Operative Technique in Plastic Surgery – Kevin C.Chung

view of male anatomy.
■ Inherently, these patients are high risk for wound complications. Most have
been on chronic immunosuppressive therapy with corticosteroids and other
immune modulators. Further, the tissue has been inflamed for years, with
notable friability.
■ The introduction of healthy vascular tissue improves wound healing and
decreased incidence of major complications.7
■ Other etiologies for perineal defects include trauma and necrotizing infections,
which require full debridement of nonviable tissue prior to reconstruction.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Perineal reconstruction can be performed for a multitude of indications, and a
thorough history should include pertinent information to each of these
conditions.
■ Prior to deciding on a reconstructive plan, the following information should be
obtained.
■ Extent of planned defect focusing critically on:
• Amount of external skin resection
• Maintenance or resection of the levator complex
• Vaginal involvement in anorectal tumors
• Presence of fistulas, which may require extended resection margins
■ History of radiation or planned adjuvant radiation therapy
■ Past abdominal/pelvic surgery including approaches that may have sacrificed
the DIEA such as a Maylard approach to gynecologic surgeries.
■ Patient goals: For resections involving the vagina, is restoration of sexual
function possible and/or desired?

FIG 2 • Vascular anatomy of the deep inferior epigastric
vessels.
■ Relevant surgical risk factors for delayed wound healing including:
• Tobacco usage
• Current or previous steroid use
• Other immune modulator medications received or planned
■ Physical examination should include a thorough examination of the perineum
and abdominal donor site.
■ Perineal examination should include evaluation of external structures, extent
of radiation damage, and an understanding of the planned resection (including
margins). Full examination of the genitalia and anus/rectum gives a better
understanding of the planned resection, although ongoing radiation treatment
may affect this estimate.

■ Donor-site examination should evaluate for previous surgical scars, tissue
laxity, and skin quality of the anterior abdominal wall. The skin should be
adequately lax for primary closure. A “pinch test” of the skin can offer a
rough estimate of the maximum skin paddle width that will still be closed
primarily. Previous or planned stomas should also be noted, along with the
presence of any ventral hernias.
FIG 3 • Intraoperative defect involving the skin of the
perineum, pelvic outlet soft tissue, and posterior wall of
the vagina.
IMAGING
■ Preoperative imaging for cancer staging can offer details on degree of
locoregional tumor involvement and necessary margins for resection. Imaging
of the abdominal donor site is typically not necessary unless there is concern of
DIEA patency.
SURGICAL MANAGEMENT
Preoperative Planning
■ Preoperative planning hinges on clear communication with the surgeon
performing the resection. A discussion of planned margins, structures to be
removed, the location of stoma(s), and adjuvant cancer therapies should be held
prior to planning reconstruction.
■ Location of any previous and planned stomas can help guide which rectus is
most amenable for flap harvest.

■ Discussion on port site locations for laparoscopic surgery is also important.
Certain paramedian port sites may injure the DIEA vessel or rectus muscle.
■ Delayed reconstruction may be indicated if margins are likely to be positive.
Positioning
■ The patient will likely be positioned in lithotomy for the resection. The entire
abdomen from below the nipples, including the perineum, and bilateral legs
should be prepped to below the knee, exposing the medial and lateral thigh.
The exposure should allow for alternative flap harvests as the ability to predict
the defect is not always accurate preoperatively.
■ Appropriate padding of all pressure points is mandatory. Common peroneal
and femoral nerve branches can develop neuropraxias with prolonged
lithotomy positioning.
■ Bilateral lower extremity sequential compression devices (SCD) should be
placed for deep venous thrombosis prophylaxis.
■ A safety belt should be used for all cases.
■ A warming blanket should be placed on the upper body to optimize
normothermic core temperatures during the case.
Approach
■ Preoperative markings for a vertical rectus flap may not be necessary, but any
midline or laparoscopic incisions should be discussed with the oncologic
surgeon.
■ If a midline incision is used, it should be placed on the flap side of the
umbilicus.
■ If laparoscopic incisions are used, discuss proximity of paramedian incision
to the rectus and the deep inferior epigastric vessels. Move these incisions
lateral to the rectus sheath if possible.
■ If a lower midline incision is used, the fascia (anterior sheath) is incised at the
level of the medial row perforators cephalad to the existing incision to preserve
as much fascia as possible.
■ The final skin paddle is often designed after the full nature of the defect is
known. A pinch test can be used to confirm that the skin can be closed
primarily, although typically 6 to 7 cm is the most needed and this can be
harvested easily from most abdomens.

T E C H N I Q U E S
■ Incision
■ The patient does not need specific markings preoperatively; however,
incisions should be discussed with the oncologic surgeon.
■ When a lower midline incision is used by the resecting surgeon, the cephalad
extension of the incision through the fascia can be paramedian, at the level of
the medial row perforators. This will allow adequate perfusion to the skin
paddle but also preserve the fascia. This requires incision of the anterior
sheath only as the muscle can be elevated off the posterior sheath.8
■ Design the skin paddle according to abdominal skin laxity and the size of
the perineal defect (TECH FIG 1). This is typically designed such that the
medial border of the flap is still in the midline.
■ An oblique skin paddle can be used, known as an oblique rectus abdominis
myocutaneous flap, or ORAM, which is a semiarticulating skin and soft
tissue paddle overlying the muscle. The incision then extends laterally
below the costal margin. Here, the periumbilical perforators perfuse the
oblique skin paddle and should be maintained as they pass through the
rectus.
TECH FIG 1 • On-table markings for a VRAM flap.
Note that the flap is situated on the contralateral side
from the planned stoma. Further, the incision is on the
flap side when curving around the umbilicus.

■ Elevation of Rectus and Skin Paddle
■ Elevate the rectus from the posterior sheath. Keep in mind that the pedicle
runs on the posterior surface of the muscle and should not be injured in this
dissection. There will be lateral branches and the motor nerves that also must
be divided.
■ Transect the cephalad muscle and suture ligate the superior epigastric
vessels.
■ Once the entirety of the rectus and the overlying skin paddle is elevated,
gently free the deep inferior epigastric pedicle as it exits the lateral border of
the muscle. It will travel into the pelvis. Here, carefully ligate all small
branches to avoid undue bleeding, which can be difficult to control in this
region.
■ Incise the posterior rectus sheath for gentle curvature of the pedicle without
undue kinking when the flap is passed into the perineal defect.
■ De-epithelization and Transposition of Skin Paddle
■ In order to transpose the flap into the pelvis, the posterior sheath must be
incised transverse inferiorly so that the pedicle is not kinked with transfer to
the pelvis. This division of the posterior sheath is made well below the
arcuate line, so there is little effect on closure strength.
■ TECH FIG 1B shows the elevated rectus with the skin paddle prior to
inset (TECH FIG 2). The skin paddle can be de-epithelized inferiorly. For
defect requiring both posterior vagina and perineum skin reconstruction, an
hourglass skin paddle is designed by de-epithelization. This is best done
prior to inset.
■ The flap is then transposed into the pelvis with a gentle twist to allow the
skin paddle to be used for external reconstruction.

TECH FIG 2 • The skin paddle can be de-
epithelialized in an hourglass pattern to allow for
combined posterior vagina (V) and perineum skin
reconstruction (P). The remainder of the de-
epithelized flap provides bulk to fill the pelvic outlet.
■ Closure
■ Abdominal donor-site closure requires approximation of the fascia and skin.
■ For fascial closure, primary tension-free approximation is best. If needed,
an anterior component separation can be performed on the contralateral
side with or without a mesh to decrease postoperative abdominal bulge or
hernia.9
■ The soft tissue should be closed in layers (Scarpa fascia, dermis, and skin).
■ Inset of the flap should allow for tension-free closure as seen in TECH FIG
1C (TECH FIG 3).
■ The muscle should be used to fill the intra-abdominal pelvic defect.

TECH FIG 3 • Inset of VRAM for perineal
reconstruction. Part of the skin paddle was used to
reconstruct the posterior wall of the vagina. The
remainder of the skin paddle was used for the perineal
incision.
PEARLS AND PITFALLS
Markings
■ Incisions should be discussed with the oncology surgeon. The
incision should be placed on the side of the flap adjacent to the
umbilicus
Spare fascia
■ The medial extent of the incision can be paramedian; to spare
fascia, the anterior sheath can be incised at the level of the
medial row perforators
Reduce hernia
and abdominal
bulge
■ Component separation can be used in patients where primary
closure without tension is not possible
■ Fascia-sparing technique
Vaginal defects
■ The skin paddle can be tubed to reconstruct vaginal defects,
whereas the muscle is used to fill in the intra-abdominal defect
Plan B
■ Alternative flaps should be available and prepped into the field.
The thigh is a good alternative donor site (gracilis or ALT)
Tunnel for
pedicled VRAM
■ Release the posterior sheath to allow passage of the flap without
kinking

POSTOPERATIVE CARE
■ Postoperative restrictions: For perineal reconstruction, it is important that the
patient does not place direct pressure on the flap by sitting or lying directly
supine. Orders should be written for turns every 2 hours, and the patient can lie
on one side or the other, but not directly supine if this would put pressure on
the flap. Foam wedges and bumps can be used to offload pressure as well.
■ Care should also be taken to avoid hip abduction or complete hip flexion as
this can put strain on or kink the pedicle.
■ We allow patient ambulation on postoperative day 1 or 2 with the aid of
physical therapy. However, sitting is not allowed for 3 weeks postoperatively
and gradually advanced with proper cushioning.
■ Drain management: Hematomas and seromas can place undue pressure on the
flap and pedicle, therefore compromising flow. Pay careful attention to drain
output, and any hematomas should be drained operatively.
■ Flap monitoring: Nursing staff should monitor the flap overnight, with checks
for capillary refill, color, and warmth every 2 to 4 hours. A Doppler stitch can
be used if needed. Evidence of congestion or ischemia should be noted
immediately. Sometimes, release of sutures can help if undue tension is the
source of the problem. Concerns for vascular compromise should prompt
operative exploration to evaluate kinking or pressure on the pedicle.
■ Review the pathology results to confirm margins are negative from the
original resection for all oncologic procedures.
COMPLICATIONS
■ Flap loss: Complete flap loss is due to compromise of the vascular pedicle.
Ideally, this would be discovered soon postoperatively with subsequent
operative salvage. However, in the case of irreversible flap loss, the tissue
should be removed and other reconstructive options should be explored.
■ Wounds: Delayed wound healing in the perineum is relatively common but
can most often be managed nonoperatively. This would include debridement as
needed, local wound care, and close monitoring.
■ Infection: Most infections can be managed with antibiotics. Interventional
drain placement is helpful for formed abscesses seen on imaging.
■ Hematoma: Hematomas are possible at both the donor and recipient site. Drain
output and physical examination are key. Hematomas should be drained
surgically.

■ Seroma: Late seromas can develop at the donor site. Most can be managed
with drains.
REFERENCES
1. Espinosa-de-los-monteros A, Arista-de la torre L, Vergara-fernandez O,
Salgado-nesme N. Contralateral component separation technique for
abdominal wall closure in patients undergoing vertical rectus abdominis
myocutaneous flap transposition for pelvic exenteration reconstruction. Ann
Plast Surg. 2016;77(1):90-92.
2. Butler CE, Gündeslioglu AO, Rodriguez-bigas MA. Outcomes of immediate
vertical rectus abdominis myocutaneous flap reconstruction for irradiated
abdominoperineal resection defects. J Am Coll Surg. 2008;206(4):694-703.
3. Devulapalli C, Jia wei AT, Dibiagio JR, et al. Primary versus flap closure of
perineal defects following oncologic resection: a systematic review and meta-
analysis. Plast Reconstr Surg. 2016;137(5):1602-1613.
4. Sunesen KG, Buntzen S, Tei T, et al. Perineal healing and survival after anal
cancer salvage surgery: 10-year experience with primary perineal
reconstruction using the vertical rectus abdominis myocutaneous (VRAM)
flap. Ann Surg Oncol. 2009;16(1):68-77.
5. Zhang W, Zeng A, Yang J, et al. Outcome of vulvar reconstruction by
anterolateral thigh flap in patients with advanced and recurrent vulvar
malignancy. J Surg Oncol. 2015;111(8):985-991.
6. Zeng A, Qiao Q, Zhao R, Song K, Long X. Anterolateral thigh flap-based
reconstruction for oncologic vulvar defects. Plast Reconstr Surg.
2011;127(5):1939-1945.
7. Hurst RD, Gottlieb LJ, Crucitti P, et al. Primary closure of complicated
perineal wounds with myocutaneous and fasciocutaneous flaps after
proctectomy for Crohn’s disease. Surgery. 2001;130(4):767-772.
8. Campbell CA, Butler CE. Use of adjuvant techniques improves surgical
outcomes of complex vertical rectus abdominis myocutaneous flap
reconstructions of pelvic cancer defects. Plast Reconstr Surg. 2011;128(2):447-
458.
9. Baumann DP, Butler CE. Component separation improves outcomes in
VRAM flap donor sites with excessive fascial tension. Plast Reconstr Surg.
2010;126(5):1573-1580.

27
CHAPTER
Gracilis Flap for Perineal
and Vaginal Reconstruction
Ajani G. Nugent, Yasmina Zoghbi, and Christopher J.
Salgado
DEFINITION
■ Perineal defects reconstructed with gracilis flaps are applied after vulvovaginal
resections or more extensive pelvic exenterations with considerable soft tissue
loss, dead space, and distortion of the introitus.1
■ Vaginal defects indicated for gracilis flap reconstruction are applied for partial
or total circumferential full-thickness portions of the vaginal canal including
mucosa and muscle layers.1,2
■ The gracilis flap is a highly vascularized muscle or myocutaneous flap that
provides regional tissue that has its own independent blood supply, fills in
pelvic dead space, and separates abdominal contents from the perineal wound.
The gracilis flap is often not in the potential radiation field.1,3
ANATOMY
■ The gracilis muscle—one of the adductors of the leg—is found in the more
superficial plane of the medial thigh muscles.
■ Derived from the Latin word gracile, which means slender, the muscle is thin
and straplike, measuring roughly 25 cm in length and tapering from superior to
inferior from about 6 to 4 cm.4
■ It takes origin from the ischiopubic ramus and inserts distally via the pes
anserinus into the medial tibia inferior to the condyle. The muscle inserts
posteromedially to the adductor longus and, along with its tendinous insertion,
can be palpated with ease in thinner patients.
■ The gracilis axis can be defined by drawing a line from the ischium to the
medial condyle of the knee. Alternately, by palpating the adductor longus with
the thigh abducted, the gracilis axis can be outlined 2 to 3 fingerbreadths

posterior to the adductor longus.
■ The gracilis flap is a type II muscle flap according to the classification of
Mathes and Nahai. It has a dominant vascular pedicle from the medial femoral
circumflex artery, a branch of the deep femoral system. Two secondary
pedicles to the gracilis muscle can be found segmentally proximal and distal to
the pedicle.5
■ The neurovascular pedicle of the gracilis free flap is made up of a single
arterial branch arising from the medial femoral circumflex artery, two vena
comitantes, and the anterior branch of the obturator nerve.6
■ On average, the vessel measures 1.6 mm in diameter and passes deep to the
adductor longus and superficial to the adductor magnus to enter the proximal
third of the gracilis.5
■ The entry point of the vascular pedicle is typically found 8 to 10 cm inferior to
the pubic tubercle.6 The proximal attachment of the muscle is often not
palpable, and the distal insertion is often used to aid in its identification.
■ The anterior branch of the obturator nerve can measure up to 12 cm in length
and is found approximately 6 cm from the pubic tubercle.5
■ The muscle can be divided into two functioning units, owing to its motor
nerve dividing into branches innervating the superior and inferior muscle
separately.7
■ Careful attention should be paid to the saphenous vein so that it is not injured
during the dissection.
PATHOGENESIS
■ Perineal defects
■ Perineal defects necessitating gracilis flap reconstruction are most often the
result of extirpative oncologic surgeries but can be the result of infectious
processes as well as trauma.1
■ Perineal malignancies most often occur in the colorectum or cervix and less
commonly in the vagina, urinary tract, or anus.1
■ Total pelvic exenteration for recurrent or locally advanced carcinomas
provides a potential oncologic cure that leaves a large pelvic defect.8
■ Vaginal defects
■ Total circumferential acquired vaginal defects usually arise from perineal
malignancies that require pelvic exenterations.1
NATURAL HISTORY

■ Perineal defects
■ Management of perineal malignancies through resection or pelvic
exenteration results in pelvic dead space.
■ Patients following pelvic exenteration often benefit from muscle or
myocutaneous flap reconstruction to obliterate dead space and provide
antibiotic delivery to these often large defects with high metabolic demands.1
■ With loss of perineal support, abdominal viscera may fall into the pelvic
basin, leading to adhesions, obstructions, fistulas, or perineal hernias.3
Gracilis flap reconstruction aids to decrease the risk of these sequelae.
■ Attempts of closing large perineal wounds, especially those previously
irradiated, by primary or secondary intention, are at high risk of dehiscence
and breakdown.
■ Perineal wounds that remain unhealed for over 6 months after surgery are
predisposed to developing chronically draining perineal sinuses3 and should
be reconstructed with preferably locoregional flaps such as the gracilis flap,
if available.
■ Vaginal defects
■ Total vaginal resection without flap repair leads to prolonged healing,
increased risk for complications, abnormal vaginal anatomy, and inadequate
function.9
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Wound size
■ Evaluation of the defect size and shape is critical in determining if the wound
should be managed through primary or secondary intention, debridement and
packing, skin grafting, or flap utilization.3
■ Radiation
■ Areas that have been previously radiated must be noted as they compromise
the surgical site and occasionally may compromise the vascularity of potential
flaps.
■ Scars
■ Thorough preoperative examination includes evaluation for lower extremity
scars, as prior surgery or trauma can influence flap selection.
■ Femoral artery
■ With intentions of using the gracilis myocutaneous flap for perineal or
vaginal repair, vascular status must be evaluated.

■ Physical exam should include palpation of the femoral, popliteal, posterior
tibial, dorsalis pedis, and anterior tibial arteries.
■ Additional evaluations are capillary refill, skin color and turgor, and Doppler
examination if pulses are not detected. Computed tomography angiography
(CTA), magnetic resonance angiography, or even angiogram is necessary to
ensure patency of arterial inflow. A venous phase with the CTA may be
obtained to evaluate the venous outflow as well.
■ Expectations
■ Typically, younger, sexually active women desire an anatomically similar,
functioning reconstruction of the vagina to both be aesthetically pleasing and
permit sexual activity after surgery.1
■ Conversely, much older patients who may be unlikely to resume intercourse
after reconstruction may benefit from a more conservative approach with less
risk of complications. Flap obliteration of the perineum without
reconstruction of the vagina may yield a quicker and less complicated
recovery for the patient.1 Patients, however, often will request reconstruction
of their vaginal canal.
IMAGING
■ Imaging in the setting of perineal or vaginal reconstruction using the gracilis
flap is generally not indicated in primary cases.
■ Angiography, CTA, or MRA may be warranted in patients with a history of
vascular disease, bypass graft involving the profunda femoris, multiple
surgeries, or radiation.
■ Postoperatively, a useful landmark to identify the gracilis flap on CT is the
subcutaneous tunnel in the medial thigh that is used to transmit the flap.10
■ If the muscular portion of the gracilis flap is denervated during harvest, it will
show changes of atrophy, specifically smaller size and internal fat attenuation
on CT.10 Due to the increased fat content, this change will also be evident on
MRI with increased signal on T1-weighed images.
■ Changes associated with denervation will also be apparent on T2-weighted
MRI due to increased cellular permeability leading to edema within the
muscle. This should not be mistaken for inflammation or tumor infiltration
within the flap, which would also increase the T2 signal intensity but would
generally concurrently enlarge the flap.10
SURGICAL MANAGEMENT

Preoperative Planning
■ As with any reconstructive procedure, a thorough understanding of pertinent
local and regional anatomy is crucial, as well as remote anatomy in the event
that free tissue options are to be considered.
■ The anticipated reconstructive options are primarily guided by the nature of
the defect. As such, detailed discussion with the resecting surgeon as it relates
to margins and secondary deficits is crucial, in conjunction with review of
preoperative imaging if available.
■ After the anticipated defect is determined, preoperative optimization should be
pursued. These measures include, but are not limited to, control of local
infection if applicable with antibiotic therapy, nutritional optimization, and
smoking cessation.
Positioning
■ For vaginal/perineal reconstruction, the patient is usually in ideal positioning
for gracilis harvest, which is usually lithotomy.
■ It is important to note the rare, but reported, association of common peroneal
nerve injury with prolonged immobilization in lithotomy. As such, appropriate
padding of the fibular head should be carried out.
■ Other positions ideal for gracilis harvest are supine, with thigh abduction
(frog-leg); however, we have often found this position not useful for harvest.
■ Rarely, for very posterior defects such as ischial pressure sores, the gracilis
may be harvested from prone position.
Approach
■ As mentioned above, gracilis harvest can be approached from both an anterior
position (lithotomy or frog-leg) and less frequently posterior (prone) position
(FIG 1).

FIG 1 • Gracilis muscle anatomy.
T E C H N I Q U E S
■ Myocutaneous Gracilis Flap
■ The skin paddle for the gracilis can be oriented either parallel or
perpendicular (transverse) to the gracilis muscle, depending on the
reconstructive needs of the flap. Both techniques rely on perforators coming
from the proximal aspect of the muscle (TECH FIG 1A).
■ Once the muscle is delineated, just medial to the palpable adductor longus
muscle, an appropriately sized skin paddle is designed. Usually, a skin paddle
width of 4 to 6 cm can be closed primarily without difficulty.
■ Pencil Doppler is then used to identify the perforators, which will either be
musculocutaneous (through the gracilis itself) or septocutaneous (in the
septum between the gracilis and adductor longus muscle).
■ An anterior incision is made through the skin, subcutaneous tissue, and into
the fascia of the adductor longus muscle. Care is taken to bevel the cut away

from the skin paddle and also to be cognizant of the saphenous vein.
■ This fascia is then elevated from an anterior to posterior direction, until the
intermuscular septum is encountered. Septocutaneous perforators will usually
be identified here.
■ Attention is then directed to making the posterior incision, once again
incising down to the fascia, this time overlying the gracilis muscle. Once
again, perforators are identified and preserved.
■ The skin paddle is then elevated inclusive of fascia and the intermuscular
septum.
■ Once the skin paddle is dissected, attention is then directed to raising the
remainder of the gracilis muscle.
■ A continuation of the anterior skin paddle incision can be made, or a smaller
distal incision can be made adjacent to the medial tibial condyle. This
secondary incision is usually 3 to 4 cm in length.
■ Dissection is carried out to the pes anserinus, at which point the tendons are
identified.
■ The gracilis can be differentiated from the sartorius muscle here using two
techniques.
■ The gracilis is usually all tendinous at this point, whereas the sartorius will
be more muscular.
■ If gracilis muscle fibers are present, they will usually be oriented in a
longitudinal manner, whereas the sartorius muscle fibers will be oriented in
an oblique manner.
■ The gracilis tendon is then ligated once pulling on the muscle proximally
will lead to tension of the muscle distally.
■ A subcutaneous tunnel between the proximal incision and distal incision is
created, and the muscle is passed from distal to proximal. This usually
requires ligation of at least one minor pedicle coming from the superficial
femoral artery. Attention is then directed proximally, where the adductor
longus muscle can be retracted laterally and the vascular pedicle (medial
femoral circumflex artery) is readily identified running superficially to the
adductor magnus muscle.
■ The pedicle is dissected from the surrounding fascial attachments as needed
for tension-free inset. The flap is now ready to be inset proximally into the
defect (TECH FIG 1B).
■ If the creation of a vaginal canal is necessary, the skin paddle may be folded

on itself as an “alpha-wrap” (TECH FIG 1C).

TECH FIG 1 • A. Surface markings of flap in frog-leg
position. B. Transverse skin paddle. C. Myocutaneous
gracilis flap ready for inset. D. Patient following Abbe-
McIndoe procedure for vaginal reconstruction and left
gracilis flap for anal sphincter and perineal restoration.
E. Elevation of left gracilis muscle prior to alpha-wrap
of incompetent anal sphincter for functional restoration
and perineal reconstruction. F. Penrose drain around
myofascial gracilis flap prior to distal disinsertion.
■ Myofascial Gracilis Flap
■ The gracilis can be harvested as a myofascial flap only as well.
■ In situations where epidermal lining is not needed, the pubic symphysis is
palpated, and a corresponding line is drawn from there to the medial tibial
condyle. This line usually corresponds to the adductor longus, which should
be easily palpable as well. The gracilis muscle will be identified

approximately 2 fingerbreadths posterior to this line.
■ To prevent inadvertent trauma to the pedicle, an 8- to 10-cm demarcation
from the pubic symphysis is made. This corresponds to the most proximal
aspect of the harvest incision. Loupe magnification is advised to prevent
injury to the pedicle. Identification of the pedicle to allow for maximum
release of the muscle if needed.
■ The incision is usually carried distally as needed for dissection of the
proximal muscle. The incision is carried deep to subcutaneous tissue and
fascia, once again, taking care to not violate the saphenous vein.
■ The gracilis muscle will be seen as the most medial and thinnest muscle, just
medial/posterior to the adductor longus (which will be bigger than the
gracilis in this area).
■ Dissection proceeds superficially and deep to the gracilis muscle, in a distal
manner. As discussed above, a counterincision is then made distally by the
medial condyle; dissection is continued accordingly.
■ Drains are often placed in the donor thigh after harvest with passive drainage
of the reconstructed site.
PEARLS AND PITFALLS
Hematoma
■ Meticulous hemostasis during flap elevation
Partial skin
necrosis
■ Ensuring wide inclusion of the fascia and intermuscular
septum
Flap loss
■ Meticulous dissection around the primary pedicle (medial
femoral circumflex artery)
Postoperative
foot drop
■ Proper padding of the lateral fibular head while in lithotomy
position
POSTOPERATIVE CARE
■ Reports in the literature on the length of follow-up vary, but there is some
general agreement of a weekly follow-up for 1 month and twice monthly for
the 2nd month until wounds are healed and then every 3 months afterward or as

needed.12 Median follow-up averages around 15 months.13–15
■ Patients should be on bed rest for at least 48 hours. They may not sit up in bed;
sitting up puts pressure on the perineal closure and flap, which can delay
wound healing.
■ We have found air-fluidized beds to be beneficial to prevent pressure on the
reconstruction and daily cleansing of the genital area to avoid bacterial
overgrowth and infections.
■ After 48 hours, they may walk with the help of a physical therapist.
■ Gram-positive and Gram-negative antimicrobial therapy is important as well
as anaerobic coverage during the hospitalization.
■ Dilation with soft vaginal conformers of the vaginal conduit is necessary to
prevent stenosis. For total vaginal reconstruction, dilating the reconstructed
canal 2 or 3 times daily with a dilator is sufficient.
■ On the 2nd postoperative day, Burke et al. recommend starting a program of 3-
times-daily perineal irrigation followed by 5 to 10 minutes of forced air-drying
using a hair blower set at room temperature.
■ The flap should be inspected daily to assess viability and primary healing. A
complete examination of the flap, including speculum insertion and digital
pelvic examination, should be performed about 1 week after surgery.
■ Donor site drains can be removed in 5 days. Sutures should be left intact for
about 7 days, and absorbable sutures, which we often use in the immediate
genital area, may be left in place.
■ Gradual resumption of physical and sexual activity is recommended as healing
progresses16 and is commonly at about 3 months after surgery.
■ Hospital stay averages no more than 20 days.16
OUTCOMES
■ Nelson and Butler prospectively analyzed 133 patients who underwent
abdominoperineal resection or pelvic exenteration and immediate
reconstruction with a pedicled VRAM (n = 114) or thigh flap (n = 19) between
1993 and 2007.17
■ Thigh flaps were found to have significantly higher rates of major
complications (42%), which included major wound dehiscence and pelvic
abscess, than VRAM flaps (15%).17
■ Thigh flap donor sites also had higher rates of infection than VRAM donor
sites and required longer healing times than did VRAM donor sites.

Furthermore, thigh flap recipient sites had higher rates of wound dehiscence,
infection, and longer healing times than VRAM flap recipient sites.17 The flap
remains an excellent option, however, to avoid abdominal donor morbidity and
in cases where the abdominal tissue is not usable.
■ Casey et al. retrospectively reviewed 99 consecutive cases of vaginal
reconstruction—this included 41 VRAM, 13 gracilis, and 45 modified
Singapore flaps.
■ The overall complication rate was higher following the gracilis (61.5%) and
Singapore flap (46.7%) than with the VRAM flap (31.7%).
■ The flap-specific complication rate was lowest in the VRAM group (22%)
compared to the gracilis (53.8%) and Singapore flaps (37.8%).
■ It is important to note that 4 of the 13 gracilis flaps were used as salvage
operations secondary to unsuccessful initial reconstruction, as opposed to
none in the VRAM or Singapore flap groups.
■ There was no difference in length of stay between the three groups, and
sexual function was adequate with all 3 types of reconstruction.18
■ Vermaas et al. reported major and minor complication rates of 43% and 0%,
respectively, in their study of reconstructions of 25 abdominoperineal resection
and pelvic exenteration defects with pedicled gracilis myocutaneous flaps;
however, they only included infection, abscess, hernia, and fistula in their
analysis.14
■ In a study on the use of bilateral gracilis myocutaneous flaps to repair total
vaginal defects by Pusic and Mehrara, a 10% risk of pelvic abscess and a 10%
to 20% incidence of skin loss were identified.19
■ Wilson et al. conducted a review of the literature and found 87 gracilis flaps:
71 for persistent perineal sinus, 5 for fistulating pelvic sepsis, and 4 for deep
presacral sepsis. Of all flaps, 31 failed to heal within 12 months (success rate
64.4%).
■ The data suggest that around a quarter of flaps take longer than 3 months to
heal.
■ The data did not show any pattern of failure with the pathology or type of
flap used (muscle only or musculocutaneous).20 This is a significant
improvement to the era prior to flap reconstruction.
COMPLICATIONS
■ Possible skin necrosis, which requires surgical debridement to achieve
secondary healing, may be seen in the myocutaneous flap.12,13

■ There is a lower incidence of skin necrosis when the flap is smaller.16
■ The gracilis myofasciocutaneous advancement flap has great vascular supply
to the cutaneous portion of the flap due to the inclusion of perforators from
the gracilis muscle and the wide preservation of the fascia above the
semitendinosus, semimembranosus, sartorius, and adductor muscles. Small
septocutaneous perforators are kept intact, which allows a larger cutaneous
territory to be harvested. This prevents the high partial flap necrosis.
■ Partial or total flap loss
■ Donor site complications include painful thigh wounds, sensory loss, abscess,
and separation or infection (ie, local Pseudomonas aeruginosa infection).14,16
■ Delayed ambulation due to medical complications related to respiratory
distress and deep venous thrombosis16
■ Seroma
■ Perineal herniation14
■ Perineal infection/abscess
■ Perineal fistula
■ Hematoma
■ Wound dehiscence
ACKNOWLEDGMENTS
Natalie Joumblat
Denise Manfrini
Amir B. Behnam
REFERENCES
1. Salgado CJ, Chim H, Skowronski PP, et al. Reconstruction of acquired defects
of the vagina and perineum. Semin Plast Surg. 2011;25(2):155-162.
2. Cordeiro PG, Pusic AL, Disa JJ. A classification system and reconstructive
algorithm for acquired vaginal defects. Plast Reconstr Surg. 2002;110(4):1058-
1065.
3. Woods JE, Beart RW Jr. Reconstruction of nonhealing perineal wounds with
gracilis muscle flaps. Ann Plast Surg. 1983;11(6):513-516.
4. Azizzadeh B, Pettijohn KJ. The gracilis free flap. Facial Plast Surg Clin
North Am. 2016;24(1):47-60.
5. Magden O, Tayfur V, Edizer M, Atabey A. Anatomy of gracilis muscle flap. J
Craniofac Surg. 2010;21(6):1948-1950.
6. Papadopoulos O, Georgiou P, Christopoulos A, Sandris P. The gracilis flap

revisited. Eur J Plast Surg. 2000;23(8):413-418.
7. Upadhyaya DN, Khanna V, Bhattacharya S, et al. The transversely split
gracilis twin free flaps. Indian J Plast Surg. 2010;43(2):173-176.
8. Kaartinen IS, Vuento MH, Hyoty MK, et al. Reconstruction of the pelvic floor
and the vagina after total pelvic exenteration using the transverse
musculocutaneous gracilis flap. J Plast Reconstr Aesthet Surg. 2015;68(1):93-
97.
9. McCraw JB, Massey FM, Shanklin KD, Horton CE. Vaginal reconstruction
with gracilis myocutaneous flaps. Plast Reconstr Surg. 1976;58(2):176-183.
10. Sagebiel TL, Faria SC, Balachandran A, et al. Pelvic reconstruction with
pedicled thigh flaps: indications, surgical techniques, and postoperative
imaging. AJR Am J Roentgenol. 2014;202(3):593-601.
11. Kamath S, Venkatanarasimha N, Walsh MA, Hughes PM. MRI appearance of
muscle denervation. Skeletal Radiol. 2008;37(5):397-404.
12. Vyas RM, Pomahac B. Use of a bilobed gracilis myocutaneous flap in
perineal and genital reconstruction. Ann Plast Surg. 2010;65(2):
225-227.
13. John HE, Jessop ZM, Di Candia M, et al. An algorithmic approach to perineal
reconstruction after cancer resection—experience from two international
centers. Ann Plast Surg. 2013;71(1):96-102.
14. Vermaas M, Ferenschild FT, Hofer SO, et al. Primary and secondary
reconstruction after surgery of the irradiated pelvis using a gracilis muscle flap
transposition. Eur J Surg Oncol. 2005;31(9):
1000-1005.
15. Whetzel TP, Lechtman AN. The gracilis myofasciocutaneous flap: vascular
anatomy and clinical application. Plast Reconstr Surg. 1997;99(6):1642-1652.
16. Burke TW, Morris M, Roh MS, et al. Perineal reconstruction using single
gracilis myocutaneous flaps. Gynecol Oncol. 1995;57(2):221-225.
17. Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for
immediate reconstruction of pelvic and perineal cancer resection defects. Plast
Reconstr Surg. 2009;123(1):175-183.
18. Casey WJ III, Tran NV, Petty PM, et al. A comparison of 99 consecutive
vaginal reconstructions: an outcome study. Ann Plast Surg. 2004;52(1):27-30.
19. Pusic AL, Mehrara BJ. Vaginal reconstruction: an algorithm approach to
defect classification and flap reconstruction. J Surg Oncol. 2006;94(6):515-
521.
20. Wilson TR, Welbourn H, Stanley P, Hartley JE. The success of rectus and

gracilis muscle flaps in the treatment of chronic pelvic sepsis and persistent
perineal sinus: a systematic review. Colorectal Dis. 2014;16(10):751-759.

28
CHAPTERGender-Affirming Surgery
Katherine M. Gast and William M. Kuzon
DEFINITION
■ Gender dysphoria is the incongruence between anatomic sex and gender
identity. It is estimated to affect 1.4 million Americans, or about 0.3% of the
population. Male-to-female transsexualism is 2 to 3 times more prevalent than
female-to-male transsexualism.
ANATOMY
■ Male
■ Penis—superficial to deep (FIG 1)
• Skin
• Dartos (superficial) fascia
• Buck (deep) fascia
• Neurovascular bundle: deep dorsal vein, dorsal artery, paired dorsal penile
nerves
• Tunica albuginea (surrounds each corpus individually)
• Erectile tissue: paired corpora cavernosa, corpora spongiosum surrounds the
urethra
■ Arterial supply
• Internal pudendal artery branches into the perineal artery to the perineum
and scrotum.
• Common penile artery branches to the bulbourethral artery, dorsal artery,
and deep cavernosal artery.
■ Female (FIG 2)
■ Clitoris and clitoral hood

■ Labia minora and labia majora
■ Urethral meatus, just anterior to vestibule and introitus
■ Vagina
PATHOGENESIS
■ Considerable evidence now supports a biological basis for determining one’s
gender identity.1–4. Gender dysphoria remains a diagnosis in the DSM-5. It is
noted that it is not a mental disorder requiring psychiatric treatment but an
incongruence between the biologically determined gender identity and the
patient’s anatomic sex.
■ There are two separate types of gender dysphoria.
■ Gender dysphoria of adolescence and adulthood (ICD10 302.85) often begins
in early childhood and persists into adolescence and adulthood.
■ It is important to recognize that gender dysphoria of childhood (ICD10
302.6) is distinctly different. In the majority of these children, gender
dysphoria is temporally limited and they will “desist” by adolescence.
• Because these two scenarios appear to be distinct, considerable expertise is
required to diagnose and treat gender-expansive children.
■ When gender dysphoria of adolescence and adulthood is confirmed, puberty
suppression is now the standard of care for young adolescents who exhibit
significant distress with development of secondary sex characteristics. Puberty
suppression is reversible and may or may not be followed by cross-hormone
treatment.
■ It is also important to note that gender dysphoria is distinct from disorders of
sexual development (DSD), where there are congenital anomalies of the
genitalia and/or are hormonally determined abnormalities of secondary sex
development.
■ This has been a source of confusion in the past when DSD children were
often assigned the gender most congruent with their anatomy or with the
anatomy most easily reconstructed surgically.
■ This resulted in inappropriate assignment of gender with patients opting to
surgically transition to their natal gender later in life. These patients were not
gender dysphoric.
■ The management of patients with anomalous genitalia or hormonal
development requires specialized, multidisciplinary expertise, and patients
presenting with a self-reported diagnosis of DSD require appropriate
evaluation and referral.

PATIENT HISTORY AND PHYSICAL FINDINGS
■ Since plastic surgeons are not trained in the evaluation and management of
gender dysphoria, internationally accepted standards of care (SOC) have been
published by the World Professional Association for Transgender Health
(WPATH). It is imperative that surgeons performing gender-affirming surgery
are familiar with these guidelines and that they have in place mechanisms to
assure that patients have met SOC before becoming surgical candidates.
■ Collaboration with local mental health providers who are familiar with this
area is the most practical way of assuring the validity of the letters of
readiness required by the SOC.
■ If that is not practical, then the surgeon must accept the responsibility of
vetting the patient’s preparation for surgery, including compliance with SOC.
■ The WPATH SOC clinical guidelines address primary care, hormonal therapy,
mental health services, and surgical treatment of transgender patients.
■ For chest surgery, patients must have one letter of readiness from a mental
health professional, and 1 year of estrogen therapy is recommend for breast
growth in male-to-female patients who desire breast augmentation.

Skin Deep dorsal vein- Superficial (dartos) fascia Deep (Buck's) fascia Intercavernous septum of Buck's fascia Urethra Prostatic urethra - Membranous urethra Bulbous urethra Spongy (cavernous) urethra Pendulous (penile) urethra B Superficial dorsal vein Dorsal artery and nerve Lateral superficial vein - Deep artery Corpus cavernosum and its tunica albuginea Corpus spongiosum and its tunica albuginea - Prostate Urogenital diaphragm - Corpus cavernosus -Tunica albuginea Corpus spongiosum -Tunica albuginea Deep artery of penis Intercavernous septum of deep (Buck's) fascia Lacunae (of Morgagni) and urethral glands (of Littré) - Lacuna magna (inconstant) Navicular fossa Glans of penis External urethral opening (meatus)

FIG 1 • A. Cross-sectional anatomy of the penis. Note
the paired corpora cavernosum and the dorsal lying
corpus spongiosum surrounding the urethra. The
neurovascular bundle for the neoclitoris flap harvested
from the glans is located on the ventral side of the penis
and is deep to the Buck fascia. B. Longitudinal section
of the male urethra.
FIG 2 • External female genitalia.
■ For genital surgery, or “bottom” surgery, patients must have two letters of
readiness, have completed 1 year of hormonal therapy, and have completed 12
months of a “real-life experience” of living in congruent gender in all
circumstances.
■ Ongoing, regular visits with a mental health professional are recommended.
The WPATH SOC are meant to be flexible guidelines and may be modified
for individual patients.
■ Physical exam of male-to-female patients should document circumcision
status, presence of any inguinal hernia, and examination of the testicles and

spermatic cords. The central perineum must be examined for hair growth since
this impacts surgical decision-making as described below.
■ Physical exam of female-to-male patients should focus on the suitability of
free flap donor sites suitable to provide tissue for phallic construction. The
radial forearm flap is the most common donor site, so an Allen test of bilateral
upper extremities is important. Since the flap must be double rolled into a
phallus, the thickness of subcutaneous tissue of the radial forearm flap, the
anterior lateral thigh flap, and the superficial circumflex iliac perforator flap
should be documented.
IMAGING
■ No diagnostic or radiologic studies are indicated.
SURGICAL MANAGEMENT
Penile Inversion Vaginoplasty
Preoperative Planning
■ Hair removal: For male-to-female patients undergoing vaginoplasty,
electrolysis or laser hair removal must be performed to remove hair of the
perineum from anus to base of penis in midline of the scrotum. The reason for
this is the perineal flap is used to widen the introitus and line the inferior
posterior aspect of the neovagina.
■ The perineal flap can be defatted and follicles scraped from the dermis, but
this compromises blood supply of the tissue.
■ In the event of a rectal injury, well-vascularized tissue over the direct repair
is advantageous to prevent rectovaginal fistula.
■ Hormone cessation: Estrogen therapy must be held 3 to 4 weeks prior to
surgery. Estrogens are increase risk of perioperative thromboembolic disease.
Hormones are resumed postoperatively when packing is removed and it can be
determined that the patient will not require a repeat trip to the operating room.
Spironolactone therapy may continue through the perioperative period.
■ Bowel prep: A standard bowel prep to cleanse the colon and rectum of stool is
performed the day prior to surgery. The patient is kept on a clear liquid diet 24
hours prior to surgery and then nothing by mouth for 6 hours prior to general
anesthetic. In the event of a rectal injury, a repair is more durable if stool is not
encountered immediately postoperatively.

Positioning
■ Patient should be positioned in standard lithotomy position with sequential
compression devices on bilateral lower extremities and pressure points
appropriately padded. Arms can be tucked at patient’s sides with padding at
elbow and wrist.
■ Patient should be prepped with Betadine including the lower abdomen, penis,
scrotum, buttocks, and perineum.
Approach
■ Penile inversion vaginoplasty with the penis skin tube lining the neovagina is
the most commonly performed technique worldwide. The neovagina is often
lengthened with full-thickness skin graft (FTSG) from the scrotum to a goal
length of 14 to 16 cm in the operating room. The scrotal skin is fashioned into
the labia majora. A portion of the dorsal glans penis is left on a dorsal
neurovascular pedicle to create a sensate neoclitoris. Prepuce skin of the penis
may be used to construct the labia minora in uncircumcised patients.
■ Sigmoid colon vaginoplasty is a technique by which a segment of the colon is
harvested by a general surgeon, secured to the sacrum to prevent prolapse, and
then brought down into the pelvis and connected to the perineal reconstruction.
Diversion colitis, excessive mucous discharge, and prolapse of the intestinal
segment limit its widespread adoption as a primary method of vaginoplasty.
T E C H N I Q U E S
■ Penile Inversion Vaginoplasty
Creation of the Perineal Flap
■ The perineal flap is located anterior to the anus centered along the midline.
The base of the flap is 3.5 cm wide and the flap is 10 cm in length. The flap
is triangular shaped and is incised and raised ventral to dorsal with a 1-cm
layer of subcutaneous fat, leaving it pedicled posteriorly adjacent to the anus
(TECH FIG 1A). A vertical incision is then made through the scrotum up to
the penile-scrotal junction. Dissection is carried down to the level of the
bulbocavernosus muscle. The bulbocavernosus muscle is dissected free from
overlying tissue along its length.

■ A Foley catheter is placed.
■ The origins of the bulbocavernosus muscles from the ischia are identified
and dissected bilaterally circumferentially (TECH FIG 1B). The base of the
bulbocavernosus muscles are clamped and divided on each side; 2-0 Vicryl
suture ligatures are employed to control bleeding.
■ The prerectal space is then dissected by dividing the plane between the
bulbocavernosus and anal sphincter. Sharp dissection through the perineal
body using cautery is used initially to the level of the urogenital diaphragm
(TECH FIG 1C).
■ Once the prerectal plane is entered, sharp and then blunt dissection is
employed using digital dissection and a sponge stick following the Foley
catheter.
■ At the level of the prostate, the rectoprostatic fascia (Denonvilliers fascia) is
detached from the tail of the prostate, and dissection proceeds anterior to
Denonvilliers. This is done bluntly with the aid of a sponge stick, which is
advanced slightly and then swept from anterior to posterior. Dissection is
carried out to the level of the peritoneum, approximately 15 cm in depth.
■ A moist sponge is placed in the neovaginal space. The rectum is filled with
half-strength saline-Betadine solution. After 2 minutes, the laparotomy
sponge is removed and inspected for Betadine. Bimanual examination with
one finger in the rectum and one in the prerectal dissection and direct
visualization of the anterior rectal wall is performed to ensure that no rectal
injury occurred. The prostate is palpated and any abnormalities noted.
■ The levator ani muscles are incised for about ½ cm on each side to widen the
space for the neovagina.
Orchiectomy
■ Bilateral orchiectomies are then performed in the usual fashion. The testicles
are dissected free from the scrotal tissue in the plane just superficial to tunica
vaginalis.
■ The spermatic chords are dissected to the external inguinal ring.
■ The vas deferens is separated from the remainder of the chord and ligated
separately with 2-0 Vicryl ties, and the chord is suture ligated with 2-0 Vicryl
at the level of the external ring. Careful attention must be paid to avoid
retraction of bleeding vessels within the cord into the inguinal canal. The
testicles are sent for pathologic examination.

Degloving of the penile shaft
■ Two centimeters proximal to the corona, the skin is incised circumferentially
and the shaft of the penis is degloved in a plane just superficial to the Buck
fascia with Metzenbaum scissors. The prepuce or dorsal penile skin is left
adjacent to the glans to serve as a clitoral hood and may be used to construct
labia minora in patients who have not undergone circumcision. The penis is
degloved to its base, and the penile shaft is pulled through the incision in the
perineum used to raise the posterior flap.
Raising the Neurovascular, Neoclitoral Flap
■ A “clitoral” flap is now raised from the dorsal area of the glans. A section of
dorsal glans penis is marked out in an appropriate shape at the terminus of the
dorsal neurovascular bundle. In addition, a portion of the distal dorsal and
lateral penile skin is kept intact to serve as a clitoral hood. The 1-cm-wide
portion of the glans will serve as the future neoclitoris. This may be shield
shaped or M shaped and coned at inset.
■ The neurovascular bundle consisting of the dorsal penile arteries, veins, and
nerve is raised as a flap by dissecting them off the underlying corporal
bodies. Dissection is begun at the midshaft of the penis, incising the Buck
fascia along the midaxis of the penis on either side. Dissection is carried to
the level of the tunica albuginea.
■ The neurovascular bundle is now raised throughout its length from its base at
the perineum to the glans portion, raising the Buck fascia and the
neurovascular bundle off the underlying tunica using sharp, scissor
dissection. The glans portion is then incised and raised with the
neurovascular bundle, taking care to include some glans erectile tissue but to
exclude the corpus cavernosum.
TECH FIG 1 • A. The perineal scrotal flap is marked
with extension of the incision up the raphe of the
scrotum. The perineal flap is used to widen the

introitus to prevent a stricture. This area should be
depilated prior to operation. B. The bulbocavernosus
muscle is fully exposed and disinserted from the
ischial tuberosities. C. The space for the neovagina is
created anterior to the rectoprostatic fascia
(Denonvilliers fascia). This is done sharply with
cautery followed by blunt dissection with a sponge
stick being careful to go slowly and gently, using a
sweeping motion from anterior to posterior.
Resection of Corpus Cavernosa and Preparation of the
Urethra
■ Dissection of the corpus spongiosum away from the corpora cavernosa is
performed in the midline cleft. The corpora cavernosa are then resected
bilaterally. This is done to the level of the ischium on each side. Suture
ligatures of 2-0 Vicryl are used to control the corporal vascular bundles.
■ The corpus spongiosum is dissected up to the level of the urogenital
diaphragm. The bulbocavernous muscle is split longitudinally and the muscle
and the spongiosum are dissected off the urethra up to the level of the
urogenital diaphragm (see TECH FIG 1B). The urethra is cut to leave about
10 cm in length distal to the urogenital diaphragm and the rest is discarded.
Creation of the Vulva and Inset of Neoclitoris
■ The neoclitoris is formed by suturing the glans flap into a cone and by
enveloping this with the dorsal penile skin as a clitoral hood (TECH FIG
2A). This is done with 3-0 Monocryl or chromic sutures. The neoclitoris is
now inset. Prior to suturing the neoclitoris in place, the pedicle of the clitoral
flap is looped anteriorly into the abdomen and stitched in place bilaterally
using interrupted 2-0 Vicryl to prevent kinking, and the clitoris is anchored to
deeper structures in the appropriate position using 3-0 Monocryl.
■ Blake drains are now placed in the prerectal space dissection and in the
lower abdomen and are brought out through separate stab incisions in the
pubic hair.
■ The penile pullback is now performed. The anchoring points are at the
penile-scrotal junction on both sides of the former penile shaft. The degloved

penis shaft is present between these two marks (TECH FIG 2B). These two
points are then tacked posteriorly to the base of the perineal flap with deep
dermal 2-0 Vicryl.
■ Once the pullback has been done, an anterior Y-shaped incision is made in
the skin anterior to the tube remaining from the degloving of the penis. The
anterior portion of the Y is at the location of the neoclitoris, and the posterior
portion is at the planned location of the urethral orifice.
■ Tacking sutures are placed from the deep dermis of the penile pullback to the
periosteum of the pelvis to anchor the central aspect of the new vulva down.
■ The urethra is split along its ventral surface to about 2 cm distal to the
urogenital diaphragm. Posterior stitches of 3-0 Vicryl in the neourethral
orifice are placed between the posterior aspect of the Y-incision and the most
anterior aspect of the ventral slit.
■ The neoclitoris is inset into its new location using the Y-shaped incision to
complete construction of the clitoral hood with the small central Y flap
(TECH FIG 2C). This is inset using interrupted 3-0 chromic or Monocryl
stitches.
■ The urethral orifice is then inset using interrupted 3-0 Vicryl stitches from
the posterior toward the anterior portion (TECH FIG 2D). The most anterior
portion of the urethral mucosa abutted the neoclitoris. Careful attention must
be made to bury any remnant erectile corpus spongiosa tissue; this will bleed
postoperatively if exposed.

TECH FIG 2 • A. The neoclitoral flap is visualized on
the right on the surgical sponge. The corpus
spongiosum (inferior with Foley catheter in place) has
been separated from the paired corpus cavernosa and
remaining glans penis. The neoclitoral flap pedicle
should be dissected to the pubic symphysis bone. B.
The corpora cavernosa are amputated at the level of
the perineum. Many surgeons prefer to leave a
corporal stump and suture the two corpora together to
provide a pedestal for the neoclitoris inset.
Alternatively, one may choose to resect the corpora
back to the ischium. C. A Y-shaped incision is made
on the anterior most aspect of the penile skin tube for
external inset of the neoclitoris and urethra. The penile
skin tube is pulled back with anticipated inversion
tension to estimate the location. D. Urethra inset. The
corpus spongiosum is excised from the periphery of
the urethra, and the mucosa is split longitudinally

along the posterior surface. It is shaped into a
diamond and inset as a fan to prevent a distal urethral
stricture.
Creation of the Vaginal Vault
■ A vaginal vault lining is constructed by insetting the posterior perineal flap
into a longitudinal incision in the penile skin tube with running 3-0 chromic
or Monocryl sutures (TECH FIG 3A). The labia majora are then constructed
by pulling the deep scrotal contents posteriorly and anchoring them to the
underlying tissue using interrupted 2-0 Vicryl stitches. The skin portion of the
scrotum is then pulled posteriorly and laterally, and an ellipse is removed to
create a labia shape. Do not over-resect the scrotal contents or skin.
■ The vaginal vault is lengthened using FTSG from the resected scrotal skin
(TECH FIG 3B). The preserved skin is defatted aggressively and sutured
over a stent into a tube 10 cm in diameter and at least 5 cm in length. The
size of the skin graft is 5 × 10 cm, and the tube of skin graft is now sutured to
the end of the penile skin tube using 3-0 Monocryl sutures. The total vaginal
length is now 14 to 16 cm.
TECH FIG 3 • A. Skin graft sutured to penile skin, prior
to inversion. The full-thickness skin graft tube is
sutured to the penile skin tube and then inverted and
placed into the prerectal space. B. Excess scrotal skin
excised after constructing the labia majora is defatted
on the back table and sutured over a 60-cc syringe to
lengthen the neovagina. A skin graft is required in the
majority of cases to provide lining for sufficient vaginal

length.
■ All remaining wounds are closed with interrupted and running 3-0 chromic
or Monocryl stitches, leaving linear incisions on either side along the line of
the labia majora.
Placement of Vaginal Pack
■ The drains are connected to suction.
■ A bacitracin ointment–impregnated vaginal packing is placed to maintain the
new vaginal vault in position without undue pressure. The end of the vaginal
pack is placed over the urethral and neoclitoral reconstruction in order to
provide some dressing.
■ The vaginal pack is held in place by through-and-through bolster stitches of
0 Prolene tied over silicone tubing lateral to the labia majora (TECH FIG 4).
■ The wound is dressed with a perineal pad and mesh panties.
■ The patient is taken out of lithotomy position.
TECH FIG 4 • Final dressing. A large vaginal pack is
placed in the neovaginal as a bolster for the full-
thickness skin graft at the apex and allow adherence
of the inverted skin tube. Spanning Prolene sutures
with drain tubing prevents pressure on the labia
majora skin.

■ Phalloplasty
Preoperative Planning
■ There is no “standard” procedure for phalloplasty, and considerable variation
in flap choice and in approach (one stage or two stage) is seen between and
even within centers.
■ Phalloplasty may be performed with radial forearm flap, SCIP flap,
anterolateral thigh (ALT) flap, latissimus dorsi myocutaneous flap, or
combination of the three to reconstruct an inner epithelialized urethra and
outer roll of skin for the phallus.
■ The phallus may be constructed from one flap in a “tube-in-a-tube” fashion
(radial forearm flap most common), or the urethra and phallic skin may be
reconstructed from two separate flaps (radial forearm flap or SCIP flap for
the urethra with an ALT flap for the phallic skin most common).
■ The choice of donor site is largely dependent on patient’s body habitus and
patient and surgeon preference.
■ Permanent hair removal on the skin to be used for the neophallus and the
neourethra should be completed to lower the risk of urethral strictures and
fistulas.
■ Allen test should be performed in bilateral upper extremities in preparation
for radial forearm flap.
Positioning
■ Patient should be positioned supine. If used, the upper extremity should be
extended on hand table with sterile tourniquet.
Approach
■ The tube within a tube may be accomplished by a double-roll technique of
the radial forearm flap, but this is limited by subcutaneous fat thickness on
the forearm (FIG 3). Alternatively, a thin radial forearm flap may be tubed
and then surrounded by a pedicled ALT or SCIP flap in thin patients.
■ In all techniques, vaginectomy is performed concomitantly by a
gynecologist. It is also common to perform a hysterectomy and bilateral
oophorectomy at the time of phalloplasty.

FIG 3 • A. Design of the radial forearm flap with volar
ulnar urethra, de-epithelialized area to suture as a
tube within a tube, and radial outer phallus. B.
Markings for radial forearm flap phalloplasty. C. Radial
forearm flap elevated. D. Radial forearm flap tubed on
the forearm to create the urethra and phallus.
■ Radial Forearm Phalloplasty
■ The patient is placed under general anesthesia in a supine position on the
operating table. The perineum, both upper legs, and the left arm are prepped
and draped in the usual sterile fashion.

Flap Dissection
■ A preoperative Allen test confirmed that there is adequate ulnar artery flow
to support the circulation of the hand without any need to reconstruct the
radial artery. A radial forearm flap is then marked out over the axis of the
radial artery. The flap is at least 20 cm wide and 15 cm long.
■ A “tube-in-a-tube” method is used to construct the neophallus with a 3-cm-
wide portion in the ulnar aspect (the most hairless part) of the flap serving as
a neourethra and the external skin of the neophallus measuring 16 × 15 cm.
The urethral skin strip is left approximately 2 cm longer than the remainder
of the neophallus so the uretheral coaptation will not lie directly subjacent to
an external skin incision.
■ The cephalic vein and the associated lateral antebrachial cutaneous nerve
(LABC) are marked out, as is the location of the medial antebrachial
cutaneous (MABC) nerve. It is sometimes possible to include the basilic vein
with the flap for additional venous outflow.
■ The arm is exsanguinated and a tourniquet is inflated for less than 120
minutes for this part of the dissection.
■ Dissection is begun by incising the margin of the skin paddle of the radial
forearm flap and dissecting distally to identify the radial artery and vena
comitans. The radial artery and vena comitans are then divided distally at the
volar wrist crease. Incisions along the radial and ulnar aspects of the flap are
completed, and the flap is raised off the muscle fascia, which is left down.
■ Dissection is continued until the brachioradialis on the radial aspect and
flexor carpi radialis on the ulnar aspect of the flap are encountered.
Proximally, the cephalic vein and its associated LABC are preserved. The
MABC is identified and preserved.
■ The interval between the brachioradialis and the flexor carpi radialis is
opened proximally, and the radial artery and its vena comitans are identified.
The flap is now elevated from distal to proximal dissecting at the level of the
deep fascia. This preserves the radial artery and its vena comitans is within
the substance of the flap.
■ The radial sensory nerve is dissected out of the substance of the flap on the
radial distal aspect of the forearm and is preserved in total. Dissection is
carried proximally until the flap is isolated on the two nerves, on two
cutaneous veins, and on the radial artery and its vena comitans.
■ A large communication between the cephalic vein and the vena comitans is

almost always present in the proximal forearm. Preserving this
communication allows a cephalic vein anastomosis to a recipient vein to
drain both the deep and superficial venous systems within the flap. All of
these structures are dissected proximally up to the antecubital fossa with side
branches of all vessels being coagulated or clipped. The radial artery and its
vena comitans are isolated right up to their takeoff at the bifurcation of the
radial and ulnar vessels.
■ The arm tourniquet is released and both the flap and the hand should have
excellent perfusion as judged by capillary refill, color, and bleeding from cut
edges. Hemostasis is obtained with bipolar electrocautery both the flap and
the recipient bed.
Construction of Neourethra
■ A neourethra is now constructed around no. 12 French Foley by tubing the
ulnar portion of the radial forearm flap. A strip of skin between the urethra
and phallus portion of the skin flap is de-epithelialized for suturing. The flap
is tubed using interrupted and running 4-0 Monocryl.
■ The reminder of the skin portion of the flap is now wrapped around the
neourethra creating the external skin portion of the penis. This is sutured with
4-0 Monocryl deep dermal and subcuticular sutures, and the neourethra is
sutured to the distal external phallus skin paddle using a running 4-0
Monocryl suture.
■ A coronaplasty may be performed now or in a delayed fashion by making an
incision 3 to 4 cm from the distal end of the phallus and advancing the distal
edge, creating a roll. A narrow ring split-thickness skin graft (STSG) is
placed behind the roll proximally, which can be harvested from the area of
the flap that has been de-epithelialized.
■ The flap is left perfused on the forearm at this time, covered with moist
sponge, and attention is then turned to the perineum.
■ Concurrently with the flap dissection, a gynecologist or urologist will
perform the vaginectomy and preparation of the recipient urethra for
anastomosis. A scrotoplasty using the labia majora can be done as well.
Preparation of the Recipient Site
■ The recipient site is prepared, dissecting the perineal urethra. The clitoris is
de-epithelialized and will be buried at the base of the neophallus. A short
midline incision allows dissection of one of the dorsal clitoral nerves for later
coaptation with the LABC; the other clitoral nerve is left intact. Because

sensory reinnervation of the neophallic free flap is variable, this preserves a
sensate, subcutaneous clitoris as an erogenous location.
■ A curvilinear longitudinal incision 12 cm long is now made over the
superficial femoral vessels in the left groin. Dissection is carried down, and
the superficial femoral vein, any venous side branches, and the saphenous
vein are identified and prepared for microsurgery. The saphenous vein
generally has a very large side branch just distal to its origin; this should be
preserved.
■ A subcutaneous tunnel is made between the perineal recipient site and the
recipient vessels in the groin. The planned recipient artery is the superficial
femoral via end-to-side anastomosis. If the radial artery will not reach, a vein
graft can be employed, or better, an AV fistula can be created using the large,
proximal branch of the saphenous vein anatomosed end to side to the femoral
vein.
■ The loop is then divided with the distal end of the loop serving as a vein
graft for the arterial revascularization.
Flap Transfer, Vascular Anastomoses, and Nerve Coaptation
■ Attention is turned back to the flap on the arm. The radial artery and its vena
comitans are divided after ligaclipping the proximal vessels. The cephalic
vein and LABC/MABC nerves are likewise divided.
■ The neophallus is transferred to the perineum, and anchoring sutures are
placed between the deep dermis portion of the flap and deep Scarpa layer of
the suprapubic area. A coaptation of the neourethra in the flap to perineal
urethra in the recipient site is performed with interrupted 4-0 Vicryl sutures.
Anterior vaginal mucosal flaps, labia minora flaps, or even a gracilis muscle
flap may be used to bolster the anastomosis.
■ The no. 12 Foley catheter is in the neourethra and left in place for 2 weeks.
A suprapubic catheter may or may not be used.
■ An end-to-end neural coaptation is performed connecting the MABC to the
ilioinguinal nerve and the LABC to one of the previously dissected dorsal
clitoral nerves in an epineural fashion with 8-0 nylon sutures. This
preservation of the innervated clitoris at the base of the phallus provides the
potential for sensory and erogenous reinnervation of the neophallus while
preserving a sensate clitoris.
■ The recipient vessels are passed through into the right groin dissection
through the tunnel made previously. The arterial anastomosis is done end to

side to the femoral artery, possibly aided by vein grafts or an AV loop as
described above. The cephalic vein is anastomosed end to end to a side
branch of the femoral or saphenous vein.
■ The clamps are released, and perfusion in the flap is evaluated by looking for
good pulsation in the artery and good venous return. The flap should become
pink and bleed from cut surfaces. The lie of the vessels is confirmed to be not
kinked or redundant.
■ The penile flap is now completely inset by tailoring the surrounding skin to
inset the neophallus (TECH FIG 5). Inset of the flap is done using
interrupted 3-0 Monocryl. The groin wound is now closed using interrupted
3-0 Vicryl stitches in the deep dermal layer and running sutures in the skin.
At the end of the procedure, sterile dressings consisting of Xeroform fluff
gauze and mesh pants are applied to the neophallus.
Closure of Donor Site and Dressings
■ Attention is now turned to repairing the donor defect on the arm. Fascia was
left down on the volar compartment with the exception of between
brachioradialis and flexor carpi radialis necessary to preserve the radial artery
perforators.
TECH FIG 5 • A. Schematic of plan for inset of the
radial forearm phalloplasty with anastomosis to the
saphenous vein and femoral artery. The lateral and
medial antebrachial cutaneous nerves are coapted to
the ilioinguinal nerve and one of the clitoral nerves.

One clitoral nerve is left in situ to retain erogenous
function of the clitoris, which is now buried beneath
the neophallus. B. Recipient site planning. This patient
has previously undergone metoidioplasty. C. Flap
inset after urethral anastomosis and nerve coaptations
and demonstrating vascular anastomoses.
■ The proximal longitudinal exposure incision is closed with interrupted 3-0
Vicryl sutures in the deep dermal layer followed by 4-0 nylon for skin
closure.
■ A good quality, moderately thick (0.0012″–00.14″ thick) skin graft is
harvested from the thigh and is meticulously sutured into the forearm donor
site as a sheet graft. This is generally done with 4-0 chromic sutures. Our
preference is to place a dressing consisting of Xeroform, mineral oil–
impregnated cotton batten, and a form-fitting, well-padded volar short-arm
splint maintaining the hand and wrist in the intrinsic plus position, although a
tie-over bolster may be used on the skin graft.
■ After the dressings are placed on the arm and the Foley is connected to bag
drainage, the patient is awakened and returned to the recovery area.
PEARLS AND PITFALLS
PENILE INVERSION VAGINOPLASTY
Rectal injury in
vaginoplasty
■ The initial dissection through the perineal body, just posterior to
the bulbocavernosus muscle, is sharp and performed with
cautery.
■ Past the urogenital diaphragm, dissection should be performed
bluntly with a sponge stick with gentle sweeping motion
anterior to posterior.
■ Any injury to the rectum should be identified on exam and
repaired in two layers.
Raising of
neoclitoral flap
in vaginoplasty
■ There is no defined plane between tunica albuginea and the
dorsal penile bundle.
■ Dissection begins at the midaxis of the penis and using small

Metzenbaum scissors carried dorsally in a lateral to medial on
both sides.
■ You will notice a difference in fiber direction between bucks
(longitudinal along the penis axis) and the more superficial
investing fascia (diagonal and transverse).
■ This is tedious.
Placement of
vaginal packing
■ Packing should extend into the apex of the neovagina. We use a
vaginal pack coated in bacitracin ointment, but many surgeons
use metronidazole gel.
■ An entire vaginal pack gauze should fit in the neovagina.
■ Sections of cut suction tubing are used as buttresses over the
labia with 0-0 Prolene sutures to tamponade the packing in
place.
Hemostasis in
vaginoplasty
■ Estimated blood loss for this procedure averages 500 cc.
■ Patients should have two large-bore peripheral IVs and an
active type and screen prior to surgical incision.
RADIAL FOREARM PHALLOPLASTY
Venous
congestion
■ Positioning of the neophallus must keep distal aspect elevated.
■ AV fistula may be created in the distal phallus from end of
radial artery and large vein.
Urethral fistula
or stricture
■ A gracilis muscle flap may be used to bolster the urethral
anastomosis at time of phalloplasty if there is significant
concern for fistula.
■ Involvement of urologist is recommended for management of
persistent fistula or strictures.
POSTOPERATIVE CARE
Penile Inversion Vaginoplasty
■ The patient must remain on bed rest overnight until postoperative day 1.
■ Examination on POD 1 should document swelling, labial incision integrity,
labial skin viability, and neoclitoral viability. After this examination, patients
are able to shuffle in their room and sit for limited periods in a well-padded
chair, but activity is otherwise limited.
■ Surgical drains and Foley catheter remain in place along with the vaginal
packing until postoperative day 5 or 6.
■ VTE prophylaxis is started 6 hours after surgery.

■ Unless a rectal injury was noted and was repaired, patients are advanced to
regular diet starting on postoperative day 1.
■ Mesh underwear and Kerlix fluff are changed daily and as needed.
■ On postoperative day 5 or 6, the vaginal packing is removed, and a speculum
exam is performed to assess viability of the neovagina lining. The drains and
Foley catheter are also removed at this time. Patients then begin vaginal rinses
with 240 cc of normal saline using red Robinson catheter 3 times daily, are
taught to perform twice-daily vaginal dilations with small-sized dilators, and
are discharged from the hospital.
■ Patients are examined again 10 to 14 days later to assess tissue viability and
ensure they are managing dilation as instructed.
■ Examination 4 to 6 weeks after the procedure should generally find nearly
complete healing. At this point, the patient may progress to a larger vaginal
dilator, begin relaxing activity restrictions, and return to work.
■ Examination about 3 months postoperatively should document full healing
before the patient is cleared for penetrative intercourse (FIG 4). Patients must
understand the need to dilate daily indefinitely or to have penetrative
intercourse to maintain vaginal depth.
■ Patients must clearly understand that they still have a prostate gland and will
still require surveillance for prostate disease as recommended by their PCP.
Phalloplasty
■ Patient must remain on bed rest overnight until postoperative day 1.
■ Surgical drains remain in for 5 to 7 days. Foley catheter remains in place for a
minimum of 2 weeks.
■ VTE prophylaxis is started 6 hours after surgery.
■ Patients are advanced to regular diet starting on postoperative day 1.

FIG 4 • Postoperative appearance at 3 months.
■ Mesh underwear and Kerlix fluff are changed daily and as needed.
■ Patients are allowed only very limited, in-room activity for 5 days. After this
interval, they are mobilized over a 1- to 2-day period.
■ A resting volar splint is kept in place for 5 to 7 days over the split-thickness
skin graft on the radial forearm donor site. It is then removed and daily
Xeroform dressing changes are performed. A removable splint is fashioned and
worn for 3 weeks. After the graft has completely epithelialized, gentle active
and passive range-of-motion exercises are initiated.
■ Drains in the groin are removed 7 to 10 days postoperatively unless there is
unusual high output, which may indicate a small lymph leak. They should then
be left in place until output is less than 30 cc/d for 2 consecutive days.
■ The Foley catheter remains in place for a minimum 2 weeks and a voiding trial
is planned. If the patient is able to spontaneously void, then the suprapubic
tube, if used, may be removed.
■ The patient is seen 2 weeks postoperatively in clinic to assess surgical
incisions, flap viability, and voiding function. They are then seen 3 months
postoperatively at which time activity restrictions may be lifted and the patient
may return to work.
■ Delayed coronaplasty and glans tattooing may be performed after 3 months
when all incisions are completely healed. Testicular implants may be placed at
this time. Erectile prosthesis, either hydrolic or semirigid, may be placed after
protective sensation is achieved in the neophallus, typically 1 year
postoperatively.
■ Erectile prosthesis may be placed after the neophallus regains protective