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Page 12 of 15 Carter et al. Plast Aesthet Res 2020;7:33 I http://dx.doi.org/10.20517/2347-9264.2020.81

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Figure 9. Placement of the T-Stat VLS Tissue Oximeter (Spectros; Portola Valley, CA) probe for monitoring of the vascular integrity of
the phalloplasty flap in the immediate postoperative period

StO has been reported as 49%-57% with a range of 40%-75% regardless of flap type [35,36,39] . There are no
2
established criteria for oximeter detection of flap compromise, although one group proposed using either
a 20-point drop in StO within a 1-h period or an absolute reading less than 30% to indicate vascular
2
[38]
compromise . Following the trends in [Hgb] and StO over time is more valuable than the absolute
2
[38]
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readings due to the heterogeneity of vessels in the flap . Some advantages of the T-Stat oximeter is the
ability to set an alarm when user-specified criteria are met, and the ability to mirror quantitative outputs to
the surgeon’s smartphone app in real time for remote monitoring [36,38] . Previous groups have found that VLS
continuous monitoring resulted in earlier detection of flap vascular compromise 1-3 h or more before clinical
examination or Doppler findings were apparent [36,39] .
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We use the T-Stat oximeter in all of our patients and consider it to be a nonnegotiable requirement at our
center for safe flap surgery. The sensor probe is placed on the neophallus by the surgeon at the conclusion of
the operation and remains in place until the patient is discharged [Figure 9].

Ultimately, flap monitoring and protective measures continue outside of the immediate postoperative period.
After discharge, patients are instructed to minimize bending at the waist of more than 20° for 4 weeks to
avoid compression of the vascular supply to the neophallus, limit walking for 4 weeks, avoid prolonged
sitting, maintain excellent genital hygiene, and to keep the neophallus positioned at 90° to the body to
[9]
minimize flap-related complications .

CLINICAL PATHWAYS
Clinical pathways (CPWs) are tools to translate evidence-based medicine to a clinical setting for a specific
clinical situation. The main goal of a CPW is to provide high quality care through aligning clinical practice
with guideline recommendations. At the same time, a CPW also seeks to minimize economic measures,
[40]
such as healthcare costs, resource allocation, and length of stay . CPWs have been used in clinical practice
internationally since the 1980s, and an estimated 80% of hospitals in the US have implemented CPWs as
of 2003 [40,41] . A 2012 Cochrane Review showed that CPW implementation consistently reduced in-hospital
[40]
complications and improved documentation without increasing patients’ length of stay or healthcare costs .
[40]
The majority of studies reported that CPWs decreased in-hospital complications for surgical procedures .
We use a robust, standardized, 5-day inpatient CPW for all phalloplasty patients. The pathway covers day-
by-day flap monitoring requirements, clinical staffing level (ICU, med-surg step-down, or general med-
surg nursing care), scheduled and as-needed (PRN) medications, activity level, diet, and more. In this way,
order sets are standardized between patients, decreasing the potential for errors and avoiding ad hoc orders
placed for each individual. Nursing expectations for daily progress is also standardized. Patients who are
not meeting the expected milestones are identified early and receive extra diagnostic/therapeutic attention.