Flap templating considerations in radial forearm phalloplasty-a surgical teaching video overview

Phalloplasty requires a flap of much larger dimensions than most other reconstructive procedures that utilize a radial forearm flap. The size of the flap pushes the boundaries of angiosomes and results in an increased potential for sequelae of hypoperfusion or partial flap loss. Donor site morbidity also has to be considered as the flap harvest includes most superficial veins and lymphatic vessels of the forearm. Lastly, all three antebrachial cutaneous nerves are included and their positioning on the flap will determine the eventual sensory outcome of the neo-phallus. Thoughtful and meticulous flap templating is therefore a critical aspect of radial forearm phalloplasty to maximize flap perfusion, prevent postoperative complications such as partial flap loss, minimize any resulting donor site morbidity and maximize flap innervation. This video article aims to provide a comprehensive visual guide covering the nuances of templating for radial forearm phalloplasty using a "Big Ben" staging method, highlighting similarities and differences between both of the main phalloplasty variations: tube-within-a-tube (TWT) and shaft-only phalloplasty (SOP). Dimensions for each component of the TWT and SOP templates are further reviewed. By adhering to the templating principles outlined, complications at both the forearm donor site and at the phallic reconstruction can be minimized.