TOTAL PENELE RECONSTRUCTION BY FRF.F SENSATE OSTEOCUTANEOUS FİBULA ELAP (Case Report)
Mustafa ŞENGEZER, Mustafa DEVECİ, M.Mümtaz GÜLER
Gata MÜitary Medical Academy and Medical Schoot, Divüion of Plastic <md Rnconstruciive Surgory
SUM M ARY
This article is focused on the free sensate osteocutaneous fib u la fla p as the option that comes closest to meet the diverse aesthetic and fu n c tio n a l goals o f tota l pe nile reconstruction. The m ain advantages o f this fla p lie in Us in trin sic rigidity, Us superior donor site location and its long vascular pedicle. This pa per presents a p a iie n t xoho underınent p h a llic re con s tru ctio n w ith fre e sensate osteocutaneous f ib u la f la p in the P la s tic Surgery Departm ent at G ülhane M ilita ry M e d ica l Academy and discusses the advantages and. shortcom ings o f this technique. Ay f a r as we know, this is the f ir s t p h a llic reconstruction perform,ed, in l'urkey by this ınethod.
Key îvords : F ib u la fla p , Penile reconstruction, Free fla p
INTR O D UCTIO N
T h e fre e fibula flap fo r long bone reconstruction was first described by Taylor et al. 1 and was used for the same purpose by others T Wei et al. 3 İn Clıina also reported the free osteocutaneous fibula flap for various clinical applications. Later, these flap s hav e been used in mandibular reconstruction 4.
Total autogeneous reconstruction o f penis has been first reported by Borogaz in 1936 4.
Reconstruction o f penis evolved from historical multistaged procedures that were fraugth witlı urethral complications, poor phallic sensitivity and questionable aesthetic vaîue 6. The advent o f nıicrosurgical tissue transfer techniques provided a nıean to complete ıııost phallic reconstructions in one stage with few er complications and more predictable results 6,7,s
The limitations o f fasciocutaneous flap s, e.i., radıal forearm, medial and lateral upper arın,
ÖZET
Bu makalede, total penis rekonstrüksiyononda hem estetik hem de fonksiyonel am açları biramda- sağlayabilen serbest osteokütan fib u la fle b i bild irilm iştir. B u fle b in en önem li a v a n t a j la r ı i n t r i n s i k s e r t liğ i, d o n o r a la n lokalizasyonunun üstünlüğü ve uzun vasküler ped ikü lü olarak sıralanabilir. B u makalede G A T A Plastik Cerrahi A D 'nd e gerçekleştirilen duyulu serbest osteokütan fib u la flebi ile penis rekonstrüksiyonu sunulmuş ve avantajları ve s ın ır lılığ ı tartış ılm ış tır. B ild iğ im iz kadarıyla bu olgu T ü rk iy e 'd e bu y ö nte m le g e rçe k le ş tirile n ilk penis rekonstrüksiyonu olgusudur.
Anahtar Kelimeler : Fibula flebi, Penis rekonstrüksiyonu, Serbest flep
have led the us e o f osteocutaneous fibula flap 8j9. Sadove et al 10 reported four cases who undenvent operation for phallic reconstruction by free sensate osteocutaneous fibula flap.
ÖPERAT İVE PROCEDURE
A skin island is planned on the lower leg skin över the fibula. A fasciocutaneous flap is raised carefully protecting the p osterior interm u scular septum th ro u glı which perforating arteries that supply the skin pass.
This mesentery is preserved in continuity with periosteum and a small amount o f muscle cuff around the anterior and posterior aspects o f fibula is also preserved. Lateral sural cutaneous nerve must be included in the flap. Peroneal artery is dissected to the bifurcation and the fibula is transected both 6 cm proximal to the lateral malleolus and distal to the knee. Flap dissection is described in detail elsewhere.
Neouretlıra is reconstructed with tubularized
Dergiye Geliş Tarihi: - Dûzelinıe Sonrası Kabul Tarihi: -
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full Lhickness skin graft harvested frotn groin area.
The fasciocutaneous island flap is then wrapped ar o un d botlı fibular bone and neourethra, and is sewn to itself (Figüre 1).
Afiler the flap is transfered to the recipient. area it is revascularised in an eııd-to-side manner to the femoral ar ter y and vein. The native urethr a is anastomoscd with neourethra.
The periosteuın o f the fibula is sewn to the tunica albuginea. Lateral s ur al cutaneous nerve and dorsal penİle nerve are coapted each other for future seıısation. Doııor site on the leg is skin grafted. A plaster splint and compression dressing is then applied and the palient is permitled weight bearing at the end o f 1 week.
CASE REPORT
A 21-yeaı-old man suffered anıp uta Lİ on o f his penis folloıving a drastic ciıcumcision accident when he was 5 ye ar s ol d. He was admitted to o ur Deparment for penıle reconsLruclion.
Physical examinadon revealed penile stump which was 1 cm. The patient described erection o f the penile stump and ejaculation. A 15 x 13 cırı skin island was m ark e d över the lef t lower leg. The fasciocutaneous flap was raised and transferred as described above (Figüre 2a, 2b, 2c). Vascular anastomoses were performed to the femoral artery and vein in an end-to-side manner by creatirg a t.unnel in the groin region. Left dorsal penile nerve was coapted to the lateral cutaneous sural nerve witlıin the flap. The periosteum o f the fibula was sutured to the tunica albuginea at the site o f am putation. W h ile recon stru ctin g the neourethra, tubularization was perform ed
Figüre 1: Schematic description of the free fibula phaliopiasiy
Figüre 2a: A skin island is marked över the left iower leg from the tibia anteriorly to the midline posteriorly b: Fibula fasciocutaneous flap is raised protecting the posterior intermuscular septum. Please note the neourethra lying by the dissecled flap c: The neophallus is seen just before transfer to the perıneıım
around a large calheter (Freııch 28) to prevent subsequent urethral strictures.
H ealing o f both the don or site and neophallus occured without any complication.
Four weeks postoperatively, a glansplasty was perform ed (Figüre 3a, 3b, 3c). Freııch 18 catheter was kept İn neourethra continuously for 6 mo.nt.hs except during voiding. This
Türk Plast Cer Derg (1995) Cilt' 3, Sayı: 2
prevented any urethral stricture forma t i on and meatal stenosis. The patieııt voids vvitlıout any difficulty (Figüre 4). The över ali follow up period was seven ırıontlıs, The patient reports full sen s ati on on the eritire neophallus. He States that he had a snccessful sexual intercourse. The bone renıaiııs iiım ly attached to the patient's residual corpora, and erection o f corpus cavernosum is transmitted Üırough the bone.
DISCUSSION
Microsurgical techııiques ar e succesfully applied to penile reconstruction. Penis amputation due to Lranma or circuınsicion accident and transsexuality are common cases for penile recoııstrnction. Although ali aesthetic and functional goals were not achieved, radial forearm and lateral upper ann flaps have been reported to be succesful for reconstruction o f penis in one stage 7,ıiJ3. For penile reconstruction specifically, tfıe fibula flap offers several advantages över these flaps 10- The fibular phallus has good intrinsic rigidity due to the large volüm e o f bone it coıısists.
Figüre 3a: Preoperative appearance ot the amputated penis, b: Postoperative lateral view of the reconstructed penis at 6 months.
c: Flexibiirty of the neophallus allows the patient comfort in his daily life.
Figüre 4: Patient is seen while volding through his reconstructed urethra
Satisfactory size can be achieved without comprimising the donor site. The vascular pedicle o f the fibula flap is o f suffİcient length to ali o w end-to-side anastomosis for the flap to the femoral artery without interpositional vein graft. It is important that the phallus have sufficient freedom o f ınotion not to interfere
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wit.h activities o f daily living. The neophallus can easily be pîaced against. ılı e abdomen.
The most important shortconıing o f the fıbula flap donor site is temporary interference with ambulation 13. Aesthetically, the lower leg donor site is preferabîe to either upper arm and forearm donor site sitıce it can be readily covered with a sock.
The radial forearm flap has led s ever al problems in penile reconstruction. Över time, the flap beconıes too soft; when penile prostheses are used, erosion occurs in most cases 14. Radial bone in the penis is thin, nnicortical and prone to fracture wheıı it is included in the radial forearm flap for phallic reconstruction. The radial foreann flâp donor site m orbidity is uııacceptable fo r ınany patients 15.
Vascularized bone grafts are believed to exhibit the great.est degree o f bone survival c o m p a re d t o th eir n o n va scu la rized counterparts 16. Some resorption ınay be expected. Given tlıe large volüme o f strong bone, even if the phallic bone was to suffer a 50
% resorption över time it tvould stili probably provide süfliden t rigidity for intromission 10.
Urethral reconstruction was perforıııed with full thickness skhı graft lıarvested froırı the groiıı region. The fascia enlıances graft take and reduces the risk o f ureLİırocutaneous fistula along the penile shaft. Most fistulas occ.ur at the proximal anastomosis to the native uretlrra but it is reported that most o f this type o f com p lica tion necessitated no surgical in t e rv en ti on s. N o fistula occured in o ur p ati en t. W e believe that the risk o f urethral strİcture can be reduced with the construction o f a urethra över a large cahber catheter. It is also important to keep the catheter in the neourethra for a long period o f time not less than three months.
Sensory recovery improved witlı time in our patien t. A t the end o f six months postoperatively the patient described full sensation rvlıich tvas tested by pin prick test. We ahned to provide protective sensation. Patient slıould be cautioned against unrealistic.
expectations that we can create or restore erogeneous sensibility.
Iıı conclusion, this flap allows fo r an
improved autogeneous prostheses, avoidance o f high com plication rate o f conventional prostheses, a natural appearance o f the phallus in its erect functional State, satisfactory sexual function for patient and partner, end-to-side anastomosis o f the vascular pedicle without the need for interpositional vein graft, improved donor site aesthetics, and reduced donor site complications. The use o f osteocutaneous free fibula flap is highly recomm ended as the choice o f treatment in penile reconstruction.
D r M ustafa Ş E N G E Z E R
G A T A Pl/ıstik ve R ekonstrüktif Cerrahi A B D 06018 Etlik, A nkara
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