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ALT Phalloplasty

Anterolateral Thigh Flap Phalloplasty

ALT phalloplasty

Source: Acta Medica Okayama, 2013. Vol. 67, No. 5, pp. 325-331. Copyright © 2013 by Okayama University Medical School

ALT Phalloplasty is a Phalloplasty procedure that uses the thigh donor site to create a sensate and aesthetically satisfactory penis that can be used for sexual intercourse and to void while standing.

The Anterolateral Thigh (ALT) Flap is a skin, fat and fascia flap that has blood supplied by the descending branch of the lateral femoral circumflex vessels and innervation provided by the lateral femoral cutaneous nerve.

While the blood supply of the ALT flap is very good, the layout of the blood vessels can vary, making the surgery complex and tedious.

The thickness of skin and sub-cutaneous fat of the thigh is an important factor in determining if the ALT flap is indicated for Phalloplasty. In the right patient, the ALT flap can be quite thin, making it a good choice for sensation, as well as Stage 1 Urethroplasty.

Patients with thicker skin and more sub-cutaneous fat in the thigh may have excess tissue bulk in the ALT flap that can be a contraindication to Stage 1 Urethroplasty or may not provide aesthetically ideal results. For these patients, Urethroplasty and a debulking procedure can be performed at later stages.

Urethroplasty can be approached in a few different ways:

  • Complete Vascularized Urethroplasty: ALT flap segment, SCIP groin flap, labia & vaginal flaps, forearm flap
  • Complete Non-vascularized Urethroplasty: buccal mucosa graft (higher rate of fistulas and strictures)
  • Partial Urethroplasty: Urethra extended to base of penis only (lowest rate of complication)
ALT phalloplasty results at 10 months post-op

10 months post-op
Source: Acta Medica Okayama, 2013. Vol. 67, No. 5, pp. 325-331. Copyright © 2013 by Okayama University Medical School

Removing hair from the ALT flap pre-operatively is required. Despite aggressive electrolysis and/or laser hair removal before surgery, some men require additional hair removal post-op, either for urethral issues or cosmetic reasons.

The staging of surgeries with ALT Phalloplasty varies greatly depending on surgeon practices and patient healing, as well as logistics. Most patients can expect to have Vaginectomy, Phalloplasty and Scotoplasty at stage 1. Urethroplasty may be done at stage 1 or stage 2, or is sometimes split over two stages (Primary and Secondary Urethral Lengthening.) Glansplasty can be performed a week after stage 1 with ALT, but is also commonly delayed to stage 2. Implantation of testicular implants is done at stage 2 or 3, and erectile implant is done in the final stage. Urethral repair surgeries and/or cosmetic surgeries may also be incorporated into these stages. In general, one can expect to be fluctuating between surgery and healing stages for up to 2 years post-operatively, and longer if there are complications.

Potential complications early on in the post-operative period can include infection, bleeding, and paresthesia (abnormal sensation from damaged nerves); urethral issues such as fistula and stricture; and partial necrosis or flap loss. Some patients may experience leg weakness or develop adhesions (esp. with pedicled ALT.) Severe complications such as compartment syndrome and muscle necrosis are rare.

The ALT donor site is fairly easily concealed, and operative time is generally less than Radial Forearm Flap Phalloplasty, however sensation is reportedly less than RFF (Monstrey et al., 2008.)

ALT Free Flap vs. Pedicled ALT Flap

The ALT flap can be used for both free flap and pedicled phalloplasty.

The term free flap refers to the "transplantation" of tissue from one site of the body to another. "Free" implies that the tissue, along with its blood supply, is completely detached from the original location ("donor site") and then transferred to another location ("recipient site") and the circulation in the tissue re-established by anastomosis of artery(s) and vein(s). This is in contrast to a "pedicled" flap in which the tissue is left partly attached to the donor site ("pedicle") and simply transposed to a new location; keeping the "pedicle" intact as a conduit to supply the tissue with blood. — Wikipedia

ALT Free Flap Phalloplasty uses an ALT flap that is completely detached from the donor site. Blood supply must be re-established by microsurgically connecting the arteries and veins of the flap and recipient site.

Pedicled ALT Phalloplasty uses an ALT flap that is left attached to the donor site at one end, while the other end is rotated to the recipient site, preserving blood supply. Microsurgical connection of blood supply is therefore not required, lowering costs and more importantly, reducing the risks of flap failure and necrosis.

Pedicled ALT Phalloplasty Studies

Pedicled ALT Phalloplasty

Pedicled ALT Phalloplasty O.R. Video
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NEW! Pre-Expanded Anterolateral Thigh Perforator Flap for Phalloplasty [full text]
Salvatore D'Arpa, Britt Colebunders, Filip Stillaert, Stan Monstrey. October 2 2016.
Preexpansion of the ALT flap allows primary donor site closure, thus avoiding not only the unsightly appearance of a skin grafted ALT donor site, but also the skin graft donor site scar. Preoperative perforator location by means of computed tomography angiography allows safe expander placement through 2 small remote incisions.

Phalloplasty with an Innervated Island Pedicled Anterolateral Thigh Flap in a Female-to-Male Transsexual [Full PDF]
Hasegawa K, Namba Y, Kimata Y. Acta Med Okayama. 2013 Oct;67(5):325-31.
As compared to a forearm flap, use of an innervated island-pedicled flap may have the following advantages in phalloplasty:1) no need for a microsurgical technique; 2) no scars at noticeable sites; 3) small functional loss in the flap donor area; 4) no sacrifice of major blood vessels.

Preoperative planning of a pedicled anterolateral thigh (ALT) flap for penile reconstruction with the multidetector CT scan.
Preoperative evaluation of ALT perforators and the subcutaneous fat tissue layer is feasible with an MDCT scan and provides precise data to make an adequate patient and perforator selection and determine the exact flap size.
Sinove Y, Kyriopoulos E, Ceulemans P, Houtmeyers P, Hoebeke P, Monstrey S. Handchir Mikrochir Plast Chir. 2013 Aug;45(4):217-22. doi: 10.1055/s-0032-1333271. Epub 2013 Mar 6.

A Novel Single-Flap Technique for Total Penile Reconstruction: The Pedicled Anterolateral Thigh Flap
Lee, Gordon K.; Lim, Angeline F.; Bird, Erin (Journal of Plastic and Reconstructive Surgery, Volume 124 Issue 1, July 2009)

Innervated island pedicled anterolateral thigh flap for neo-phallic reconstruction in female-to-male transsexuals
Rubino, C.; Figus, A.; Dessy, L.A.; Alei, G.; Mazzocchi, M.; Trignano, E.; Scuderi, N. Journal of Plastic, Reconstructive & Aesthetic Surgery vol. 62 issue 3 March, 2009. p. e45-e49

Reconstructive Surgery for Severe Penile Inadequacy: Phalloplasty with a Free Radial Forearm Flap or a Pedicled Anterolateral Thigh Flap
N. Lumen, S. Monstrey, P. Ceulemans, E. van Laecke, and P. Hoebeke. Adv Urol. 2008; 2008: 704343.
Phallic reconstruction using the free radial forearm flap (RFF) or the pedicled anterolateral thigh flap (ALTF) has been routinely used in female-to-male transsexuals. Sensitivity in the RFF was superior compared to the ALTF.

More journal articles »

What Is Combined ALT/Forearm Phalloplasty?

Combined ALT/Forearm Phalloplasty is a variant of the ALT Phalloplasty procedure which uses a pedicled thigh donor flap to create the phallus, plus a small forearm graft to create the neo-urethra. Read more here.

Surgeons Who Offer ALT Phalloplasty

Last updated: 01/11/17