Phalloplasty in complete aphallia and ambiguous genitalia

The most common indications for phalloplasty in children include aphallia, micropenis/severe penile inadequacy, ambiguous genitalia, phallic inadequacy associated with epispadias/bladder exstrophy and female to male gender reassignment in adolescents. There are many surgical options for phalloplasty; both local pedicled tissue as well as free tissue transfer. The advantages of local tissue include a more concealed donor site, less complex operation and potentially faster recovery. However, pedicled options are generally less sensate, making placement of a penile prosthesis more risky and many children with bladder exstrophy have been previously operated upon making the blood supply for local pedicled flaps less reliable. This Here the authors discuss free tissue transfer, including the radial forearm, the anterolateral thigh, the scapula and latissimus, and the fibula free flaps, as well as local rotational flaps from the abdomen, groin, and thigh. The goal of reconstruction should be an aesthetic and functional (ability to penetrate) phallus, which provides tactile and erogenous sensation, and the ability to urinate standing. Ideally, the operation should be completed in one to two operations with minimal donor site morbidity. There are advantages and disadvantages of each of flap and thus the choice of donor site should be a combination of the patient's preference and surgeon's ability to produce a consistent result.