Since 2001, we have been performing phalloplasty with a radial forearm free flap as the flap of first choice in female-to-male transsexuals (FTMTS). In the present case, a 22-year-old FTMTS with a negative Allen test, we achieved good results by performing phalloplasty with an innervated island pedicled anterolateral thigh flap using the "tube within a tube" technique, in which the penis and urethra are constructed with a single flap. While phalloplasty with an island-pedicled or free anterolateral thigh flap has been reported previously, the present case seems to be the first of phalloplasty with an innervated island-pedicled anterolateral thigh flap using the "tube within a tube" technique. As compared to a forearm flap, use of an innervated island-pedicled flap may have the following advantages in phalloplasty:1) no need for a microsurgical technique;2) no scars at noticeable sites;3) small functional loss in the flap donor area;4) no sacrifice of major blood vessels. Thus, this technique seems to be a useful clinical alternative for phallic reconstruction

Hasegawa, Kenjiro

Kimata, Yoshihiro

Namba, Yuzaburo

Okayama University Scientific Achievement Repository

Phalloplasty with an Innervated Island Pedicled Anterolateral Thigh Flap in a Female-to-Male TranssexualKenjiro Hasegawa＊,  Yuzaburo Namba,  and Yoshihiro KimataDepartment of Plastic and Reconstractive Surgery,  Okayama University Graduate School of Medicine,   Dentistry and Pharmaceutical Sciences,  Okayama 700-8558,  JapanSince 2001,  we have been performing phalloplasty with a radial forearm free ﬂap as the ﬂap of ﬁrst choice in female-to-male transsexuals (FTMTS).  In the present case,  a 22-year-old FTMTS with a negative Allen test,  we achieved good results by performing phalloplasty with an innervated island pedicled anterolateral thigh ﬂap using the “tube within a tube” technique,  in which the penis and ure-thra are constructed with a single ﬂap.  As compared to a forearm ﬂap,  use of an innervated island-pedicled ﬂap may have the following advantages in phalloplasty: 1) no need for a microsurgical tech-nique; 2) no scars at noticeable sites; 3) small functional loss in the ﬂap donor area; 4) no sacriﬁce of major blood vessels.  Thus,  this technique seems to be a useful clinical alternative for phallic recon-struction.Key words: gender identity disorder,  sex reassignment surgery (SRS),  phalloplastyhe Japanese Society of Psychiatry and Neurology published “the diagnostic and therapeutic guide-lines for patients with gender identity disorder” in 1997 [1].  According to these guidelines,  we began performing sex reassignment surgery (SRS) in patients with gender identity disorder in January 2001,  and have performed phalloplasty in 23 female-to-male transsexuals (FTMTS) as of December 2008 [2].  Although radial forearm free ﬂaps have been used as the ﬂaps of ﬁrst choice,  deep inferior epigastric artery perforator ﬂaps,  superﬁcial circumﬂex iliac artery ﬂaps,  etc.,  have also been used in patients with a negative result of the Allen test and in those not wish-ing to have the ﬂap taken from the forearm.　 In the present case,  an FTMTS patient with a negative Allen test underwent phalloplasty with an innervated island pedicled anterolateral thigh ﬂap using the so-called “tube within a tube” technique,  in which the penis and urethra are constructed with a single ﬂap,  and good results were obtained.Case　 The patient was a 22-year-old who had been diag-nosed as a FTMTS and had initiated hormone therapy 5 years previously,  according to “The diagnostic and therapeutic guidelines for patients with gender iden-tity disorder” of the Japanese Society of Psychiatry and Neurology [1].  The patient had undergone bilat-eral mastectomy 4 years earlier and ovariohysterec-tomy and urethral lengthening 2 years earlier.  We planned to perform phalloplasty in this patient.　 Before surgery,  the Allen test on the left hand was negative and multidetector-row computed tomography (MDCT)-angiography also showed circulatory impair-ments in the left superﬁcial and deep palmar arches TActa Med.  Okayama,  2013Vol.  67,  No.  5,  pp.  325ﾝ331CopyrightⒸ 2013 by Okayama University Medical School.Case Report http ://escholarship.lib.okayama-u.ac.jp/amo/Received February 19,  2013 ; accepted June 10,  2013.＊Corresponding author.  Phone : ＋81ﾝ86ﾝ223ﾝ7214; Fax : ＋81ﾝ86ﾝ235ﾝ7210E-mail : k-hase@md.okayama-u.ac.jp (K.  Hasegawa)(Fig.  1); we therefore dropped the idea of recon-struction using a left radial forearm free ﬂap.  A search for perforators using acoustic Doppler ﬂowm-etry revealed 2 perforators at a distance one-third distal to the center of the right anterolateral thigh,  and MDCT-angiography conﬁrmed perforators at the same site (Fig.  2A,  2D).  In addition,  MDCT-angiography revealed the descending branch of the lateral circumﬂex femoral artery (DB-LCFA) with a length of approximately 15cm (Fig.  2A,  2B),  and phalloplasty with an innervated island pedicled antero-lateral thigh ﬂap was therefore planned.　 The ﬂap was designed preoperatively.  The position of the perforators identiﬁed by acoustic Doppler ﬂowmetry was marked on the skin of the right thigh,  and the ﬂap was designed such that the mark was located at its center.  The ﬂap consisted of 3 portions:  a 4×15cm rectangular lateral segment for use in the construction of the neourethra; a trapezoidal medial segment with a proximal width of 12cm,  a distal width of 9cm,  and a length of 11cm for use in the construc-tion of a neophallus; and a deepithelialized 1×13cm 326 Acta Med.  Okayama　Vol.  67,  No.  5Hasegawa et al.Fig. 1　 Preoperative multidetector-row computed tomography (MDCT) angiography showed circulatory impairments in the left superﬁcial and deep palmar arches.15cmACB DFig. 2　 Preoperative MDCT-angiography of the left thigh revealed the descending branch of the lateral circumﬂex femoral artery (DB-LCFA) with a length of approximately 15cm (length from the origin of the descending branch to the skin perforator).  Yellow arrow: origin of the descending branch,  White arrow: skin perforator.rectangular middle segment to suture the ﬂap (Fig.  3).　 The ﬂap was raised with the patient in the supine position.  The skin and underlying fascia were incised at the medial border of the ﬂap and dissected subfas-cially in a medial to lateral direction.  Two perforators in the intermuscular septum between the rectus femo-ris and vastus lateralis were identiﬁed and preserved.  Subsequently,  the DB-LCFA was dissected in the intermuscular septum.  Motor branches of the femoral nerve running parallel to the vascular pedicle were carefully separated.  Next,  2 lateral femoral cutane-ous nerves were identiﬁed at the proximal border of the ﬂap,  dissected an additional 5cm proximally,  and divided.  Subsequently,  the lateral border of the ﬂap was incised down to the fascia,  and dissection was continued in a lateral to medial direction under the fascia of the vastus lateralis muscle.  The distal bor-der of the ﬂap was then incised,  and the ﬂap was ele-vated in a distal to proximal direction.　 A W-shaped incision was made in the pubic skin (Fig.  4),  and the innervated nerve island-pedicled ALT ﬂap was moved to the genital area through a tunnel under the rectus femoris and sartorius muscles.  The lateral ﬂap segment was wrapped around an 18 Fr urethral catheter to create a neourethra (Fig.  5A).  In addition,  the neourethral tube was covered by the medial ﬂap segment to create a tube within a tube.  The neourethra was anastomosed to the external ori-ﬁce of the urethra that had been lengthened up to the level of the clitoris in the previous surgery.  Two dorsal nerves of the clitoris,  which were the terminal branches of the pudendal nerve,  were identiﬁed on both sides of the clitoris (Fig.  5B) and anastomosed to the 2 lateral femoral cutaneous nerves of the ﬂap (Fig.  5C).  The fascia of the neophallus was sutured to the pubic periosteum,  followed by closure of the skin (Fig.  6A,  6B).  The ﬂap donor site was covered with a split-thickness skin graft taken from the con-tralateral thigh (Fig.  6C).　 Antibiotics were given for 7 days,  but no antico-agulants were administered after the surgery.  The patient was kept on bed rest for 7 days and then allowed to walk.  Fourteen days later,  the urethral catheter was removed and the patient became able to urinate in the standing position (Fig.  7A).  The post-operative course was uneventful,  without complica-tions such as ﬂap necrosis,  formation of a urethrocu-taneous ﬁstula,  or urethral stenosis.  Six months postoperatively,  the patient was able to feel sexual sensations in the reconstructed phallus.  Ten months after the surgery,  sculpturing of the neoglans was 327Phalloplasty with an Island Pedicled ALT ﬂap in a FTMTSOctober 201315cm14cmneourethraneophallusdeepithelializedareaA BFig. 3　 The 22-year-old female-to-male transsexual patient.  A,  the patientʼs condition before surgery; B,  ﬂap design in the right thigh.328 Acta Med.  Okayama　Vol.  67,  No.  5Hasegawa et al.BACneourethraneophallusLFCNdorsal clitoral nerves DB-LCFAnerve suturesdescending branch of lateral circumﬂex femoral artery and veinFig. 5　 Intraoperative ﬁndings.  A,  a neourethra was constructed with the lateral segment of the innervated island-pedicled ALT ﬂap that was moved to the genital area; B,  two dorsal nerves of the clitoris were identiﬁed on both sides of the clitoris; C,  a neophallus was constructed using the “tube within a tube” technique,  and 2 lateral femoral cutaneous nerves were sutured to 2 dorsal nerves of the clitoris.BAclitorisexternal urethraloriﬁceFig. 4　 The genital areaʼs condition before surgery.  A,  the external urethral oriﬁce was seen just below the clitoris because of urethral lengthening performed 2 years earlier; B,  skin incision lines in the genital area.329Phalloplasty with an Island Pedicled ALT ﬂap in a FTMTSOctober 2013BA skin graftCFig. 6　 The patientʼs condition immediately after surgery.  A,  frontal view; B,  lateral view; C,  the ﬂap donor site was covered with a split-thickness skin graft taken from the contralateral thigh.BAFig. 7　 Postoperative course.  A,  the patientʼs condition 3 weeks after surgery.  The patient became able to urinate in the standing position; B,  the patientʼs condition 11 months after surgery.  Sculpturing of the neoglans was additionally performed 10 months after the surgery.additionally performed,  and an aesthetically good penis was constructed (Fig.  7B).Discussion　 The ﬁrst literature report of phalloplasty was made by Bogoras in 1936,  who constructed a penis with a pedicled abdominal tubed ﬂap implanted with rib car-tilage [3].  Thereafter,  in 1946,  Maltz introduced the concept of inserting an outside-in tubed ﬂap within a tubed abdominal pedicle graft to reconstruct the phallus with a urethra [4].  This method was later improved and popularized by Gillies and Harrison [5].  In 1971,  Kaplan and Wasser were the ﬁrst to report a method for the construction of a sensitive penis;  they used a scrotal ﬂap to construct a urethra and a medial thigh ﬂap to construct the penile shaft [6].　 In 1982,  Puckett et al.  reported free ﬂap phallo-plasty using a microsurgical technique [7],  and researchers have subsequently reported phalloplasty using various free ﬂaps [8-10].  In particular,  Chang and Hwang reported phalloplasty with a radial forearm free ﬂap using the “tube within a tube” technique in 1984,  which is an excellent method from both an aesthetic and functional perspective [8].  Gilbert et al.  [10] and Hage and Graaf [11] have reported the characteristics of an ideal phalloplasty as follows: (1) one-stage operation; (2) capacity to urinate in the standing position; (3) tactile and erogenous sensibil-ity; (4) enough bulk to tolerate the insertion of a penile prosthesis; (5) aesthetic acceptability; (6) a small and inconspicuous scar at the ﬂap donor site;  and (7) no functional loss in the ﬂap donor area.  Although forearm ﬂaps are considered to be almost ideal for phalloplasty,  there is the problem of leaving a conspicuous scar on the forearm.  Phalloplasty with various ﬂaps has been reported even after the report of Chang and Hwang [12-15],  such as that with an island- pedicled [14] or free [15] anterolateral thigh ﬂap; the present case,  we performed phalloplasty with an innervated island-pedicled anterolateral thigh ﬂap using the “tube within a tube” technique [17] in a female-to-male transsexual.　 When compared to forearm ﬂaps,  this procedure has the following advantages in phalloplasty: 1) no need for a microsurgical technique; 2) no scars at noticeable sites; 3) small functional loss in the ﬂap donor area; 4) no sacriﬁce of major blood vessels.  On the other hand,  it has the disadvantages of 1) high anatomical variability in ALT ﬂap perforators,  and 2) thick ﬂaps are obtained from obese patients.  Based on these ﬁndings,  it is considered that this procedure is appropriate for patients with a negative Allen test and for those who do not wish to have the ﬂap taken from the forearm; furthermore,  a preoperative search for ALT ﬂap perforators is necessary not only by acoustic Doppler ﬂowmetry,  but also by color Doppler ultra-sonography and MDCT angiography.  In addition,  it should be kept in mind that if no dominant perforators are found intraoperatively,  there is an option to use other ﬂaps [15].  Thus far we have used deep inferior epigastric artery perforator ﬂaps [12] and superﬁcial circumﬂex iliac artery ﬂaps [16] as island-pedicled ﬂaps that do not require a microsurgical technique for patients with a negative result of the Allen test and for those not wishing to have the ﬂap taken from the forearm for cosmetic reasons.  These ﬂaps have the disadvantage of not being innervated,  while they have the advantage that the ﬂap donor site can usually be sutured in a one-stage operation.  Medial thigh ﬂaps are among the pedicled ﬂaps that can be used as inner-vated ﬂaps [6],  but to the best of our knowledge,  there have been no reports of phalloplasty with a medial thigh ﬂap using the “tube within a tube” tech-nique.  Although more clinical experience is needed in the future,  this procedure seems to be a useful alter-native for phallic reconstruction.　 At present in Japan,  SRS for patients with gender identity disorder is not covered by medical insurance,  and the patients have to pay for all surgery costs.  At our facility,  there are no diﬀerences in surgical costs between island-pedicled ﬂap phalloplasty and free-ﬂap phalloplasty for FTMTS.  In the future,  when SRS is covered by medical insurance,  the medical cost of island-pedicled ﬂap phalloplasty is expected to become lower than that of free-ﬂap phalloplasty by approxi-mately 300,000 yen.References 1. The Japanese Society of Psychiatry and Neurology: The diagnos-tic and therapeutic guidelines for patients with gender identity dis-order,  2nd ED,  Seishin Shinkeiggaku Zassi (2002) 104: 618-632 (in Japanese). 2. Namba Y,  Hasegawa K,  Watanabe T and Kimata Y: Phalloplasty in female to male transsexuals.  Keiseigeka (2009) 52: 1343-1350 (in Japanese).330 Acta Med.  Okayama　Vol.  67,  No.  5Hasegawa et al. 3. Bogoras N: Uber die volle plastische wieder herstellung eines zum koitus fahigen penis.  Zentralbl Chir (1936) 63: 1271-1276. 4. Maltz M: Maltz reparative technique for the penis; in Evolution of Plastic Surgery,  Maltz M ed,  Froben Press,  New York (1946) pp278-279. 5. Gillies H and Harrison RJ: Congenitalabsence of the penis.  Br J Plast Surg (1948) 1: 8-28. 6. Kaplan I and Wasser D: A rapid method for constructing a func-tional sensitive penis.  Br J Plast Surg (1971) 24: 342-344. 7. Puckett CL,  Reinisch JF and Montie JE: Free ﬂap phalloplasty.  J Urolo (1982) 128: 294-297. 8. Chang TS and Hwang WY: Forearm ﬂap in one-stage reconstruc-tion of the penis.  Plast Reconstr Surg (1984) 74: 251-258. 9. Upton J,  Mutimer KL,  Loughlin K and Ritchie J: Penile recon-struction using the lateral arm ﬂap.  J R Coll Surg Edinb (1987) 32:  97-101.10. Gilbert DA,  Horton CE,  Terzis JK,  Devine CJ,  Winslow BH and Devine PC: New concepts in phallic reconstruction.  Ann Plast Surg (1987) 18: 128-136.11. Hage JJ and Graaf FH: Addressing the ideal requirements by free ﬂap phalloplasty.  Microsurgery (1993) 14: 592-598.12. Davies DM and Matti BA: A method of phalloplasty using the deep inferior epigastric ﬂap.  Br J Plast Surg (1988) 41: 165-168.13. Harashina T,  Inoue T,  Tanaka I,  Imai K and Hatoko M: Recon-struction of penis with free deltoid ﬂap.  Br J Plast Surg (1990) 43: 217-222.14. Rubino C,  Figus A,  Dessy LA,  Alei G,  Mazzocchi M,  Trignano E and Scuderi N: Innervated island pedicled anterolateral thigh ﬂap for neo-phallic reconstruction in female-to male transsexuals.  J Plast Reconstr Aesthet Surg (2009) 62: e45-49.15. Felici N and Felici A: A new phalloplasty technique: the free anterolateral thigh ﬂap phalloplasty.  J Plast Reconstr Aesthet Surg (2006) 59: 153-157.16. Koshima I,  Namba Y,  Nagai A,  Nakatsuka M,  Sato T and Kuroda S:  Penile reconstruction with bilateral superﬁcial circumﬂex iliac artery perforator (SCIP) ﬂaps.  J Reconstr Microsurg (2006) 22: 137-142.17. Gordon KL,  Angeline FL and Erin TB: A Novel Single-Flap Technique for Total Penile Reconstruction: The Pedicled antero-lateral thigh ﬂap.  Plast Reconstr Surg (2009) 124: 163-166.331Phalloplasty with an Island Pedicled ALT ﬂap in a FTMTSOctober 2013

Phalloplasty with an Innervated Island Pedicled Anterolateral Thigh Flap in a Female-to-Male Transsexual

Since 2001, we have been performing phalloplasty with a radial forearm free flap as the flap of first
choice in female-to-male transsexuals (FTMTS). In the present case, a 22-year-old FTMTS with a
negative Allen test, we achieved good results by performing phalloplasty with an innervated island
pedicled anterolateral thigh flap using the “tube within a tube” technique, in which the penis and urethra
are constructed with a single flap. As compared to a forearm flap, use of an innervated islandpedicled
flap may have the following advantages in phalloplasty: 1) no need for a microsurgical technique;
2) no scars at noticeable sites; 3) small functional loss in the flap donor area; 4) no sacrifice of
major blood vessels. Thus, this technique seems to be a useful clinical alternative for phallic reconstruction

1.  Abstract.  Line 5Error and delete:While phalloplasty with an island-pedicled or free anterolateral thigh flap has been reported previously,  the present case seems to be the first of phalloplasty with an innervated island-pedicled anterolateral thigh flap using the “tube within a tube” technique.2.  page 330.  Line 5 form the bottom,  in the left column.Error:however,  seems to be the first report of phalloplasty with an innervated island-pedicled anterolateral thigh flap using the “tube within a tube” technique.Correction:we performed phalloplasty with an innervated island-pedicled anterolateral thigh flap using the “tube within a tube” technique [17] in a female-to-male transsexual.3.  page 331.  Add reference [17]17.  Gordon KL,  Angeline FL and Erin TB: A Novel Single-Flap Technique for Total Penile Reconstruction: The Pedicled anterolateral thigh flap.  Plast Reconstr Surg (2009) 124:  163-166.　In the article by Hasegawa K et al.  entitled “Phalloplasty with an Innervated Island Pedicled Anterolateral Thigh Flap in a Female-to-Male Transsexual”,  which appeared in the October 2013 issue,  Vol. 67,  No. 5,  pp325-331,  following corrections should be listed.Acta Med.  Okayama,  2014Vol.  68,  No.  3,  pp.  183ﾝ190CopyrightⒸ 2014 by Okayama University Medical School.Erratum with Corrected and Republished Article http ://escholarship.lib.okayama-u.ac.jp/amo/Phalloplasty with an Innervated Island Pedicled Anterolateral Thigh Flap in a Female-to-Male TranssexualKenjiro Hasegawa＊,  Yuzaburo Namba,  and Yoshihiro KimataDepartment of Plastic and Reconstractive Surgery,  Okayama University Graduate School of Medicine,   Dentistry and Pharmaceutical Sciences,  Okayama 700-8558,  JapanSince 2001,  we have been performing phalloplasty with a radial forearm free ﬂap as the ﬂap of ﬁrst choice in female-to-male transsexuals (FTMTS).  In the present case,  a 22-year-old FTMTS with a negative Allen test,  we achieved good results by performing phalloplasty with an innervated island pedicled anterolateral thigh ﬂap using the “tube within a tube” technique,  in which the penis and ure-thra are constructed with a single ﬂap.  As compared to a forearm ﬂap,  use of an innervated island-pedicled ﬂap may have the following advantages in phalloplasty: 1) no need for a microsurgical tech-nique; 2) no scars at noticeable sites; 3) small functional loss in the ﬂap donor area; 4) no sacriﬁce of major blood vessels.  Thus,  this technique seems to be a useful clinical alternative for phallic recon-struction.Key words: gender identity disorder,  sex reassignment surgery (SRS),  phalloplastyhe Japanese Society of Psychiatry and Neurology published “the diagnostic and therapeutic guide-lines for patients with gender identity disorder” in 1997 [1].  According to these guidelines,  we began performing sex reassignment surgery (SRS) in patients with gender identity disorder in January 2001,  and have performed phalloplasty in 23 female-to-male transsexuals (FTMTS) as of December 2008 [2].  Although radial forearm free ﬂaps have been used as the ﬂaps of ﬁrst choice,  deep inferior epigastric artery perforator ﬂaps,  superﬁcial circumﬂex iliac artery ﬂaps,  etc.,  have also been used in patients with a negative result of the Allen test and in those not wish-ing to have the ﬂap taken from the forearm.　 In the present case,  an FTMTS patient with a negative Allen test underwent phalloplasty with an innervated island pedicled anterolateral thigh ﬂap using the so-called “tube within a tube” technique,  in which the penis and urethra are constructed with a single ﬂap,  and good results were obtained.Case　 The patient was a 22-year-old who had been diag-nosed as a FTMTS and had initiated hormone therapy 5 years previously,  according to “The diagnostic and therapeutic guidelines for patients with gender iden-tity disorder” of the Japanese Society of Psychiatry and Neurology [1].  The patient had undergone bilat-eral mastectomy 4 years earlier and ovariohysterec-tomy and urethral lengthening 2 years earlier.  We planned to perform phalloplasty in this patient.　 Before surgery,  the Allen test on the left hand was negative and multidetector-row computed tomography (MDCT)-angiography also showed circulatory impair-ments in the left superﬁcial and deep palmar arches TActa Med.  Okayama,  2013Vol.  67,  No.  5,  pp.  325ﾝ331CopyrightⒸ 2013 by Okayama University Medical School.Case Report http ://escholarship.lib.okayama-u.ac.jp/amo/Received February 19,  2013 ; accepted June 10,  2013.＊Corresponding author.  Phone : ＋81ﾝ86ﾝ223ﾝ7214; Fax : ＋81ﾝ86ﾝ235ﾝ7210E-mail : k-hase@md.okayama-u.ac.jp (K.  Hasegawa)(Fig.  1); we therefore dropped the idea of recon-struction using a left radial forearm free ﬂap.  A search for perforators using acoustic Doppler ﬂowm-etry revealed 2 perforators at a distance one-third distal to the center of the right anterolateral thigh,  and MDCT-angiography conﬁrmed perforators at the same site (Fig.  2A,  2D).  In addition,  MDCT-angiography revealed the descending branch of the lateral circumﬂex femoral artery (DB-LCFA) with a length of approximately 15cm (Fig.  2A,  2B),  and phalloplasty with an innervated island pedicled antero-lateral thigh ﬂap was therefore planned.　 The ﬂap was designed preoperatively.  The position of the perforators identiﬁed by acoustic Doppler ﬂowmetry was marked on the skin of the right thigh,  and the ﬂap was designed such that the mark was located at its center.  The ﬂap consisted of 3 portions:  a 4×15cm rectangular lateral segment for use in the construction of the neourethra; a trapezoidal medial segment with a proximal width of 12cm,  a distal width of 9cm,  and a length of 11cm for use in the construc-tion of a neophallus; and a deepithelialized 1×13cm 326 Acta Med.  Okayama　Vol.  67,  No.  5Hasegawa et al.Fig. 1　 Preoperative multidetector-row computed tomography (MDCT) angiography showed circulatory impairments in the left superﬁcial and deep palmar arches.15cmACB DFig. 2　 Preoperative MDCT-angiography of the left thigh revealed the descending branch of the lateral circumﬂex femoral artery (DB-LCFA) with a length of approximately 15cm (length from the origin of the descending branch to the skin perforator).  Yellow arrow: origin of the descending branch,  White arrow: skin perforator.rectangular middle segment to suture the ﬂap (Fig.  3).　 The ﬂap was raised with the patient in the supine position.  The skin and underlying fascia were incised at the medial border of the ﬂap and dissected subfas-cially in a medial to lateral direction.  Two perforators in the intermuscular septum between the rectus femo-ris and vastus lateralis were identiﬁed and preserved.  Subsequently,  the DB-LCFA was dissected in the intermuscular septum.  Motor branches of the femoral nerve running parallel to the vascular pedicle were carefully separated.  Next,  2 lateral femoral cutane-ous nerves were identiﬁed at the proximal border of the ﬂap,  dissected an additional 5cm proximally,  and divided.  Subsequently,  the lateral border of the ﬂap was incised down to the fascia,  and dissection was continued in a lateral to medial direction under the fascia of the vastus lateralis muscle.  The distal bor-der of the ﬂap was then incised,  and the ﬂap was ele-vated in a distal to proximal direction.　 A W-shaped incision was made in the pubic skin (Fig.  4),  and the innervated nerve island-pedicled ALT ﬂap was moved to the genital area through a tunnel under the rectus femoris and sartorius muscles.  The lateral ﬂap segment was wrapped around an 18 Fr urethral catheter to create a neourethra (Fig.  5A).  In addition,  the neourethral tube was covered by the medial ﬂap segment to create a tube within a tube.  The neourethra was anastomosed to the external ori-ﬁce of the urethra that had been lengthened up to the level of the clitoris in the previous surgery.  Two dorsal nerves of the clitoris,  which were the terminal branches of the pudendal nerve,  were identiﬁed on both sides of the clitoris (Fig.  5B) and anastomosed to the 2 lateral femoral cutaneous nerves of the ﬂap (Fig.  5C).  The fascia of the neophallus was sutured to the pubic periosteum,  followed by closure of the skin (Fig.  6A,  6B).  The ﬂap donor site was covered with a split-thickness skin graft taken from the con-tralateral thigh (Fig.  6C).　 Antibiotics were given for 7 days,  but no antico-agulants were administered after the surgery.  The patient was kept on bed rest for 7 days and then allowed to walk.  Fourteen days later,  the urethral catheter was removed and the patient became able to urinate in the standing position (Fig.  7A).  The post-operative course was uneventful,  without complica-tions such as ﬂap necrosis,  formation of a urethrocu-taneous ﬁstula,  or urethral stenosis.  Six months postoperatively,  the patient was able to feel sexual sensations in the reconstructed phallus.  Ten months after the surgery,  sculpturing of the neoglans was 327Phalloplasty with an Island Pedicled ALT ﬂap in a FTMTSOctober 201315cm14cmneourethraneophallusdeepithelializedareaA BFig. 3　 The 22-year-old female-to-male transsexual patient.  A,  the patientʼs condition before surgery; B,  ﬂap design in the right thigh.328 Acta Med.  Okayama　Vol.  67,  No.  5Hasegawa et al.BACneourethraneophallusLFCNdorsal clitoral nerves DB-LCFAnerve suturesdescending branch of lateral circumﬂex femoral artery and veinFig. 5　 Intraoperative ﬁndings.  A,  a neourethra was constructed with the lateral segment of the innervated island-pedicled ALT ﬂap that was moved to the genital area; B,  two dorsal nerves of the clitoris were identiﬁed on both sides of the clitoris; C,  a neophallus was constructed using the “tube within a tube” technique,  and 2 lateral femoral cutaneous nerves were sutured to 2 dorsal nerves of the clitoris.BAclitorisexternal urethraloriﬁceFig. 4　 The genital areaʼs condition before surgery.  A,  the external urethral oriﬁce was seen just below the clitoris because of urethral lengthening performed 2 years earlier; B,  skin incision lines in the genital area.329Phalloplasty with an Island Pedicled ALT ﬂap in a FTMTSOctober 2013BA skin graftCFig. 6　 The patientʼs condition immediately after surgery.  A,  frontal view; B,  lateral view; C,  the ﬂap donor site was covered with a split-thickness skin graft taken from the contralateral thigh.BAFig. 7　 Postoperative course.  A,  the patientʼs condition 3 weeks after surgery.  The patient became able to urinate in the standing position; B,  the patientʼs condition 11 months after surgery.  Sculpturing of the neoglans was additionally performed 10 months after the surgery.additionally performed,  and an aesthetically good penis was constructed (Fig.  7B).Discussion　 The ﬁrst literature report of phalloplasty was made by Bogoras in 1936,  who constructed a penis with a pedicled abdominal tubed ﬂap implanted with rib car-tilage [3].  Thereafter,  in 1946,  Maltz introduced the concept of inserting an outside-in tubed ﬂap within a tubed abdominal pedicle graft to reconstruct the phallus with a urethra [4].  This method was later improved and popularized by Gillies and Harrison [5].  In 1971,  Kaplan and Wasser were the ﬁrst to report a method for the construction of a sensitive penis;  they used a scrotal ﬂap to construct a urethra and a medial thigh ﬂap to construct the penile shaft [6].　 In 1982,  Puckett et al.  reported free ﬂap phallo-plasty using a microsurgical technique [7],  and researchers have subsequently reported phalloplasty using various free ﬂaps [8-10].  In particular,  Chang and Hwang reported phalloplasty with a radial forearm free ﬂap using the “tube within a tube” technique in 1984,  which is an excellent method from both an aesthetic and functional perspective [8].  Gilbert et al.  [10] and Hage and Graaf [11] have reported the characteristics of an ideal phalloplasty as follows: (1) one-stage operation; (2) capacity to urinate in the standing position; (3) tactile and erogenous sensibil-ity; (4) enough bulk to tolerate the insertion of a penile prosthesis; (5) aesthetic acceptability; (6) a small and inconspicuous scar at the ﬂap donor site;  and (7) no functional loss in the ﬂap donor area.  Although forearm ﬂaps are considered to be almost ideal for phalloplasty,  there is the problem of leaving a conspicuous scar on the forearm.  Phalloplasty with various ﬂaps has been reported even after the report of Chang and Hwang [12-15],  such as that with an island- pedicled [14] or free [15] anterolateral thigh ﬂap; the present case,  we performed phalloplasty with an innervated island-pedicled anterolateral thigh ﬂap using the “tube within a tube” technique [17] in a female-to-male transsexual.　 When compared to forearm ﬂaps,  this procedure has the following advantages in phalloplasty: 1) no need for a microsurgical technique; 2) no scars at noticeable sites; 3) small functional loss in the ﬂap donor area; 4) no sacriﬁce of major blood vessels.  On the other hand,  it has the disadvantages of 1) high anatomical variability in ALT ﬂap perforators,  and 2) thick ﬂaps are obtained from obese patients.  Based on these ﬁndings,  it is considered that this procedure is appropriate for patients with a negative Allen test and for those who do not wish to have the ﬂap taken from the forearm; furthermore,  a preoperative search for ALT ﬂap perforators is necessary not only by acoustic Doppler ﬂowmetry,  but also by color Doppler ultra-sonography and MDCT angiography.  In addition,  it should be kept in mind that if no dominant perforators are found intraoperatively,  there is an option to use other ﬂaps [15].  Thus far we have used deep inferior epigastric artery perforator ﬂaps [12] and superﬁcial circumﬂex iliac artery ﬂaps [16] as island-pedicled ﬂaps that do not require a microsurgical technique for patients with a negative result of the Allen test and for those not wishing to have the ﬂap taken from the forearm for cosmetic reasons.  These ﬂaps have the disadvantage of not being innervated,  while they have the advantage that the ﬂap donor site can usually be sutured in a one-stage operation.  Medial thigh ﬂaps are among the pedicled ﬂaps that can be used as inner-vated ﬂaps [6],  but to the best of our knowledge,  there have been no reports of phalloplasty with a medial thigh ﬂap using the “tube within a tube” tech-nique.  Although more clinical experience is needed in the future,  this procedure seems to be a useful alter-native for phallic reconstruction.　 At present in Japan,  SRS for patients with gender identity disorder is not covered by medical insurance,  and the patients have to pay for all surgery costs.  At our facility,  there are no diﬀerences in surgical costs between island-pedicled ﬂap phalloplasty and free-ﬂap phalloplasty for FTMTS.  In the future,  when SRS is covered by medical insurance,  the medical cost of island-pedicled ﬂap phalloplasty is expected to become lower than that of free-ﬂap phalloplasty by approxi-mately 300,000 yen.References 1. The Japanese Society of Psychiatry and Neurology: The diagnos-tic and therapeutic guidelines for patients with gender identity dis-order,  2nd ED,  Seishin Shinkeiggaku Zassi (2002) 104: 618-632 (in Japanese). 2. Namba Y,  Hasegawa K,  Watanabe T and Kimata Y: Phalloplasty in female to male transsexuals.  Keiseigeka (2009) 52: 1343-1350 (in Japanese).330 Acta Med.  Okayama　Vol.  67,  No.  5Hasegawa et al. 3. Bogoras N: Uber die volle plastische wieder herstellung eines zum koitus fahigen penis.  Zentralbl Chir (1936) 63: 1271-1276. 4. Maltz M: Maltz reparative technique for the penis; in Evolution of Plastic Surgery,  Maltz M ed,  Froben Press,  New York (1946) pp278-279. 5. Gillies H and Harrison RJ: Congenitalabsence of the penis.  Br J Plast Surg (1948) 1: 8-28. 6. Kaplan I and Wasser D: A rapid method for constructing a func-tional sensitive penis.  Br J Plast Surg (1971) 24: 342-344. 7. Puckett CL,  Reinisch JF and Montie JE: Free ﬂap phalloplasty.  J Urolo (1982) 128: 294-297. 8. Chang TS and Hwang WY: Forearm ﬂap in one-stage reconstruc-tion of the penis.  Plast Reconstr Surg (1984) 74: 251-258. 9. Upton J,  Mutimer KL,  Loughlin K and Ritchie J: Penile recon-struction using the lateral arm ﬂap.  J R Coll Surg Edinb (1987) 32:  97-101.10. Gilbert DA,  Horton CE,  Terzis JK,  Devine CJ,  Winslow BH and Devine PC: New concepts in phallic reconstruction.  Ann Plast Surg (1987) 18: 128-136.11. Hage JJ and Graaf FH: Addressing the ideal requirements by free ﬂap phalloplasty.  Microsurgery (1993) 14: 592-598.12. Davies DM and Matti BA: A method of phalloplasty using the deep inferior epigastric ﬂap.  Br J Plast Surg (1988) 41: 165-168.13. Harashina T,  Inoue T,  Tanaka I,  Imai K and Hatoko M: Recon-struction of penis with free deltoid ﬂap.  Br J Plast Surg (1990) 43: 217-222.14. Rubino C,  Figus A,  Dessy LA,  Alei G,  Mazzocchi M,  Trignano E and Scuderi N: Innervated island pedicled anterolateral thigh ﬂap for neo-phallic reconstruction in female-to male transsexuals.  J Plast Reconstr Aesthet Surg (2009) 62: e45-49.15. Felici N and Felici A: A new phalloplasty technique: the free anterolateral thigh ﬂap phalloplasty.  J Plast Reconstr Aesthet Surg (2006) 59: 153-157.16. Koshima I,  Namba Y,  Nagai A,  Nakatsuka M,  Sato T and Kuroda S:  Penile reconstruction with bilateral superﬁcial circumﬂex iliac artery perforator (SCIP) ﬂaps.  J Reconstr Microsurg (2006) 22: 137-142.17. Gordon KL,  Angeline FL and Erin TB: A Novel Single-Flap Technique for Total Penile Reconstruction: The Pedicled antero-lateral thigh ﬂap.  Plast Reconstr Surg (2009) 124: 163-166.331Phalloplasty with an Island Pedicled ALT ﬂap in a FTMTSOctober 2013

For Vol.67, No.5 pp325-331 Phalloplasty with an Innervated Island Pedicled Anterolateral Thigh Flap in a Female-to-Male Transsexual

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Phalloplasty with an Innervated Island Pedicled Anterolateral Thigh Flap in a Female-to-Male Transsexual

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