned; the splint is worn an additional 2 weeks and the garment is worn for 3 to 6
months.

FIGURE 454.9 Schematic representation of urethral and neurovascular connections. (From Cohen, ref. 9, with
permission.)
FIGURE 454.10 Neophallus at completion of operation.
Urine is preferentially drained via the suprapubic catheter, allowing the urethral catheter to be capped. The
reduces tension on the neophallus and meatus. In the third to fourth postoperative week, a retrograde
urethrogram can be performed, by inserting a small catheter alongside the indwelling urethral catheter. The
urethral catheter may be removed, if there is no evidence of extravasation or fistula. The suprapubic tube may be
removed 1 to 2 days after normal micturition is established.
CLINICAL RESULTS
Sensation in the neophallus is tested by subjective light touch and biothesiometry. The neophallus is
insensate for the first month postoperatively, and therefore careful positioning of both neophallus and

P.1232
urinary catheter is necessary to avoid inadvertent pressure injury. Most patients have recovered gross
tactile sensation at 4 to 6 months. By 6 to 9 months, they are usually able to stimulate the shaft of the
neophallus to orgasm, and have biothesiometry threshold measurements three to four times that of their
index fingers. It is safe to consider insertion of a penile prosthesis only after protective sensation develops
(11). Sexually active patients describe erogenous sensation leading to orgasm.
The modified radial forearm flap design has eliminated the otherwise frequent complication of meatal
stenosis. Urethral
stone formation has not been a problem in our patients. Complications with the proximal urethral
anastomosis, including sinuses, fistulae, and strictures, are relatively uncommon. Most fistulae close
spontaneously. Proximal anastomotic suture-line strictures may be treated with internal urethrotomy. In our
experience, one or two neodymium-Yag laser or coldknife urethrotomies, followed by a short period of self-
catheterization, have resulted in a stabilized widely-patent urethra. All patients were ultimately able to void
standing.
Maintaining a good coronal ridge is difficult. The suturing technique described in Figure 454.5 has led to
variable long-term results. Adding a strip of tendon or dermis does not appear to help much. Recently, we
have been securing the rolled-back portion of the neoglans loosely with sutures, and skin grafting the
exposed subcutaneous tissue.
The greatest drawback of the radial forearm flap is the unsightly donor site. The thicker the graft used to
close it, the better the aesthetic result. Functional disability of the donor extremity has been rare, although
we have had one patient with a radial nerve palsy that resolved, and one patient with postoperative carpal
tunnel syndrome that required release. Considering the high quality of penile construction possible with the
radial forearm flap, the resultant donor-site scar is usually well-tolerated by patients.
SUMMARY
The radial forearm flap, as part of a cooperative effort among the reconstructive plastic surgeon, urologist,
and psychiatrist, allows reconstruction of a neophallus that is aesthetically and psychologically satisfying.
The procedure provides protective and erogenous sensation, a neophallus of appropriate size and shape to
allow a penile prosthesis permitting successful coitus, and lets the patient void in a standing position
through a distal meatus.
References
1. Chang TS, Hwang WY. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg
1984;74:251.
2. Meyer R, Daverio PJ, Dequesne J. One-stage phalloplasty in transsexuals. Ann Plast Surg 1986;16:472.
3. Koshima I, Tai T, Yamasaki M. One-stage reconstruction of the penis using an innervated radial forearm
osteocutaneous flap. J Reconstr Microsurg 1986;3:19.
4. Gilbert DA, Williams MW, Horton CE, et al. Phallic innervation via the pudendal nerve. J Urol 1988;41:160.

5. Siemer E. Penile construction by the radial arm flap. Clin Plast Surg 1988;15:425.
6. Semple JL, Boyd JB. The “cricket bat forearm flap” in one-stage reconstruction of the penis. Presented at
the Annual Meeting of the Canadian Society of Plastic Surgery, Pointe-du-lac, Quebec, 1988.
7. Gottlieb LJ, Levine LA. A new design for the radial forearm free flap phallic construction. Plast Reconstr
Surg 1993;92:276.
8. Trengove-Jones G, Colon LB, Horton C, et al. A new concept in penoscrotal reconstruction: the one-stage
free sensory combined radial forearm free flap. Presented at the Annual Meeting of the American Society of
Reconstructive Microsurgery, Scottsdale, Arizona, 1992.
9. Cohen M, ed. Mastery of plastic and reconstructive surgery. Boston: Little, Brown, 1994;1401-1407.
10. Gottlieb LJ, Tachmes L, Pkelet RW. Improved venous drainage of the radial artery forearm free flap: use
of the profundus cubitalis vein. J Reconstr Microsurg 1993;9:281.
11. Levine LA, Zachary LS, Gottlieb LL. Prosthesis placement after total phallic reconstruction. J Urol
1993;149:593.

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Chapter 455
“Cricket Bat” Flap: One-Stage Free Forearm Flap Phalloplasty
J. B. BOYD
Since the cricket bat flap (1) relies on transverse folding to separate skin cover from urethra, none of the tissue
lies far from the vascular pedicle. The flap is narrow enough to occupy the least hairy portion of the forearm, and
the urethra is formed by hairless anterior wrist skin.
INDICATIONS
Reliable, one-stage, sensate, peno-urethral reconstruction is ideal for creating a penis in female-to-male
transsexuals, and for use after iatrogenic or traumatic loss. Methods based on the original “Swiss roll”
technique (2)—where the forearm skin is divided in two by a longitudinal deepithelialized strip, and then
rolled in on itself—result in an extremely wide flap with questionable peripheral perfusion and inadequate
venous drainage. The fistula rate is high (3), undesirable hairy skin is recruited for the neourethra, and
repair of the donor site is a major undertaking.
The cricket bat modification has been used for penile reconstruction, whether in traumatic, surgical, or
congenital cases, and in cases of gender dysphoria. Further modifications in its design permit its use in
partial peno-urethral defects and in the treatment of complicated hypospadias.
FIGURE 455.1 Section of a radial forearm flap showing disposition of the radial artery, with respect to the
vascular septum, the brachioradialis, and the flexor carpi radialis. (From Soutar et al., ref. 4, with
permission.)
ANATOMY
The skin of the anterior forearm receives a significant blood supply from the radial artery via perforating
septocutaneous vessels passing to the skin along the vascular septum between the brachioradialis and the
flexor carpi radialis muscles (Fig. 455.1). These perforators are plentiful in the distal third of the forearm, but
proximally, where tendons give way to muscle bellies, they become sparser. Nevertheless, it is safe to raise a
septum-based skin flap anywhere along the course of the radial artery.
After emerging from the septum, the vessels branch laterally and medially, piercing the deep fascia and quickly
passing to the subdermal plexus. These vessels do not travel far on the surface of the deep fascia; therefore,

very little of it needs to be harvested with the flap.
Practically all of the anterior forearm skin can be taken safely. Limits extend from the antecubital fossa to the
transverse wrist crease, and from the ulnar border of the forearm to the posterolateral aspect of the radial border.
Beyond these medial and lateral boundaries, the viability of the skin is questionable. Raising a flap of such
dimensions would require the entire vascular septum to be preserved.
The radial artery originates a few centimeters distal to the antecubital fossa, and then passes distally along the
radial side of the pronator teres, lying between the biceps tendon and the bicipital aponeurosis. It crosses
anterior to the pronator teres, just proximal to that muscle's insertion into its tubercle on the lateral surface of the
radius. In the distal third of the forearm, it first overlies the flexor pollicis longus, and finally the pronator
quadratus. Septocutaneous branches from the radial artery pass along the vascular septum between the
brachioradialis and flexor carpi radialis muscles, to supply the skin (Fig. 455.1).
The radial artery is accompanied by venae comitantes. These vessels are constant, but of variable diameter.
Often, they are inconveniently small for microvascular anastomosis. In the region of the bifurcation of the brachial
artery, there is a confluence of veins. Here, the venae comitantes of both ulnar and radial arteries communicate
with each other, as well as with one or more of the large subcutaneous veins of the forearm. This confluence
may be incorporated advantageously with the donor vein of the cricket bat flap.
Classically, there are three major subcutaneous veins in the anterior forearm: the cephalic, the median, and the
basilic. The cephalic vein lies on the dorsoradial, and the basilic on the dorsoulnar, aspect of the wrist. At the
mid-forearm level, they pass around their respective borders, and then proceed proximally on the radial and ulnar
sides of the anterior forearm. The median vein lies in the midline of the anterior forearm. Just distal to the
antecubital fossa, it bifurcates into two: the median cephalic and the median basilic. The former angles radially to
join the cephalic, and the latter ulnarly to join the basilic. The cephalic and basilic veins then pass up the arm on
either side of the biceps muscle. There are variations in this basic pattern. Perforating veins connect the
superficial veins to the deep system at various points.
Both venous systems are capable of draining the flap alone. Superficial veins are often preferred because of
their greater diameter and their independence from the arterial pedicle. However, care should be taken to ensure
that the superficial veins have not previously been canalized and undergone partial or complete thrombosis.
Whichever vein is selected for draining the cricket bat flap, the surgeon should ensure that the vein occupies the
full length of the flap, particularly the distal “handle” portion. Both systems may be combined by preserving the
confluence of veins in the proximal forearm.
The median antebrachial cutaneous nerve (C8, T1) enters the forearm in the company of the basilic vein. It soon
gives off a number of large anterior branches, which pass down the radial side of the basilic vein and supply the
ulnar half of the anterior forearm as far as the wrist. An ulnar branch supplies the ulnar border of the forearm.
The lateral antebrachial cutaneous nerve (C5,6) is the forearm continuation of the musculocutaneous nerve. It
enters the forearm on the ulnar side of the cephalic vein and, via multiple branches, supplies the radial half of the
forearm as far as the wrist, as well as the dorsoradial aspect of the forearm.
FLAP DESIGN AND DIMENSIONS
The cricket bat flap consists of a longitudinally-oriented skin paddle in which both the urethral segment and the
outer covering portion of the flap lie directly over the radial artery (Fig. 455.2). The narrow, 3-cm-wide “handle”
lies in the anterior wrist. The remaining 9-cm-wide “blade” of the flap will constitute the outer covering of the
reconstructed penis and is situated proximally. Each segment of the cricket bat measures approximately 12 cm in
length.
A useful modification of this flap is to flare out its distal end to 4 cm. As we shall see, this lessens the risk of

P.1234
stenosis at the urethral anastomotic site.
OPERATIVE TECHNIQUE
The flap is designed slightly off-center. This has two advantages: the risk of vessel kinking is minimized when
the flap is folded in on itself; and, during final closure, the two seams are made to lie remote from each other,
thus lessening the risk of fistula formation.
The cricket bat flap is elevated like any other radial forearm flap (5), but the median and lateral cutaneous nerves
of the forearm are included for sensory reinnervation. The proximally- based pedicle provides a 3- to 4-cm length
of radial artery and accompanying veins for anastomosis with recipient vessels.
FIGURE 455.2 The cricket bat flap is a longitudinal design in which the radial artery and the venae comitantes
run the entire length of the flap. The distal portion of the “handle” may be flared out to 4 cm, reducing the risk of
stenosis at the suture line. (From Semple et al., ref. 1, with permission.)
Once the flap is raised, the distal urethral segment is tubed on a #16 Foley catheter (Fig. 455.3). It is then
anastomosed to the urethral remnant, using a single-layer everting closure of 4-0 Vicryl sutures. The flap is
folded back 180 degrees at the junction of the “blade” and “handle” (Fig. 455.4). The wider “blade” portion of the
flap is tubed around the urethral reconstruction and is then sutured to itself on the ventral surface (Fig. 455.5).
Because the flap is folded in half, the length of the penis is limited to half the length of the forearm in total
reconstruction.
FIGURE 455.3 Once the flap is raised, the distal segment is tubed over a Foley catheter. (From Semple et al.,
ref. 1, with permission.)

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FIGURE 455.4 The flap is then folded back 180 degrees at the junction of the “blade” and the “handle.” (From
Semple et al., ref. 1, with permission.)
The most useful recipient vessels are the greater saphenous vein and the deep inferior epigastric artery (DIEA).
To obtain a workable pedicle, the saphenous vein is divided half-way down the thigh and turned up into the groin
region, where it is anastomosed to the DIEA as an arteriovenous fistula (Corlett loop). The loop is then divided at
a convenient point for the donor vessels. The pudendal nerves are located dorsally and are anastomosed to the
lateral and medial antebrachial cutaneous nerves.
For the return of sexual function, it is necessary to insert inflatable prostheses. In total reconstructions, the
implants should be placed within Dacron sheaths, which are anchored to the pubis for stability. This surgery is
best carried out after the return of sensation. To enhance the cosmetic appearance, a glans penoplasty may also
be performed.
CLINICAL RESULTS
A typical case of total penile reconstruction is illustrated in Figure 455.5. The flap is easily modified for
management of partial defects or the treatment of complex hypospadias (Fig. 455.6). Of seven cases
carried out, all flaps have survived although one patient returned to the O.R. for revision of a venous
anastomosis. There were no partial sloughs of skin or areas of fat necrosis. All patients ultimately passed
urine in a continuous stream without fistulous leaks, although temporary fistulae were present in three
patients. In each case, the fistula arose at the site of urethral anastomosis and closed with conservative
management. One patient developed a urethral stricture at the same location, which responded to simple
dilatation. Sensory recovery was surprisingly good, and one individual subsequently fathered a child.
Donor-site scars were well-tolerated; tissue expansion was offered to all, and performed on none.
SUMMARY
The cricket bat flap has six main advantages over the “Swiss roll” technique. 1) The flap is well-
vascularized throughout, with adequate venous drainage. 2) The distal, thin, and hairless portion of the flap
is used for urethral reconstruction. 3) Distally, the donor defect is narrow, minimizing tendon exposure. 4)
Separation of the suture seams protects against fistula formation. 5) There is no suture line at the urethral
opening. 6) The technique may be customized for partial reconstructions.

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FIGURE 455.5 A 25-year-old man with surgical amputation of the penis was left with a 2-cm stump of
corpora and an inadequate urethra. A: Preoperative view. B: A one-stage free forearm phalloplasty using a
cricket bat flap design was planned on the left, non-dominant arm. C: The flap elevated, to show the off-
center relationship of the “handle” and “blade.” D: Recipient artery and vein were the deep inferior
epigastric vessels (DIEVs) on the right side. Normally, the DIEV is too small at the level at which it needs to
be divided. For this reason, we recommend that the greater saphenous vein be pedicled up (refer to text).
The pudendal nerves were isolated in the stump and anastomosed to the medial and lateral cutaneous
nerves of the forearm. E: Postoperative appearance of the penile reconstruction at 6 months. F:
Postoperative appearance of the meatus. (Continued)

FIGURE 455.5 (Continued) G: Urethrogram showing excellent patency and caliber at the anastomosis. H:
The patient could void with an excellent stream. I: Donor site on left arm. (From Semple et al., ref. 1, with
permission.)
References
1. Semple JL, Boyd JB, Farrow GA, et al. The “cricket bat” flap: a one-stage free forearm flap phalloplasty.
Plast Reconstr Surg 1991;88:514.
2. Chang TS, Hwang WY. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg
1984;74:251.
3. Matti BA, Matthews RN, Davies DM. Phalloplasty using the free radial forearm flap. Br J Plast Surg
1988;41:160.
4. Soutar D. The radial forearm flap: a versatile method for intraoral reconstruction. Br J Plast Surg
1985;36:1.
5. Song R, Gao Y, Yu Y, Song Y. The forearm flap. Clin Plast Surg 1982;9:21.

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Chapter 456
Scrotal Flap
V. C. LANIER JR.
Owing to the abundant vascularity, ease of dissection beneath the dartos, and tremendous elasticity, scrotal
flaps can cover a vast area without compromising the circulation or the primary use of the scrotal tissue (see Fig.
456.1).
INDICATIONS
Flaps using scrotal tissue have been employed in the treatment of traumatic injuries (1), hypospadias (2, 3),
fistulas of
the perineum (4), urethroplasties (5), carcinoma of the penis (6), labia reconstruction in transsexual males
(7), and pressure sores (8, 9, 10).
FIGURE 456.1 Arterial circulation to the scrotum.
Avulsive injuries with loss of 50 percent of the scrotum can be managed by elevating the remaining scrotal
skin as a large flap and obtaining coverage of both testes (1).
Many variations of the scrotal flap for urethral reconstruction have been reported (2, 3). They have been
successfully used in reconstruction of the perineal urethra for entities other than hypospadias (4, 5, 6).
Conversion of male transsexuals uses the inverted skin of the penis to create a vagina, and the redundant
scrotal flaps are used in the construction of the labia. This is described as a two-stage procedure, with the
vagina constructed initially, followed by the labia approximately 3 weeks later (7).
Scrotal flaps have been applied to the management of pressure sores of the ischium (8, 9) and those of the
pubic ramus that are associated with necrosis of the penis (10) (see Fig. 456.2).
ANATOMY
Scrotal skin is very thin, deeply pigmented, contains hair follicles and sebaceous glands, and is abundantly
supplied with elastic tissue and smooth muscle. The median raphe divides the skin into lateral halves from the
ventral aspect of the penis to the anus (11).

FIGURE 456.2 Rotation arc of scrotal flaps.
The dartos lies directly beneath the skin and consists of elastic fibers, connective tissue, and smooth muscle.
The dartos is attached to and inseparable from the skin, is free of fat, and contains a generous blood supply.
Avulsion of scrotal skin is always associated with a loss of the underlying and intimately attached dartos; testes
and spermatic cord are, however, protected by a plane of loose areolar tissue directly beneath the dartos (12,
13).
The highly vascularized skin and dartos of the scrotum are supplied by the internal pudendal artery, the
superficial external pudendal artery, and the deep external pudendal artery (Fig. 456.1).
The internal pudendal artery in the male arises from the anterior trunk of the internal iliac and passes through the
lesser sciatic foramen about 4 cm above the lower margin of the ischial tuberosity. The artery courses along the
inferior ramus of the pubis and terminates as the perineal artery, with its many terminal divisions constituting the
posterior scrotal branches. The superficial external pudendal artery arises from the femoral artery and courses
medially across the spermatic cord to terminate in the lower abdomen, penis, and scrotum. The deep external
pudendal artery arises from the femoral artery and courses deep and medially to the medial aspect of the thigh to
terminate in the scrotum by anastomosing with the posterior scrotal branches of the perineal artery, described
above.
Venous outflow is through the venae comitantes of the internal pudendal artery and superficial and deep external
pudendal arteries into the internal iliac and femoral veins, respectively. The circulation provided by these vessels
and the anastomoses within the scrotal skin and dartos permit the scrotum to be useful for a variety of pedicle
flaps as well as microsurgical repair. A completely amputated penis and scrotum have been successfully
replanted using the profunda artery and a dorsal vein of the penis (14).
Lymphatic drainage is into the inguinal and femoral nodes. Scrotal lymphatics do not accompany the pudendal
vessels and have no connection with the testes and their tunics (15). Scrotal lymphedema occurs with blockage
of the inguinal and femoral nodes.
The scrotum is innervated by the ilioinguinal and external spermatic nerves, which course through the inguinal
canal. Entering from the perineum are the pudendal branch of the posterior femoral cutaneous nerve and
superficial perineal branches of the internal pudendal nerves.
FLAP DESIGN AND DIMENSIONS
The bilateral circulation permits a circular rotation of the flap to the pubic area anteriorly and the perineal and
ischial areas posteriorly, as well as local rotations to the penis (Figs. 456.2 and 456.3).
SUMMARY