Radial forearm free flap
This flap was as gold standard of phalloplasty for many years. For executing the flap sufficient tissue including skin, fat, facia, vessels and nerves is removed from forearm of the non-dominant hand. The size of the flap depends on physical properties of patient, i.e the length of forearm and subcutaneous fat thickness. The average length is about 12 to 15 cm. Without urethral reconstruction half of forearm circumference is removed but for urinary diversion three fourth is used. Advantages of the flap is good sensation and acceptable incidence of urinary complications. The major drawback of the RFF has always been the unattractive donor site scar on the forearm . Also microsurgical anastomosis is mandatory with related risk of thrombosis. In thin patients the size of the phallus is small, and in some cases fat resorption might lead to phallus deflation. In addition laser hair removal of urethroplasty portion of flap is mandatory.
Anterolateral thigh(ALT) flap
Another good option for phalloplasty is anterolateral thigh flap. Like RFF it has good sensory nerves for obtaining tactile and sexual senses. The flap is harvested from mid portion of anterior thigh. Its length is between 12-18 cm and its diameter depends on fat thickness. Ideal size phallus can be harvested with pinch test of 2-2.5 cm or fat thickness less than 12 mm. Unfortunately the subcutaneous fat layer in transmen individuals with XX chromosomes is abundant, and for those with pinch test more than 3 cm large phallus is unavoidable. Thus in these patients decreasing the thickness of fat is necessary by direct resection or liposuction. Its main advantages is well hidden scar and avoidance of microsurgical anastomosis. The major problem with ALT phalloplasty is urethroplasty. Because of tissue thickness the tube-in-tube technique of RFF is not applicable and more complicated procedures should be considered or rely on skin graft for urinary diversion with significant complications.
Free fibula flap
Erection of phalloplasty is a challenging issue. One solution for the problem is incorporation of bone within the flap. Maintenance of the bone survival is dependent on own circulation. One of the best choice is free fibula flap, because the length and diameter of the bone is very good. The average length is about 13-16 cm.
Because there is no need for penile prosthesis, tactile sense is not as essential as other flaps. The flexibility of the flap is possible at its base, thus positioning and coverage it within underwear is possible.
The major drawbacks are difficulty of urinary diversion and unsightly scar in leg. Also the surgery is more complicated.
Latissimus dorsi flap
The flap is harvested from axilla and is the only technique that incorporate muscle within the flap. Usually its size is very large and suitable candidates are thin individuals.
There is no sensory nerve in the flap, thus penile prosthesis extrusion might not be preventable. Also urinary diversion is possible only by skin graft.
