(400) Phalloplasty – Sensate Radial Forearm Free Flap for Creation of Neourethra and Neophallus in Gender Affirmation Surgery: A Case Report

Introduction The radial forearm free flap (RFFF) originated in 1978 in China and was developed and reported to the rest of the world by Ruyao Song. It was used for construction of penis in transgenders by Biemer in the early 1980s who fabricated skin graft within the flap for the neourethra. Chang and Hwang reported tube within a tube by folding the flap in order to for a vascularized neourethra within the neophallus in 1984. With a growing number of requests for gender affirmation surgery, it is imperative to understand the intricacies of the same. The aim of phalloplasty is to construct an aesthetically acceptable neophallus, ability to void urine while standing, tactile and erogenous sensation and rigidity sufficient for sexual activity. The RFFF is considered a good option as it can achieve these goals. For these reasons, we chose the RFFF with certain modifications for our case. Several modifications have been made to the flap design as described by Chang. We have fashioned it with a centrally placed urethra with distal extension to create a neoglans. Including coaptation of sensory nerve would also provide good tactile and erogenous sensation Objective Radial artery forearm free flap is a good option to create neourethra and plallus Methods Flap was marked with maximum dimensions being 18x14 cm. The distal incision was performed first and the radial artery and cephalic vein were identified and they were ligated and divided distally after confirming patency of ulnar artery.Flap incisions was harvested suprafascially taking care to include the cephalic vein, basilic vein, the lateral and medial antebrachial cutaneous nerve. Radial artery and its venae comitantes were included in the flap all along its length including the proximal communicating vessel between the cephalic vein and the venae comitantes. A 12 french foleys catheter was placed on the central portion of the flap and was wrapped by the flap by suturing the de-epithelized portions onto each other in multiple layers forming a tube in tube technique of phallus.The rest of the flap was then wrapped around itself to create a neophallus. The distal portion of the flap was incised and folded on itself to fashion a neoglans and sutures placed to itself to create a corona Results In our case, tactile sensation was achieved with the lateral antebrachial cutaneous nerve coapted to the ilioinguinal nerve.Common complications that can occur in the procedure are partial necrosis, urethrocutaneous fistula and urethral stenosis Conclusions With increasing number of transgender patients requesting for gender affirmation surgery, it is vital to understand intricacies of phalloplasty. Among the various options we believe the radial artery forearm free flap is a good option as was demonstrated in our case report where creation of a viable, sensate neophallus and neourethra was possible with this flap. However extent of radial artery territory may require exclusion of the dorsoulnar border. Disclosure No