If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
To identify the relative success rates, including aesthetic success, of three penis reconstruction techniques, we reviewed 44 cases of penis reconstruction carried out over the past 12 years. The three operative methods we surveyed involved: lower abdominal pedicled fascia flaps; paraumbilical island flaps; and free forearm flaps. Reconstructions survived in only half of the patients receiving lower abdominal pedicled fascia flaps, but 100% success rates were obtained with paraumbilical island flaps and free forearm flaps. The paraumbilical island flap is safe in terms of its blood supply, and the operative procedure is relatively simple in that it does not require microsurgery. Although, the flap is thicker than the forearm skin flap, its shape is satisfactory in slim patients; furthermore, it can be defatted secondarily. The free forearm skin flap provides the best shape, but skilled microsurgery is necessary to carry out the procedure, and damage is likely to the forearm. In conclusion, the best methods to repair defects in the penis in our experience are the paraumbilical island flap and free forearm flap. Lower abdominal pedicled fascia flaps are unsuitable for penile reconstruction and should be used less often.
Phalloplasty including urethroplasty is a formidable task in perineal trauma, congenital defect or transsexuals. Bogoras (1936) was one of the first to construct a penis with surgical techniques, and from then on, skin flaps were gradually being substituted for traditional tube pedicle flaps in penis reconstruction. Many types of flaps have been applied, such as the lower abdominal pedicled fascia flap, paraumbilical island flap, and free forearm flap.
introduced one-stage reconstruction of the penis with an abdominal fasciocutaneous flap in 1986. These flaps were now commonly used in penis reconstruction and their surgical designs were in ceaseless modification for better appearance and function. Here, we report our clinical data and experiences with these methods over 12 years.
Patients and methods
We report penis reconstructions of 44 patients from April, 1991 to March, 2003. All cases were full or major defects of the penis due to congenital defects (eight cases) or various traumas (36 cases; Table 1). We used lower abdominal pedicled fascia flaps in eight cases (Figure 1, Figure 2), paraumbilical island flaps in 18 (Fig. 3) and free forearm flaps in 18 (Fig. 4).
Figure 1An 18-year-old man with a full penile defect caused by a dog bite. (A) Preoperative view. (B) A lower abdominal fascia flap was designed. Two designs in different directions can be used. (C) Seven days after operation, 50% necrosis was seen in this flap.
Figure 3Penis reconstruction using a paraumbilical island flap. (A) Design of flap before operation. (B) Intraoperative view. (C) Three weeks after operation.
Figure 4Penis reconstruction using a free forearm flap. (A) A micropenis patient postoperative view. (B) Design of flap. (C) A month after operation. A good stream can be seen.
We designed an upward flap like a table tennis racket (Fig. 1(B)), its handle (10 cm×3 cm) starting at the femoral artery below the inguinal ligament, and its board (10–12 cm×12–14 cm) located in the lower abdomen. It contained the arteria epigastrica superficialis and arteria circumflexa ilium superficial in its subcutaneous fascia. We used two designs to reconstruct the urethra and corpus penis. The first design was to reconstruct the urethra with the lateral portion of the flap and the corpus penis with the medial portion. The second design was to reconstruct the urethra with the upper portion of the flap and the corpus penis with the lower. This dissection was started from cephalad and lateral, and the flap was raised with the deep fascia towards the groin, forming a 3–5 cm wide pedicle and transposing it via a subcutaneous tunnel or incision to the penile root. For the overabundant tissues of the pedicle, the subcutaneous tunnel was seldom used for transposition. Then, we removed the epidermis in the conjunctional folded part, and rotated and sutured it to the nub of the original penis. It is important that the flap pedicle contain known vessels, which provide a blood supply to the distal region. We should preserve the arteria epigastrica superficialis and arteria circumflexa ilium superficial in the pedicle as possible, even though it is more difficult for their small caliber and anatomic variation.
Paraumbilical island flap
This is a flag-like pedicled flap (Fig. 3(A)). Its pole is the pedicle, about 10 cm in length, containing the inferior epigastric vessels, starting from the beating point of the femoral artery below the inguinal ligament; and the banner, 10–12 cm in length and 12–14 cm in width, is the main part of the flap. This dissection was initiated in inner lateral, incising the anterior rectus sheath, exposing the rectus muscle and the place where the perforators penetrate into the muscle. The rest part of the flap was then dissected deep to the rectus sheath. In paraumbilical area of 1.5–2 cm, we sought for 1–3 major skin perforator and divided the muscle deep to the trunk vessel, thus formed the island flap. We rotated the flap via the subcutaneous tunnel and reconstructed the urethra with the lateral part of the flap and the corpus penis with the medial; afterwards it was pivoted on the inferior epigastric vessels and sutured it to the penile stump. The key point was to take care to isolate the flap, so as not to injure the inferior epigastric vessels or major paraumbilical skin perforators. The local blood supply was better if the flap contained two to three skin perforators.
Free forearm flap
We designed a flap of 10–12 cm in length and 12–14 cm in width, proximal to the wrist and centered on the radial artery (Fig. 4(B)). We reconstructed the penis with the palm-side part of the flap, which contained the radial artery and vein and the cephalic vein, and the urethra with the contiguous dorsal part, which contained branches of the radial artery and cephalic vein. After cutting off the pedicle, we performed end-to-end or end-to-side anastomosis between the radial artery and femoral artery or its sub-branches, and anastomosed the cephalic vein and radial vein to the great saphenous vein and its sub-branches. The lateral antebrachial cutaneous nerve is readily identifiable and can be coapted with the dorsal nerve of the penis to achieve erogenous sensation.
In all these methods, an auto-costal cartilage rod (8–10 cm in length and 1.2 cm in diameter) was partially inserted in the remaining cavernous tissue and sutured in place with 3/0 nylon. Postoperatively, the reconstructed penis was still erectile. If the corpus cavernosum was absent, a transplant was sutured to the periosteum at the inferior border of the puvic symphysis. Finally, when penis reconstruction was almost finished, we reversed the front portion of the inner flap and sutured it to the outer flap to form the glans.
Results
From April, 1991 to March, 2003, we used these three methods in 44 patients (aged from 18 to 46 years). Follow-up ranged from 6 months to 5 years. Excellent results were obtained in the patients reconstructed with paraumbilical island flaps and free forearm flaps, while poor results was in those with lower abdominal pedicled fascia flaps (Table 2), and all the cases of necrosis required secondary debridement. Four of them had secondary penile reconstructions with free forearm flaps or paraumbilical flaps 1–2 years later. Of all the cases, there were six cases of urinary fistula to be corrected by secondary operations (suturing urethra directly or repaired by local flap) and three cases of urinary stricture to be corrected by urethral dilatation. Among our 40 successful cases, six of 32 patients who had sex lives after their operations reported satisfactory, 18 partially satisfactory, and eight dissatisfactory. The other eight patients had no sexual function postoperation. Cases of paraumbilical flaps, compared with those of free forearm flaps, were more bulky and less conformity in appearance, but similar in length (Table 3). There was no significant difference in urination and sexual function (Table 4).
Table 2Results of three methods of penis reconstruction
The donor site was resurfaced by a split-thickness skin graft in all the patients. In the group of lower abdominal flaps, two cases had no first intention healing and healed after dressing change or secondary skin graft to the donor sites; in the paraumbilical flaps, three cases had no first intentions, of which two healed by dressing change and one healed by secondary skin graft; in the free forearm flaps, five cases had no first intention healing three healed by dressing change and two healed by secondary skin graft.
Discussion
The paraumbilical flap is an island flap pedicled with the deep inferior epigastric vessels. It is large and anatomically constant and has the best blood supply of the above described methods. However, it is bulky in obese patients. Its shape is satisfactory in thin patients, and it can also be defatted later.
The free forearm flap is the thinnest of all the types and is suitable for shaping, however, it requires skilled microsurgical techniques and entails damage to the forearm.
The lower abdominal flap theoretically has a dual blood supply from the arteria epigastrica superficialis and arteria circumflexa ilium superficial, and there have been several reports of its successful applications.
However, we found that the epigastrica superficialis and circumflexa ilium superficial vessels were much smaller and more variable than the inferior epigastric vessels, and the narrow fascia pedicle often cannot contain the two groups of vessels in it. After multiple folding of the flap in the urethra and corpus penis, the distal part of it often showed a severe blood supply dysfunction. In our eight cases of this method, four showed serious necrosis of more than half the distal part, and fractional necrosis was seen in the other four. Although, we had paid great attention to protecting the blood vessels, it was difficult to confirm the two groups of vessels were contained in one pedicle. We found that the distal blood supply was unsatisfactory and that necrosis was very likely to occur after the operation. In our opinion, therefore, this method should be used much less often, and perhaps just for repairing small penile defects. If used, we should assure that the two groups of vessels are adjacent to each other by Doppler check, and confirm them all to be contained in the pedicle before transferring. Otherwise, other methods are indicated.
The urinary fistula is more often in the paraumbilical island flap group then in the free forearm flap group. We think the reason is that the paraumbilical island flap is thicker than the forearm skin flap, so it is a little difficult to suture with the penile stump then the forearm flap. This problem can be overcome by a more careful suture technique in subsequent cases.
In conclusion, we consider the paraumbilical island flap and the free forearm flap to be the preferred methods for patients with penis loss. The paraumbilical island flap is safe in terms of its blood supply, and the operative procedure is relatively simple, in that it does not require microsurgery. Although the flap is thicker than the forearm skin flap, its shape is satisfactory in slim patients; furthermore, it can be defatted secondarily. The free forearm skin flap provides the best shape, but it should be used only with the consent of the patient and performed by a skilled surgeon, damage is likely to the forearm and the problem of donor site is more often than the other methods. It should also be used cautiously in aged patients, especially in those with arteriosclerosis. In spite of several reports of success with the lower abdominal fascia flap, we found it was apt to cause blood supply dysfunction.
We think that ensuring the blood supply of the flap is the key to success. This includes not only protecting the pedicle vessels or skin perforators in lifting the flap, but also avoiding pressure on the pedicle and adjacent flaps. The folded skin and corpus penis should be adequately wide, or they are apt to compress the urethra and affect the blood supply of it. Another important thing is to avoid the urinary fistula by suturing the new urethra carefully, especially at the point with the nub of the original penis.
It should be pointed out that in our early cases we paid little attention to the specific design of the glans and the inner part was not sutured with the outer part in the location of coronary sulcus (Fig. 1(B)), so the glans' appearance was not satisfactory. For this reason, in subsequent cases, we designed a little quadrate flap in the distal end of the inner part (Fig. 3(A)). As a result, this would be convenient for suturing and the location was just in coronary sulcus, so the glans showed better appearance.
References
Shenaq S.M.
Dinh T.A.
Total penile and urethral reconstruction with an expanded sensate lateral arm flap: case report.
00337-6&id=gr1.jpg){kind=link}
00337-6&id=gr2.jpg){kind=link}
00337-6&id=gr3.jpg){kind=link}
00337-6&id=gr4.jpg){kind=link}