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MLD Phalloplasty
Image source: microsurgeon.org

MLD Phalloplasty

Musculocutaneous Latissimus Dorsi Flap Phalloplasty

MLD Phalloplasty is a surgery that uses tissue from a back muscle to create a good sized phallus that enables standing-to-pee, as well as erectile function with a penile implant.

The musculocutaneous* latissimus dorsi (MLD) flap comes from part of a back muscle and includes the thoracodorsal vessels and nerve. The blood supply is connected to the femoral artery and saphenous vein or the deep inferior epigastric artery and vein.

The thoracodorsal nerve is connected to the ilioinguinal nerve. Because the thoracodorsal nerve is a motor nerve and not a sensory nerve, sensation in the phallus is not expected with this procedure. No nerve connection is done to the dorsal clitoral nerve. Even so, some patients report tactile sensation in the phallus.

"In our series, less than 20% of patients reported tactile sensation of the neophallus, confirming one of the main drawbacks of this procedure. The majority of sensation is limited to the clitoris, which is incorporated at the base of the neophallus, and the proximal part of the urethra, which is created from the hairless flaps of genital skin (clitoral skin and labia minora skin)... Erogenous sensation based on clitoral stimulation was reported by all 119 patients. None of the patients reported problems or difficulties in sexual arousal, masturbation or orgasms. In all patients who had received penile implants, sexual intercourse with complete penetration was totally adequate." — Dr. Miroslav L. Djordjevic, Novel surgical techniques in female to male gender confirming surgery

Only a thin strip of muscle is harvested. The resulting scar is a long, mostly linear scar that runs from under the arm, slightly curved, down to the lower back. In most cases, the donor site can be closed primarily with the incision; sometimes a split thickness skin graft is needed.

This technique yields a penis that is 13-16cm in length and 10-12cm in girth. Secondary debulking procedures are sometimes needed to reduce the size of the phallus.

Urethroplasty is typically done in two stages: primary urethral lengthening and secondary urethral lengthening. Some surgeons will incorporate a buccal mucosa graft.

For the the scrotoplasty, the labia majora are joined in the midline over the neourethra creating a one-sac scrotum. (Depending on the surgeon, the scrotoplasty technique used with MLD may not include rotation of the labial flaps.)

Placement of a penile implant can also be done in a later stage. Dr. Vesely from the Czech Republic has described the innervation of the latissimus for erectile function.

While pre-operative hair removal is typically not required the donor site needs to be treated by a professional massage therapist for at least three months prior to surgery to improve skin elasticity, enabling direct closure of the donor site (no graft required).

Advantages: Less conspicuous donor site, relatively hairless donor site, good aesthetic outcomes, possibilities for penetrative sex, preserved erogenous sensibility, voiding while standing and acceptable donor site morbidity.

Disadvantages: Poor sensitivity of the phallus; phallus can be large, requiring additional debulking procedures.

MLD Phalloplasty Surgeons

MLD Phalloplasty was popularized in Serbia by Dr. Sava Perovic in the mid 2000s. Following his death, it was further developed by Dr. Rados Djinovic and Dr. Miroslav Djordjevic.

Dr. Djordjevic is Professor of Urology and Surgery at the School of Medicine, University of Belgrade, Serbia and the leader of the Belgrade Center for Genital Reconstructive Surgery. He is well known for educating surgical colleagues from around the world, and is part of the International Teaching Faculty at Mount Sinai's Center for Transgender Medicine and Surgery in New York City.

Dr. Kathy Rumer with Dr. Miroslav Djordjevic (R) and Dr. Djordjevic's assistant, Dr. Borko Stojanovic (L) after performing several MLD Phalloplasty surgeries at Hahnemann University Hospital in Philadelphia in February 2019.

Dr. Kathy Rumer with Dr. Miroslav Djordjevic (R) and Dr. Djordjevic's assistant, Dr. Borko Stojanovic (L) after performing several MLD Phalloplasty surgeries in Philadelphia in Feb 2019.

“I have had the amazing opportunity to train with Dr. Djordjevic in the past at his clinic in Belgrade. During that time together we established a meaningful bond of professional collaboration and personal friendship. His vast knowledge and experience in the field of reconstructive urology, coupled with his willingness to share that expertise with us and others has contributed greatly to the availability of competent gender affirming surgeons worldwide. Under his dedicated tutelage he has strategically elevated the core competency of the surgical team at Hahnemann University Hospital so that we can now extend our newly acquired knowledge in support of those in the transgender community seeking these procedures. He is the real deal!” — Dr. Kathy Rumer

In the USA, MLD phalloplasty is offered by the following surgeons:

MLD Phalloplasty is also performed in Serbia by Dr. Rados P. Djinovic; in India by Dr. Sanjay Pandey; in Czech Republic by Dr. Jirí Veselý; in Belarus by Dr. Aleh Stasevich ("Thoracodorsal Flap Phalloplasty") and in Russia by Dr. Menschikov Konstantin Anatolyevich.

VIDEO: Total Phalloplasty Using a Musculocutaneous Latissimus Dorsi Flap

Oct 6, 2009 / Duration: 08:30 / Views: 1538
Authors: Sava V. Perovic, Rados P. Djinovic, Marko Z. Milosavljevic
Institution: Department of Urology, School of Medicine, University of Belgrade, Serbia

VIDEO: Total Phalloplasty Using a Musculocutaneous Latissimus Dorsi Flap

More Videos

Journal Articles

Musculocutaneous latissimus dorsi flap for phalloplasty in female to male gender affirmation surgery.
Djordjevic ML, Bencic M, Kojovic V, Stojanovic B, Bizic M, Kojic S, Krstic Z, Korac G. World J Urol. 2019 Jan 23.
Between January 2007 and May 2017, 129 female transsexuals, aged 20-53 years (mean 24 years) underwent total phalloplasty using latissimus dorsi free flap. Urethral lengthening was performed by combining a vaginal flap, labia minora flaps and a clitoral skin flap. Suitable sized testicular implants are inserted into the new scrotum. Penile prosthesis implantation, additional urethral lengthening and glans reshaping were performed in the following stages. Satisfactory voiding in standing position was confirmed in all patients. Six urethral fistulas and two strictures were observed and repaired by minor revision. Malleable and inflatable prostheses were implanted in 39 and 22 patients, respectively.

Novel surgical techniques in female to male gender confirming surgery. [FULL TEXT]
Djordjevic M. translational Andrology and Urology, Vol 7, No 4 (August 2018).

Total Phalloplasty Combined with Metoidioplasty As a One-Stage Procedure in Female-to-Male Transsexuals: Is It Possible?
M. Djordjevic, D. Stanojevic, V. Kojovic, M. Bizic and M. Majstorovic. Belgrade Gender Dysphoria Team, School of Medicine, University of Belgrade, Serbia. Poster (PDF) presented at the 13th Congress of the European Society for Sexual Medicine.

Total phalloplasty in female transsexuals: technique and outcomes.
Djordjevic M., Kojic S., Stanojevic D., Jocic D., Bizic M. Eur Urol Suppl 2011;10(9):579.

Combined total phalloplasty and metoidioplasty as a single stage procedure in female to male gender reassignment surgery.
Kojovic V, Bizic M, Majstorovic M, Kojic S, Stanojevic D, Korac G, Djordjevic M. EurUrolSuppl, 2009;8(8):648

Total Phalloplasty Using a Musculocutaneous Latissimus Dorsi Flap
Sava V. Perovic, Rados Djinovic (British Journal of Urology, Reconstructive Urology, Volume 100 Issue 4, Sep 2007)

 

Last updated: 02/08/24



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