Redo phalloplasty and/or urethraplasty after previous flap failure in phalloplasty in transgender men: surgical considerations and outcomes.

Background: Primary phalloplasty in transgender men can be performed using a single or double free or pedicled flap to reconstruct the shaft and, if desired, the urethra. Vascular complications may result in total or partial loss of the used flap(s). Surgical management after flap loss in primary phalloplasty presents a challenge to the reconstructive surgeon.

Aim: To describe our experience with surgical reconstructive management after primary phalloplasty flap loss in transgender men and report on the clinical and participant-reported outcomes.

Methods: All transgender men who underwent a secondary reconstructive procedure after failure of the primary procedure between January 1989 and December 2023, at our institution, were identified. A retrospective chart review was conducted, recording relevant demographic and clinical data. In addition, participants were invited to complete a non-validated questionnaire consisting of questions regarding surgical outcomes, (sexual) functionality, and sexuality.

Outcomes: Surgical outcomes, flap failure, and self-reported outcomes.

Results: Eighteen individuals were included in this study, who underwent flap reconstruction of the phalloplasty shaft (n = 7), the urethra (n = 4), or both (n = 7). Primary phalloplasty was performed with urethral lengthening (UL) in 16 (89%) and without in 2 (11%). There were no redo phalloplasty flap failures. In those with UL 13/16 (81%) were able to void while standing. Eleven individuals completed the follow-up questionnaire. Most participants were "satisfied" (45%) or "very satisfied" (27%) with the appearance of their penis. All participants (strongly) agreed that when looking back, they would undergo the surgery all over again.

Clinical implications: Practical surgical tips, deducted from our experiences, are provided for gender surgeons performing (revision) phalloplasty and urethroplasty.

Strengths and limitations: Strengths are the unique set of surgical reconstruction cases that has taught us valuable lessons. Data from this study can be used to optimize pre-operative counseling regarding flap loss complications and the outcomes of the subsequent management. Weaknesses comprise the retrospective nature, the low number of included individuals, and use of non-validated questionnaires for self-reported outcomes.

Conclusion: Flap loss after primary phalloplasty in transgender men is a serious complication. Successful secondary reconstruction of the phalloplasty can be performed using a new pedicled or free flap.