Introduction: One of the options that can be employed within the context of gender-affirming masculinizing genital reconstruction is the anterior lateral thigh (ALT) flap. Our objective is to demonstrate our technique with ALT flap phalloplasty.
Methods: This is a 25-year-old trans male who desired to void in a standing position. Given the subcutaneous thickness of less than 1 cm in his thigh and concerns related to donor-site scarring, the shared decision was to proceed with phalloplasty with an ALT flap constructed in a “tube within a tube” technique.
Results: Acoustic Doppler followed by fluoro angiography to confirm perforator location helped outline the ALT flap. A suprapubic tube (SPT) was inserted under direct cystoscopic guidance. Anterior vaginal wall flap was mobilized and tubularized around the catheter. Clitoris was de-epithelialized. A semilunar suprapubic skin incision was made. Clitoris was sutured to the pubic periosteum. The remaining vaginal mucosa was ablated with electrocautery. Colpocleisis was completed using concentric stitches. The patient was then taken out of lithotomy position and the ALT flap was elevated. Dissection was performed to the intermuscular septum between the rectus femoris and the vastus lateralis. Descending branch of the lateral femoral circumflex artery was identified. The lateral femoral cutaneous nerve was dissected proximally. The flap was elevated on a single perforator and repeat fluorescence angiography confirmed intact perfusion. The urethra was reconstructed over an 18 Fr. council tip catheter and closed in a layered fashion. Methylene blue confirmed urethral integrity. Shaft skin was wrapped around the phallic portion of the urethra and closed in a layered fashion. The left ilioinguinal nerve was clipped for later coaptation with the lateral femoral cutaneous nerve. The flap was passed beneath the rectus femoris, sartorius, and then subcutaneously into the recipient site over the pubic symphysis. The anastomosis between the phallic urethra and elongated native urethra was performed over an 18 Fr. council tip catheter using interrupted stitches. Scrotoplasty was performed using labia majora flaps. The flap was then inset in a layered fashion. The donor site was closed by reapproximation and advancing the skin edges. A split-thickness skin graft was harvested from the thigh and applied over the donor site. The donor site was dressed with wound VAC. The procedure lasted 12 hours with an estimated blood loss of 550 ml. The patient was discharged on day 18. The urethral catheter was removed after a 30 days retrograde urethrogram (RUG). SPT was removed a month later. The patient initially voided without issues but then started to notice urine leakage through a phallic skin defect. RUG demonstrated distal phallic urethral stricture and a small urethrocutaneous fistula just proximal to it. The stricture was dilated with sounds. The patient was instructed to do intermittent self-calibration. Voiding improved, stricture did not recur and fistula healed spontaneously. No other urinary complications were encountered.
Conclusions: ALT flap is a valid option for gender-affirming phalloplasty. It can be considered in patients with favorable body habitus who are concerned with donor-site scarring.