The patients remain in bed during a one-week postoperative time period, after which the transurethral catheter is removed. At that time, the suprapubic catheter was clamped, and invalidate was begun. effective invalidate might not be observed for several days. Before removal of the suprapubic catheter, a cystography with voiding urethrography was performed. In the beginning 50 patients of this series, the defect on the forearm was covered with full-thickness skin grafts taken from the groin area. In subsequent patients, the defect was covered with split-thickness hide grafts harvested from the medial and anterior thigh ( Fig. ). once the urethra is lengthened and the acceptor ( recipient ) vessels are dissected in the groin area, the patient is put into a supine situation. The release dither can be transferred to the pubic area after the urethral anastomosis : the radial artery is microsurgically connected to the common femoral artery in an end-to-side fashion and the venous anastomosis is performed between the cephalic vein and the greater saphenous vein ( Fig. ). One forearm nerve is connected to the ilioinguinal nerve for protective sense and the other heart of the arm is anastomosed to one of the abaxial clitoral nerves for erogenous sensation. The clitoris is normally denuded and buried underneath the penis, thus keeping the possibility to be stimulated during sexual sexual intercourse with the neophallus. simultaneously, the plastic surgeon dissects the loose vascularize flap of the forearm. The universe of a penis with a tube-in-a-tube proficiency is performed with the flap however attached to the forearm by its vascular pedicel ( Fig. ). This is normally performed on the ulnar expression of the bark island. A small skin flap and a skin graft are used to create a corona and simulate the glans of the penis ( Fig. ). For the genitoperineal transformation ( vaginectomy, urethral reconstruction, scrotoplasty, phalloplasty ), two surgical teams operate at the lapp time with the affected role inaugural placed in a gynecological ( lithotomy ) position. In the perineal area, a urologist may perform a vaginectomy, and lengthen the urethra with mucous membrane between the minor labiae. The vaginectomy is a mucosal colpectomy in which the mucosal lining of the vaginal cavity is removed. After extirpation, a pelvic floor reconstruction is constantly performed to prevent possible diseases such as cystocele and rectocele. This reconstruction of the situate separate of the urethra is combined with a scrotal reconstruction by means of two transposition flaps of the greater labium resulting in a very natural looking bifid scrotum .
The Ideal Goals of Penile Reconstruction in FTM Surgery
What can be achieved with this radial forearm beat proficiency as to the ideal requisites for penile reconstruction ?
A ONE-STAGE PROCEDURE
In 1993, Hage 20 stated that a complete penile reconstruction with erection prosthesis never can be performed in one single operation. Monstrey et aluminum, 29 early in their series and to reduce the number of surgeries, performed a ( screen of ) all-in-one procedure that included a SCM and a dispatch genitoperineal transformation. however, subsequently in their series they performed the SCM first most often in combination with a total hysterectomy and oophorectomy. The reason for this change in protocol was that drawn-out operations ( > 8 hours ) resulted in considerable blood loss and increased secret agent risk. 30 furthermore, an aesthetic SCM is not to be considered as an easy operation and should not be performed “ quickly ” before the major phalloplasty operation .
AN AESTHETIC PHALLUS
Phallic construction has become predictable enough to refine its aesthetic goals, which includes the use of a technique that can be replicated with minimal complications. In this respect, the radial forearm flap has respective advantages : the flap is thin and ductile allowing the construction of a normal sized, tube-within-a-tube penis ; the flap is easy to dissect and is predictably well vascularized making it safe to perform an ( aesthetic ) glansplasty at the distal end of the beat. The final examination cosmetic result of a radial forearm phalloplasty is a subjective determination, but the ability of most patients to shower with other men or to go to the sauna is the usual cosmetic barometer ( Fig. ) .Open in a separate window The electric potential aesthetic drawbacks of the radial forearm dither are the need for a rigidity prosthesis and possibly some volume loss over time .
TACTILE AND EROGENOUS SENSATION
Of the assorted flaps used for penile reconstruction, the radial forearm flap has the greatest sensitivity. 1 Selvaggi and Monstrey et alabama. always connect one antebrachial nerve to the ilioinguinal heart for protective sense and the early forearm heart with one dorsal clitoral heart. The denude clitoris was always placed immediately below the phallic shaft. Later handling of the neophallus allows for stimulation of the still-innervated clitoris. After one year, all patients had regained tactile sensitivity in their penis, which is an absolute requirement for condom interpolation of an erecting prosthesis. 31 In a long-run follow-up study on postoperative sexual and forcible health, more than 80 % of the patients reported improvement in sexual satisfaction and greater rest in reaching orgasm ( 100 % in practicing postoperative FTM transsexuals ). 32
VOIDING WHILE STANDING
For biological males angstrom well as for FTM transsexuals undergoing a phalloplasty, the ability to void while standing is a high precedence. 33 unfortunately, the report incidences of urological complications, such as urethrocutaneous fistulas, stenoses, strictures, and hairy urethras are highly high in all series of phalloplasties, equally high as 80 %. 34 For this reason, certain ( well-intentioned ) surgeons have even stopped reconstructing a complete neo-urethra. 35, 36 In their series of radial forearm phalloplasties, Hoebeke and Monstrey placid reported a urological complication rate of 41 % ( 119/287 ), but the majority of these early fistulas closed spontaneously and ultimately all patients were able to void through the newly reconstructed penis. 37 Because it is nameless how the newly urethra—a 16-cm skin tube—will affect bladder routine in the long term, lifelong urologic follow-up was powerfully recommended for all these patients .
Complications following phalloplasty include the general complications attendant to any surgical intervention such as minor wound healing problems in the groin sphere or a few patients with a ( minor ) pneumonic embolism despite adequate prevention ( interrupting hormonal therapy, fractioned heparin subcutaneously, elastic stockings ). A vaginectomy is normally considered a peculiarly difficult mathematical process with a high risk of postoperative run, but in their series no major bleedings were seen. 30 Two early patients displayed symptoms of nerve compression in the lower leg, but after reducing the distance of the gynecological position to under 2 hours, this complicatedness never occurred again. apart from the urinary fistulas and/or stenoses, most complications of the radial forearm phalloplasty are related to the free tissue transplant. The sum dither bankruptcy in their series was identical low ( < 1 %, 2/287 ) despite a slightly higher anastomotic rewrite pace ( 12 % or 34/287 ). About 7 ( 3 % ) of the patients demonstrated some degree of skin slough or partial roll necrosis. This was more often the case in smokers, in those who insisted on a large-sized penis requiring a larger flap, and besides in patients having undergo anastomotic rewrite. With smoking being a significant hazard factor, under our stream policy, we no longer operate on patients who fail to quit smoking one year prior to their operation .
NO FUNCTIONAL LOSS AND MINIMAL SCARRING IN THE DONOR AREA
The major drawback of the radial forearm flap has constantly been the unattractive donor web site scar on the forearm ( Fig. ). Selvaggi et aluminum conducted a long-run follow-up sketch 38 of 125 radial forearm phalloplasties to assess the academic degree of functional loss and aesthetic stultification after harvesting such a large forearm dither. An increased donor web site unwholesomeness was expected, but the early and late complications did not differ from the rates reported in the literature for the smaller flaps as used in point and neck reconstruction. 38 No major or long-run problems ( such as functional limitation, steel injury, chronic pain/edema, or cold intolerance ) were identified. ultimately, with esteem to the aesthetic consequence of the donor site, they found that the patients were identical accepting of the donor site scar, viewing it as a worthwhile tradeoff for the creation of a penis ( Fig. ). 38 Suprafascial beat dissection, full moon thickness peel grafts, and the function of cutaneous substitutes may contribute to a better forearm scar .Open in a separate window
For the FTM patient, the finish of creating natural-appearing genitals besides applies to the scrotum. As the labium majora are the embryological counterpart of the scrotum, many previous scrotoplasty techniques left the hair-bearing labium majora in situ, with midplane closure and prosthetic implant filling, or brought the scrotum in front man of the legs using a V-Y plasty. These techniques were aesthetically unappealing and evocative of the female genitalia. Selvaggi in 2009 reported on a novel scrotoplasty technique, which combines a V-Y plasty with a 90-degree turn of the labial consonant flaps resulting in an anterior substitution of labial skin ( Fig. ). The excellent aesthetic result of this male-looking ( anteriorly located ) scrotum, the functional advantage of fewer urological complications and the easier implantation of testicular prostheses make this the proficiency of choice. 39Open in a separate window
In a radial forearm phalloplasty, the interpolation of erecting prosthesis is required to engage in sexual sexual intercourse. In the past, attempts have been made to use bone or cartilage, but no good long-run results are described. The rigid and semirigid prostheses seem to have a high perforation rate and therefore were never used in our patients. Hoebeke, in the largest series to date on erecting prostheses after penile reconstruction, only used the hydraulic systems available for impotent men. A recent long-run follow-up report showed an explantation rate of 44 % in 130 patients, chiefly due to malpositioning, technical failure, or infection. still, more than 80 % of the patients were able to have normal intimate intercourse with penetration. 37 In another survey, it was demonstrated that patients with an erection prosthesis were more able to attain their sexual expectations than those without prosthesis ( Fig. ). 32
Open in a separate window A major concern regarding erectile prostheses is long-run follow-up. These devices were developed for impotent ( older ) men who have a shorter life anticipation and who are sexually less active than the largely younger FTM patients .