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Page 6 of 15 Carter et al. Plast Aesthet Res 2020;7:33 I http://dx.doi.org/10.20517/2347-9264.2020.81

Figure 5. Intraoperative display of small anterolateral thigh flap perforators, measuring < 1 mm in diameter

Figure 6. Preoperative marking of an anterolateral thigh flap donor site showing (1) as short-as-possible urethral extension; (2) de-
epithelialization of the proximolateral dermis next to the urethral extension; (3) sparing of the fat around the urethral extension. Circled
dots represent the location of three flap perforators identified with a handheld Doppler

(3) The vascularity of an ALT flap relies on the patient’s anatomy, specifically the perforators arising from the
[3,9]
descending branch of the lateral circumflex femoral artery . It is advantageous to include the largest and as
[9]
many perforators as possible when designing this particularly large flap . When using the ALT flap, we use a
handheld Doppler to mark the patient’s dominant perforators while the patient is awake in the preoperative
holding area. An example of particularly small ALT perforators is shown in Figure 5.

(4) When using the ALT flap, we advise the patient to stop injecting testosterone into the donor thigh.
Common formulations of depo testosterone contain benzyl benzoate, benzyl alcohol, and a large amount of
cottonseed oil (736/100 mg of testosterone), creating a nidus of scar, which is best avoided in flap donor sites.
In fact, we advocate that standard instructions for intramuscular testosterone injections should be modified
from “switch thigh injection sites from side to side with each injection” to “pick a side and stick to it” in a
patient who thinks they may ever be interested in ALT phalloplasty.

Figure 6 illustrates the preoperative marking of an ALT donor site from our center highlighting these
configuration modifications.

We are interested in using imaging technology, perhaps CT angiogram, as some other groups have reported,
[6,9]
to select the thigh with the most robust perforator blood supply in the future . However, this has not
[17]
currently been shown to be effective in improving outcomes .
RFF donor site coverage
Once a fasciocutaneous RFF flap is removed, the underlying tendons, muscles, and nerve are exposed.
[18]
Historically, the RFF donor site has been managed with a single layer split thickness skin graft (STSG) .