Phalloplasty with free (septocutaneous) fibular flap sine fibula

The free prefabricated fibular flap has been used as a good alternative to the free radial forearm flap in female-to-male sex reassignment surgery. We describe a new technique of harvesting the flap without sacrificing the fibula. The neophallus is thinner, more elegant, less rigid and able to contain a hydraulic penile prosthesis.

Five biologically female patients underwent reassignment surgery using this technique. Average patient age was 30 years (range 24 to 37) and average followup was 25 months. All patients underwent total hysterectomy, salpingo-oophorectomies, vaginectomy and urethral prelamination 6 months before flap surgery. The lateral calf cutaneous island was raised on the peroneal artery septocutaneous perforators without disrupting the continuity of the fibula. Urethro-urethral anastomosis was done 3 months later.

All patients sustained good results with no flap loss. Voiding from a standing position was achieved and the neophallus was esthetically acceptable. Donor morbidity was minimal with no disturbance to ambulation compared to the conventional method, in which the fibula is sacrificed.

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