Technique of Total Phalloplasty with Reinnervated Latissimus Dorsi Myocutaneous
Free Flap in Female-to-Male Transsexuals
Vesely J, Hyza P, Ranno R, Cigna E, Monni N, Stupka I, Justan I, Dvorak
Z, Novak P, Ranno S
Clinic of Plastic and Aesthetic Surgery, St. Anna University Hospital,
Masaryk University in Brno, Brno, Czech Republic
Ann Plast Surg. 2007; 58: 544-50
- From December
2001 to September 2005, the technique of total penile reconstruction
with a reinnervated free latissimus dorsi myocutaneous flap was used
in 22 patients (24-38 years old) with gender dysphoria. These patients
were followed up for at least 11 months (range, 11-44 months). All flaps
survived. Complications include hematoma (7 cases), vascular thrombosis
(2 cases), partial necrosis (1 case), excessive swelling of the neophallus
(3 cases), and skin graft loss at the donor site (1 case). Of the 19
patients included in the final evaluation, the transplanted muscle was
able to obtain contraction in 18 (95%) cases and 8 patients (42%) had
sexual intercourse by contracting the muscle to stiffen and move the
neopenis. The described technique of neophalloplasty proved to be a
reliable technique and the muscle movement in the neophallus can be
expected in almost all cases. The muscle contraction in the neophallus
leads to “paradox” erection-stiffening, widening, and shortening
of the neopenis, which allows for sexual intercourse in some patients.
Subsequent reconstruction of the urethra is possible.
Functioning free muscle flaps have recently been shown to successfully
restore volitional voiding in patients with acontractile bladders (1).
Apart from the anastomosis of the flap, vasculature to suitable vessels
at the recipient site function is achieved by microsurgical coaptation
of the motor nerve supplying the flap muscle to a recipient motor nerve
supplying an abdominal muscle. The transferred muscle starts acting
as a “piggyback” muscle to the same muscle with which it
shares its new innervation.
The authors of this paper have applied the same principle for phalloplasty
in female-to-male transsexuals. In addition to obtaining a neophallus,
the majority of patients were able to contract the muscle after a mean
of 4 months. Almost half of the patients used the muscle contraction
to stiffen the penis and were thus able to have intercourse.
Contrary to the sole use of latissimus dorsi muscle in detrusor, myoplasty
phalloplasty needs a large portion of the overlying skin similar to
musculocutaneous flaps used for breast reconstruction. Therefore, the
rate of donor site morbidity was larger than previously reported (2),
but according to the authors, 83 % considered donor site morbidity as
The fact that no urethral reconstruction was done in these patients
may be seen as a downfall. However, the possibility of actively stiffening
the neophallus may be appealing for some patients. The mean follow-up
of almost two years with some patients just followed for a year is too
short. Some patients apparently had considerable shrinkage of the graft
and this number might get larger with a longer follow-up. However, the
concept of using a functioning muscle transfer for phalloplasty is worth
to be considered and shows furthermore the possible versatility of this
technique applicable in various fields of urology.
A, Ninkovic M, Kölle D, Knapp R, Anderl H, Bartsch G: Restoration
of voluntary emptying of the bladder by transplantation of innervated
free skeletal muscle. Lancet. 1998; 351: 1483-5.
2. Ninkovic M, Stenzl A, Schwabegger A, Bartsch G, Prosser R, Ninkovic
M: Free neurovascular transfer of latisstmus dorsi muscle for the treatment
of bladder acontractility: II. Clinical results. J Urol. 2003; 169: 1379-83.
Arnulf Stenzl &
Dr. Karl-Dietrich Sievert
Department of Urology