Double flap phalloplasty in transgender men: Surgical technique and outcome of pedicled anterolateral thigh flap phalloplasty combined with radial forearm free flap urethral reconstruction

INTRODUCTION: Radial forearm free flap (RFFF) tube‐in‐tube phalloplasty is the most performed phalloplasty technique worldwide. The conspicuous donor‐site scar is a drawback for some transgender men. In search for techniques with less conspicuous donor‐sites, we performed a series of one‐stage pedicled anterolateral thigh flap (ALT) phalloplasties combined with RFFF urethral reconstruction. In this study, we aim to describe this technique and assess its surgical outcome in a series of transgender men. PATIENTS AND METHODS: Between January 2008 and December 2015, nineteen transgender men (median age 37, range 21–57) underwent pedicled ALT phalloplasty combined with RFFF urethral reconstruction in one stage. The surgical procedure was described. Patient demographics, surgical characteristics, intra‐ and postoperative complications, hospitalization length, and reoperations were recorded. RESULTS: The size of the ALT flaps ranged from 12 × 12 to 15 × 13 cm, the size of the RFFFs from 14 × 3 to 17 × 3 cm. Median clinical follow‐up was 35 months (range 3–95). Total RFFF failure occurred in two patients, total ALT flap failure in one patient, and partial necrosis of the ALT flap in one patient. Long‐term urinary complications occurred in 10 (53%) patients, of which 9 concerned urethral strictures. CONCLUSIONS: In experienced hands, one‐stage pedicled ALT phalloplasty combined with RFFF urethral reconstruction is a feasible alternative surgical option in eligible transgender men, who desire a less conspicuous forearm scar. Possible drawbacks comprise flap‐related complications, difficult inner flap monitoring and urethral complications.