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Page 8 of 17 Khavanin et al. Plast Aesthet Res 2020;7:47 I http://dx.doi.org/10.20517/2347-9264.2020.63

A B

Figure 6. Before (A) and after (B) images of a patient undergoing radial forearm free flap phalloplasty following partial amputation
of the penis due to an improvised explosive device. The grafted skin just proximal to the corona can be tattooed to further refine the
aesthetics of the neophallus

various technical modifications performed, total flap loss was rare with an incidence of 1.5%, with another
7.4% experiencing partial/distal flap loss. Urethral fistulas were much more common with an incidence of
nearly 30% - of which 41% were able to be managed conservatively. Urethral strictures were less common
[3]
and occurred in 8.2% of phalloplasties . In one of the largest single center experiences with RFFF
[23]
phalloplasties, Monstrey et al. reported similar outcomes with a 41% incidence of urologic complications
and a 44% rate of penile prosthesis removal.

Nonetheless, patients tend to be happy with their RFFF reconstruction. As many as 75%-100% report the
ability to void while standing, 97% are satisfied with cosmesis, and 87% of patients reported sensation in
[26]
[27]
the neophallus . With appropriate innervation, 80% of patients are able to achieve orgasm .
ALT
The ALT flap [Figure 7], based on perforators of the descending branch of the lateral circumflex femoral
vessels, can be used as both a pedicled and free flap for phalloplasty. Sensation to the flap is provided by
the lateral circumflex femoral nerve. Some authors described harvesting an additional cuff of fascia with
the flap that can be used to create a neo-tunica that will cover the eventual penile prosthesis . Because
[28]
of the bulk of the thigh subcutaneous tissues relative to the forearm, some surgeons do not arrange the
flap in the “tube within a tube” configuration; instead, a separate skin graft is often harvested and wrapped
around a catheter and sewn to the native urethra proximally. In thinner patients, a 1.5 cm strip can be de-
epithelialized and tabularized as in RFFF at the cost of a bulkier construct at the time of initial flap transfer.
Other surgeons, including Mutaf and colleagues, have described a chimeric flap in which the skin perfused
by the sartorius perforators is harvested and used to create the neourethra within the tubed ALT [29,30] .