Revision Phalloplasty: Evaluation, Algorithms, and Techniques for Salvage after Major Complications

Phalloplasty is among the most complex and technically demanding reconstructive procedures. As a larger pool of surgeons perform this difficult procedure, more patients will present with major complications. There are few published data on the comprehensive evaluation and management of these patients, particularly those needing correction of multiple ongoing complications, which may require consideration of starting over with a new microsurgical procedure versus salvage of the existing flap.

A literature review on complications of phalloplasty was conducted in combination with drawing upon the experience of 2 high-volume phalloplasty teams (Johns Hopkins/Harvard and GU Recon Clinic/Buncke Clinic) in treating patients with severe postsurgical issues. The purpose was to analyze critical factors and develop algorithms for secondary revision.

Common complications of phalloplasty include urethral strictures and fistulas, diverticula, excess bulk, phalloplasty malposition, hypertrophic or keloidal scarring, and partial or total flap loss. In severe cases, local flaps or free flaps may be required for reconstruction. The decision to revise the existing neophallus or start over with a new flap for phalloplasty is particularly critical. Multidisciplinary team collaboration is essential to develop comprehensive plans that will resolve multiple concomitant problems while meeting patient goals for a functional and aesthetic neophallus.

Preserving the original flap for phalloplasty is ideal when feasible. Additional local or free flaps are sometimes necessary in situations of significant tissue loss. In severe cases, complete redo phalloplasty is required. The algorithms proposed provide a conceptual framework to guide surgeons in analyzing and managing severe complications after phalloplasty.

Therapeutic, V.