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Monstrey, Stan J. M.D., Ph.D.

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Plastic and Reconstructive Surgery: August 2010 - Volume 126 - Issue 2 - p 684-685
doi: 10.1097/PRS.0b013e3181df7279
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It is a pleasure to comment on this letter written by David A. Gilbert concerning our article entitled “Penile Reconstruction: Is the Radial Forearm Flap Really the Standard Technique?” 1 Dr. Gilbert has always been and still is the authority on the reconstruction of male genital defects.

Dr. Gilbert rightfully mentions that, indeed, meticulous record-keeping is an absolute requirement when reporting the outcomes of phalloplasty surgery.

Our rather complete postphalloplasty documentation is a result of our very close cooperation with the urologists of our gender team and the fact that a lifelong urologic follow-up is mandatory for these patients.

My colleagues and I were somewhat surprised that Dr. Gilbert prefers the ulnar-based forearm flap above the radial forearm flap. By using the radial forearm flap, we have always been able to locate the skin part that is used for urethral reconstruction on the much less hairy ulnar part of the forearm.

In our opinion, the radial forearm flap is as malleable and supple as the ulnar forearm flap; the vascular pedicle is similar; and because, in most patients, the entire or almost entire circumference of the forearm is used, we somewhat doubt that the ulnar-based forearm flap would result in a less obvious forearm scar than the radial forearm flap.

We also agree with Dr. Gilbert when he mentions that lengthening the short female urethra before the definitive phalloplasty/urethroplasty (an operation similar to the metoidioplasty) reduces the postoperative fistula rate. However, we do not prefer this additional operation on a routine basis because (with an increasing learning curve) this complication has been considerably reduced and because this would mean an extra operation to the already three surgical procedures. However, we do perform this additional lengthening of the urethra operation in patients who have a greater risk of developing complications because of obesity, advanced age, history of smoking, diabetes, and other factors.

The problem of penile prosthesis implantation is not yet completely solved. These prostheses are normally used by elderly biological men who are no longer that sexually active. Thus, this indication is completely different from the young postphalloplasty female-to-male transsexual. Dr. Gilbert's comments confirm what we also consider as the keys to success for erectile prosthesis implantation: protective sensation to the tip of the phallus, fixation of the implants to the inferior pelvic rami, soft-tissue handling with double-layer closure, and a closed drainage system to minimize the risk of seroma, all this in combination with intravenous antibiotic therapy. Again, we would like to thank Dr. Gilbert for his comments.

Stan J. Monstrey, M.D., Ph.D.

Department of Plastic Surgery

Ghent University Hospital

De Pintelaan 185

Ghent B9000, Belgium


1. Monstrey S, Hoebeke P, Selvaggi G, et al. Penile reconstruction: Is the radial forearm flap really the standard technique? Plast Reconstr Surg. 2009;124:510–518.

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