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Penile Reconstruction: Is the Radial Forearm Flap the Standard Technique?

Gilbert, David A. M.D.

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Plastic and Reconstructive Surgery: August 2010 - Volume 126 - Issue 2 - p 684
doi: 10.1097/PRS.0b013e3181df71f5
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Having been involved in genitourinary reconstruction for the past 30 years, I read with interest the article entitled “Penile Reconstruction: Is the Radial Forearm Flap Really the Standard Technique?” by Monstrey et al. (Plast Reconstr Surg. 2009;124:510–518).

The authors represent a well-recognized genitourinary reconstructive team that has pushed the boundaries of penile reconstruction (actually phallic construction) for the past 20 years. Their series, in which they successfully completed 287 phalloplasties, represents the largest series yet reported. Their meticulous record-keeping is laudable and highly desired when reporting the outcomes of phalloplasty surgery. Historically, incomplete postphalloplasty documentation has been an Achilles heel of this challenging operation.1

Our experience in Norfolk essentially mirrors the Ghent group's report. In our series of 128 cases over 20 years, our choice in the majority of penile reconstructions was the ulnar-based forearm flap, for the following reasons: it has a longer vascular leash, it is more malleable and supple, it is less hairy, and it has a less obvious forearm scar than the radial forearm flap.

On further reflection, two differences in our respective results jump out. First, our postoperative fistula rate dropped precipitously when we converted our female-to-male transgender subjects to two surgical stages and lengthened the short female urethra before the definitive phalloplasty/urethroplasty. Second, we have an 85 percent penile prostheses implantation success rate. We have closely adhered to our implantation protocol for the past 40 cases: the presence of preoperative protective sensation to the phallic tip, fixation of the implants to the inferior pelvic rami, a closed drainage system to reduce the risk of seroma, and 3 days of intravenous antibiotic therapy.

To repeat, this article has a prominent place in phallic reconstruction, if for no other reason than its meticulous follow-up results. The authors' documentation will probably have more impact than the anatomical description of the radial forearm flap that is embedded in the title.

David A. Gilbert, M.D.

Division of Plastic Surgery

Eastern Virginia Medical School

Norfolk, Va. 23510


1. Gilbert DA, Jordan GH. Reconstruction of male genital defects: Congenital and acquired. In: Mathes SJ, ed. Plastic Surgery. 2nd ed. Philadelphia: Saunders; 2006.

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