Total penile reconstruction (TPC) is challenging, with surgical goals including an acceptable cosmetic and functional phallus, with restoration of sufficient penile length for social integration.
This video highlights the complete process of TPC utilizing the radial artery free forearm flap (RAFFF).
RAFFF phalloplasty creates a cosmetically acceptable phallus with tactile and orgasmic sensation, incorporated neo-urethra enabling urinary and/or ejaculatory drainage, whilst ensuring length and rigidity to enable penetrative sexual intercourse. RAFFF stages include: 1) Phallus formation with neourethra and microvascular transfer to the recipient site; 2) Glans sculpture utilising the modified Norfolk technique; 3) Penile implant insertion. Each stage is performed at 3-monthly-intervals; Complications being dealt with during the following stage, reducing overall procedure numbers.
1) Forearm flap is raised preserving neurovascular components, with a medial component to form the neo-urethra. The lateral phallic part wrapped around the urethra in a ‘tube within a tube’ fashion. Recipient site is prepared with complete disassembly of the penis. The phallus is transposed to the recipient area and spatulated urethral anastomosis performed. Vascular, neural and urethral microsurgical anastomoses are performed. The donor forearm is covered with a full-thickness buttock skin-graft.
2) A neo-glans is fashioned using a circumferential incision; full thickness skin is lifted and rolled to form a pseudo coronal ridge, with a full thickness graft inserted into the proximal defect. The abdominal skin incision (graft site), offers convenient access for reservoir placement.
3) Penile implant is performed through a peno-scrotal incision. A vascular graft distal cap is applied to the tip of the cylinder, minimizing distal erosion risk.
For cases shown in this video, the post operative course was uneventful.
RAFFF yields reliable cosmetic and functional results. Patients must be warned, however, that the process requires several staged procedures that the complication rates are significant.