Antero Lateral Thigh Flap Phalloplasty

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The anterolateral thigh flap is another good option for phallic reconstruction.33 This is a musculocutaneous (perforator) rather than a fasciocutaneous based-flap and is based on the perforator vessels through vastus lateralis and rectus femoris from the descending branch of the lateral circumflex femoral artery (Chap. 7). The ALT flap is very reliable from a vascular point of view and is commonly used in reconstructive surgery. Rubino et al. described the ALT flap in order to create a neophallus for a female to male transsexual patient which incorporated a strip of vascularized fascia lata wrapped around the prosthesis.34 For phalloplasty, a 16 x 16 cm (14 x 20 cm if incorporating neourethra) flap needs to be raised (Fig. 11.30). The dissection is a little more difficult than for the radial forearm flap because of the perforators but

Fig. 11.30 The anterolateral thigh flap with a Line drawn between the anterior superior iliac spine and lateral condyle at knee. Midway between these two lie the main perforators. Use hand-held dop-pler to find the perforators and then base flap on them

ALT Phalloplsty

Fig. 11.31 A split-skin graft is used to cover the defect

Penile Skin Graft

Fig. 11.31 A split-skin graft is used to cover the defect does not require the use of a tourniquet. Another advantage is that the vascular pedicle is sometimes long enough to reach the pubic area after tunneling under the rectus femoris tendon, obviating the need for microsurgical vascular anastomoses. A disadvantage is that the ALT flap has a thick subcutaneous layer and is much hairier which makes simultaneous neourethral construction using the "tube within tube" technique difficult. Often the phalloplasty is made from the ALT flap and the neourethra is then formed from a narrow (4 cm wide) radial forearm flap.22 If a neourethra is being constructed at the same time then the long axis of the flap is in line with the thigh (Figs. 11.31 and 11.32).

There is only one cutaneous nerve with the ALT flap so the potential sensation is suboptimal. Careful patient selection is therefore particularly important in order to

Fig. 11.32 Result of ALT phalloplasty in a patient presenting with congenital micropenis

Fig. 11.32 Result of ALT phalloplasty in a patient presenting with congenital micropenis

Flap Phalloplasty

gain a good cosmetic result from the ALT flap phalloplasty especially if the urethra is being fashioned primarily. Due to the large skin paddle, a split-skin graft is used to cover the donor site which is generally a large defect although it can be concealed by long undergarments.

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