Recent reconstruction has utilized free radial forearm flap and more recently the viable alternative of the free fibular flap has gained attention. The donor site of this fibular flap is not without its morbidity however.

A recent report by Dabernig, Schaff and colleagues from Glasgow, United Kingdom, describes the use of a free fibular flap without the fibula. The report is published in the November 2006 issue of the Journal of Urology.

Over a one-year period, 5 female-to-male transsexual patients underwent neophalloplasty using the sensate free (septocutaneous) fibular flap without the fibula. Average age of the patient was 30 years; average follow-up was 25 months (range 18-30). All underwent total hysterectomy, salpingo-oophorectomies, vaginectomy and urethral prelamination 6 months before flap surgery. A urethral lengthening procedure is performed at this time using a caudally based pedicled flap raised from the anterior vaginal wall.

Prelamination is performed as follows. The lateral aspect of the lower leg was prepared for flap harvesting. The peroneal artery septocutaneous perforators are marked using an 8 MHz Doppler ultrasound. A tunnel is dissected bluntly with an intramedullary nail in the prospective donor leg between 2 semicircular incisions. A thick 4 x 22 cm split thickness skin graft is harvested from the left thigh which is then sutured in a spiral fashion around a 22 Fr catheter to become the neourethra. This urethra is moistened with saline, attached to the nail and then brought through the tunnel. The catheter is left in as a stent while the flap remains in place on the lower leg for 6 months. Neophalloplasty with the prelaminated urethra is performed 6 months after the first operation. A large skin paddle (20 cm long by 12 cm wide), incorporating the prelaminated neopenile urethra, is utilized for neophallus construction. The recipient vessels are the femoral artery and branches of the long saphenous vein. The preserved lateral sural cutaneous nerve is coapted to a branch of the clitoral nerve, leaving the main nerve intact. The donor defect is covered by full-thickness skin grafts from the groin bilaterally. About 3 months after successful free tissue transfer, the adjacent neomembranous urethra and neopenile urethras are anastomosed.

Analysis of the results showed that all patients sustained good results with no flap loss. Voiding from a standing position was achieved and the neophallus was esthetically acceptable. Sexual intercourse was attainable in all patients and was deemed satisfactory. Donor morbidity was minimal with no disturbance to ambulation compared to the conventional method in which the fibula is sacrificed. There were two urethral complications 2 months after surgery. One patient had distal stenosis at the meatus which was dilated with good outcome. One patient had a stenosis at the urethro-urethral anastomosis which was treated with an end-to-end urethroplasty with good results.

The free fibular flap without the fibula is a challenging refinement of neophallus construction that confers benefits to the recipient and donor sites and is a welcome addition to the armamentarium for neophalloplasty.

Dabernig J, Chan LKW, Schaff J

J Urol. 2006:176 (5):2085-88

Written by Michael J. Metro, MD, a Contributing Editor with UroToday.

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