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Page 4 of 15 Carter et al. Plast Aesthet Res 2020;7:33 I http://dx.doi.org/10.20517/2347-9264.2020.81

Figure 2. Cystoscopic appearance of abundant hair in the proximal penile urethra, which became calcified by urinary solutes and created
an obstructive intraurethral trichobezoar/hairball

Figure 3. Comparison of penile girth after liposuction by postoperative day (POD), showing a 20% decrease in girth over time. Of note,
there is prominent ecchymosis and swelling immediately after the procedure, which subsides with time

preoperative depilitation . While we continue to recommend thorough preoperative depilitation, especially
[14]
of the neourethral portion of the future flap, the optimal hair removal protocol has yet to be devised.

Implications of donor site adiposity
Donor site individualization based on patient preference is our practice. However, certain body habitus
types may have more favorable outcomes by choosing one flap type over another. For instance, particularly
thin individuals should avoid the RFF because the resultant neophallus may be disproportionately thin.
Conversely, these thin individuals tend to do especially well with ALT flaps, as the donor site will not be
too thick for creating an aesthetic and proportionate neophallus. Individuals with increased adiposity of the
[3]
anterior thigh should avoid ALT flaps if possible and may do particularly well with a RFF flap instead . We
advise our patients of these considerations before they finalize their choice of donor site.

Especially thick ALT flaps create several problems. The first is that the resultant neophallus may be
disproportionately large in circumference. Contouring these very large neophalluses down to an aesthetic,
biologically-appropriate size may be difficult or even impossible. Most ALT flap patients will require one
liposuction session to reduce penile girth [Figure 3]. However, some particularly large ALT neophalluses
may require multiple liposuction procedures, open surgical reduction of ventral penile skin to decrease girth
of the shaft, and contouring of the base of the neophallus to create a more proportional outcome. Even with
multiple revision surgeries, excellent aesthetic results may never be achievable.

The second major problem with too-thick ALT flaps is the possibility that the neourethra cannot be made in
the first stage. Using the tube-within-a-tube (TWT) technique, it may be impossible to close a particularly