PURPOSE: Phalloplasty patients often desire a pouch-like, anteriorly positioned scrotum and perineal reconstruction to achieve natural-appearing external male genitalia. The labia majora are the embryologic homolog of the scrotum, making it the ideal donor tissue for neoscrotoplasty. The flap blood supply is derived from the pudendal vascular system. Detailed review of the flap harvest technique (first mentioned by Monstrey et al1) and analysis of the outcomes of labia majora flap scrotoplasty and perineal reconstruction will help providers better understand and care for transmasculine patients who have had genital surgery.
METHODS: We retrospectively reviewed the outcomes of phalloplasty patients who underwent either primary or secondary labia majora flap scrotoplasty and perineal reconstruction from October 1, 2017, to October 1, 2018. Bilateral elevation, rotation, and flap advancement from the posterior to anterior position formed a pouch-like scrotum. Scrotoplasty was followed by multilayered closure of the resultant perineal wound with apposition of the inner thigh skin to complete the perineal reconstruction.
RESULTS: The mean follow-up was 7 months (0.5–12 months). Out of the 60 total scrotoplasty patients, 47 had labia majora flap scrotoplasty and perineal reconstruction at the time of phalloplasty. The remaining 13 underwent scrotoplasty secondarily. Unilateral distal flap necrosis occurred in 3 patients (5%); all 3 were ipsilateral to the groin dissection required for phalloplasty. Wound dehiscence was observed at the perineoscrotal junction and along the perineal closure in 11 patients (18%) and 1 patient (1.7%), respectively. All wounds were managed conservatively and healed well except for 3 patients who developed urethrocutaneous fistulas at the perineoscrotal junction site. Two of the 3 patients also had fistulas at the midline anterior scrotum and a concomitant urethral anastomotic stricture. All 3 patients required fistula repair, and 2 required urethroplasty. The patient who had a perineal wound dehiscence also had a perineal hematoma, a perineal urethrocutaneous fistula, and a urethral stricture. No scrotal hematomas were seen.
CONCLUSIONS: Labia majora flap scrotoplasty via a bilateral rotational advancement technique and perineal reconstruction can be safely done during or after phalloplasty. Minor wound complications are common and frequently heal with conservative management. Wounds that do not heal are often associated with a urethral complication. Hematomas of the scrotum and perineum are rare.
REFERENCE:
1. Monstrey SJ, Ceulemans P, Hoebeke P. Sex reassignment surgery in the female-to-male transsexual. Semin Plast Surg. 2011;25:229–244.