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

Figure 7. Six-week postoperative appearance of radial forearm flap donor site covered with thin Integra®, 18/1000-inch thick split
thickness skin graft, and negative pressure wound therapy for 8 days. Note excellent take of the skin graft, minimal step-off, and plump,
nonadherent configuration of the graft

However, using an STSG alone can be associated with significant donor site morbidity [11,18] . STSGs may
adhere to the exposed tendons and reduce the strength and range of motion, lead to contractures, and is
frequently distressing to the patient [13,18] .

Recently, we and others have been using artificial dermal substitutes such as Integra® Wound Matrix
(Thin) (Integra LifeSciences; Plainsboro, NJ) to improve RFF donor site healing and cosmesis [6,13,18] .
Integra® is a synthetic acellular dermal regeneration template that is composed of a bilaminate sheet of
[19]
cross-linked bovine tendon collagen coated with shark glycosaminoglycans (chondroitin-6-sulfate) .
Originally developed for the coverage of burn wounds, Integra® provides a scaffolding for revascularization
and growth of the neodermis while creating a gliding surface against the underlying nerve, muscle, and
[19]
tendon . We place the thin Integra® over the wound, followed by an 18/1000-inch unmeshed STSG, and
TM
then apply negative pressure wound therapy with a V.A.C device (KCI; San Antonio, TX) for at least
9 days postoperatively, and sometimes up to 12 days. We have found that this method of single-stage Integra®
and immediate STSG application has equivalent graft take results as the staged approach. Though a staged
approach is the most common, single-stage Integra® application has been described by others in a variety of
applications previously [20-23] .

We have found that using Integra® under the usual STSG in this way results in improved cosmesis with a
noticeably thicker result and less step-off. It also minimizes the risk of tight adhesion of the STSG to the
underlying deep arm structures [13,18] . Other groups have also documented improvement in skin elasticity,
motor function, range of movement, wound contractures and hypertrophic scar formation with Integra® [13,18] .
Figure 7 displays one of our patient’s RFF donor site managed with thin Integra®, STSG, and negative
pressure wound therapy at six weeks after surgery.

URETHRAL LENGTHENING COMPLICATIONS
The most common complications of phalloplasty involve the urethral lengthening portion of the procedure.
In recent years, improved surgical technique has greatly decreased the rate of neourethral complications, but
all-cause urinary complications from phalloplasty are still reported to be between 35%-58% . The rate of
[4,8]
complications is so high that patients should decide if urinating from the tip of the neophallus is imperative
for their treatment goals, as maintaining the external urethral orifice in the native position and forgoing
[6]
standing voiding forever greatly reduces the risk of urinary complications .
In general, urinary strictures tend to have significant morbidity, and open surgical intervention is required
in most (94%-96%) stricture patients . The management options of neourethral stricture after phalloplasty
[24]