[Phalloplasty in female-to-male transsexuals: experience from 259 cases].

BACKGROUND: The free radial forearm flap is state of the art for a phalloplasty in female-to-male transsexuals. Alternatives are the free fibula flap or the pedicled groin flap.

METHOD: In a retrospective study, 269 phalloplasties performed between 1993 and 2009 were analysed for success rates and complications. The operative technique for the radial forearm flap in 2 designs and the groin flap penile reconstruction are described.

RESULTS: Indications for penile reconstruction were transsexualism in 96.3%. We used 135 radial forearm flaps, 119 groin flap reconstructions, 2 fibula, one scapula and 2 pedicled randomised flaps. Of the radial forearm flaps, 10 flaps had a thrombosis (3 arterial, 4 venous, 3 combined) on postoperative day 0, 1 (n=5), 4, 4, 5 and 24. Six revisions were successful; 4 flaps failed (3%). 12 flaps (9%) showed a partial or superficial necrosis which required an operative revision.

CONCLUSION: The radial forearm flap can be performed in various designs. If the patient wishes a glans plasty the Gottlieb design is favoured. In obese patients with a short forearm the Chang design is recommended as it provides a sufficient pedicle length for anastomosis without a venous interpositional graft. The radial forearm flap has a high success rate, but late thromboses and partial necrosis are particular problems. Surgically, we recommend a trapezoid design, a skin graft if there is any sign of tension, a subfascial dissection and sufficient subcutaneous veins for drainage of the ulnar urethra. The groin flap penile reconstruction is a rare alternative for patients who wish a larger bulk, refuse to accept a stigmatising scar on the forearm and whose priority is not voiding while standing.