Partial Flap Loss in Gender Affirming Phalloplasty

Area of Science:

• Reconstructive surgery
• Microsurgery
• Urology

Background:

• Phalloplasty flaps are larger and tubularized more extensively than for other uses.
• Partial flap loss (PFL) incidence is known, but donor site/technique comparisons and etiology are under-detailed.
• This study reviews institutional experience with PFL in phalloplasty.

Purpose of the Study:

• To analyze the incidence, causes, and management of partial flap loss (PFL) in phalloplasty.
• To identify risk factors and patterns associated with PFL in phalloplasty procedures.
• To improve outcomes by understanding PFL in phalloplasty.

Main Methods:

• Retrospective cohort study of phalloplasty patients (2016-2020) by a single surgeon.
• PFL defined as requiring sharp excision of necrotic tissue and reconstruction.
• Collected data on patient, flap, and intraoperative variables.

Main Results:

• 6 of 76 phalloplasties (7.9%) experienced PFL.
• All PFL cases occurred in tube-within-tube (TWT) phalloplasties (5 radial forearm free flap, 1 pedicled anterolateral thigh).
• Shaft PFL (4/6) treated with excision ± Integra and grafting; urethral extension PFL (2/6) required necrotic segment excision.

Conclusions:

• Partial flap loss (PFL) occurred in 7.9% of phalloplasty cases, exclusively in the TWT cohort.
• Acute PFL linked to macrovascular venous congestion; subacute PFL linked to microvascular arterial ischemia.
• Most PFL involved the shaft, preserving the urethral segment.