(199) Anterolateral Thigh Flap Phalloplasty for Micropenis

Abstract Introduction Congenital micropenis is defined as a normally formed penis with a stretched penile length less than 2.5 standard deviations below the mean for that man’s age and ethnicity. Micropenis may present as an isolated condition or with other genital or multi-system abnormalities. Penile reconstruction or phalloplasty may be required where topical and systemic hormonal treatment have failed. The most common flap used for phalloplasty is the radial artery forearm free flap phalloplasty. Other alternatives include the anterolateral thigh (ALT), musculocutaneous latissimus dorsi and abdominal flaps. Objective The aim of this video is to illustrate the technique for penile reconstruction using a pedicled ALT flap without integrated urethra. Methods A 21-year-old man with micropenis and hypospadias from a disorder of sexual differentiation (46XY) presents for penile reconstruction following multiple failed attempts at hypospadias repair. He requested an ALT flap without integrated urethra because he is dependent on a long-term suprapubic catheter due to a hypocontractile bladder. Intraoperative vascular doppler identified 3 perforators from the descending branch of the lateral circumflex iliac artery of the left leg. The flap was designed centred on the perforators with dimensions of 14cm (length), 13cm (width at base) and 12cm (width at tip). The flap was raised carefully and transferred to the recipient groin. The neophallus was constructed and microsurgical anastomosis of the lateral cutaneous of the thigh to one of the dorsal penile nerves with 8/0 nylon was completed. The partially divided left vastus lateralis muscle was re-approximated and the skin edges drawn in and flattened. The left thigh was then resurfaced with a 14/1000 of an inch split-thickness skin graft from the contralateral thigh. All wounds were dressed. Results The man had an uneventful post-operative course with careful vascular monitoring, and he was discharged on day 10. He is currently awaiting glans-sculpting and will eventually proceed with insertion of an inflatable erectile device. Conclusions Penile reconstruction using an ALT flap can be offered to a well-informed and motivated man with a micropenis following appropriate assessment. As shown, the technique requires careful dissection of the perforator vessels and can usually be transferred as a pedicled flap. Pedicled flaps do not require microvascular anastomosis and therefore have a lower risk of vascular compromise. Further esthetic and functional refinements like the insertion of an erectile device are possible in later stages, if desired. Disclosure No