Pedicled anterolateral thigh flap phalloplasty combined with radial forearm free flap urethral reconstruction in gender-affirming surgery: a report of two cases

This case report presents two female-to-male (FTM) patients, aged 21 and 35 years, respectively, who underwent phalloplasty and urethral reconstruction at our institution. The patients’ requests included a phallus >9 cm, concealed donor-site scars, and the ability to void while standing. In the first case, a 4.5×13-cm radial forearm free flap (RFFF) taken from the nondominant side was retrieved and anastomosed to the deep inferior epigastric artery and vein. Simultaneously, a 10×16-cm pedicled anterolateral thigh (ALT) flap was relocated to the genital area and wrapped around the RFFF after nerve coaptation. The second case involved a 5.5×14-cm RFFF and a 20×13-cm pedicled ALT flap using a similar procedure. Both cases had stable double flaps with no complications, and Foley catheters were removed at 14 days and 3 months after surgery, respectively. Double-flap phalloplasty is thus a viable option for patients with a short forearm circumference or a preference for a less visible forearm scar.