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Fibula Free Flap Phalloplasty

Fibula Free Flap Phalloplasty
Photo shows vertically oriented flap.
Source

In 1992, Dr. Sadove et al. were the first surgical team to use the Fibula Free Flap for Phalloplasty. Free Fibula Flap (FFF) Phalloplasty is a good alternative to the radial forearm phalloplasty for patients who do not want a forearm scar. FFF Phalloplasty offers:

  • Less prominent scarring;
  • Natural rigidity with fibula bone;
  • Length of the flap's vascular pedicle (blood supply).

Sensation: Tactile sensation in the top and some area of the bottom of the phallus is provided by re-innervating the flap with the lateral sural cutaneous nerve (LSCN). The LCSN may be connected to one of the two dorsal clitoral nerves. While some patients have claimed to have erogenous sensation in the phallus this is not the expected result, and for this reason the contralateral clitoral dorsal nerve and the clitoris should be left untouched in those who wish to preserve erogenous sensation.

Rigidity: With Phalloplasty, obtaining rigidity to allow for sexual intercourse generally relies on the implantation of an erectile device or penile implant (or the use of an external device.) Inspired by the penis bone found in animals such as dogs, Dr. Sadove devised the use of the osteocutaneous fibula flap, in which the harvested fibula bone is transplanted and fixed to the pubic symphysis, providing rigidity.

The condition of this flap was found to be favourable after up to 1 year of follow-up, however there are risks of bone esorption, curving and fracture. Furthermore, the rigid appearance of the phallus can be difficult to conceal and may be a source of embarrassment.

Aesthetics: Additional debulking surgery is typically required to slim down the phallus. Glansplasty can also be performed. If desired, the clitoris can be buried or left unburied. Without pre-operative hair removal, the skin of the phallus will grow hair. Post-operative hair removal, shaving and/or a chemical depilatory may be desired to improve aesthetics.

Dr. Daniel Freet - Phalloplasty in Houston"Fibula Flap Phalloplasty is an option for a person that does not want the forearm scar and is ok with having more than one surgery to complete the phallus. The person considering this type of Phalloplasty must also understand and accept the fact that the transplanted fibula bone may cause future problems such as breakage of the bone or instability and thus inability to use it for penetration." — Dr. Daniel Freet

Functional Loss In Donor Area: Some patients reported some ankle instability when standing on one leg, as well as discomfort in the donor area and at the medial aspect of the distal tibia when running.

Fibula Free Flap Phalloplasty
Left leg has had fibula harvested.
The upper 6 cm of fibula was left in situ.
Source

The FFF Phalloplasty procedure is offered by the following surgeons:

Journal Articles

The anatomy of free fibula osteoseptocutaneous flap in neophalloplasty in transgender
surgery. [FULL TEXT]
Zaheer U, Granger A, Ortiz A, Terrell M, Loukas M, Schober J. Clin Anat. 2018 Mar;31(2):169-174. doi: 10.1002/ca.23018. Epub 2018 Jan 23.
Surgical text descriptions enhanced by new anatomic illustrations.

A new protocol for complete phalloplasty with free sensate and prelaminated osteofasciocutaneous flaps: experience in 37 patients.
Schaff J, Papadopulos NA. Microsurgery. 2009;29(5):413-9.

Enlarged Range of Free Flaps for Phalloplasty in Transsexual Reassignment Surgery
Description of our concept for complete phalloplasty, applied in 66 female-to-male transsexuals using free prelaminated osteofasciocutaneous fibula or fasciocutaneous forearm flaps.
Schaff J., International Journal of Transgenderism, Volume 10, Issue 1, 2007. Published online: 15 Oct 2008

Long-Term Fate of the Bony Component in Neophallus Construction with Free Osteofasciocutaneous Forearm or Fibula Flap in 18 Female-to-Male Transsexuals
 Papadopulos, Nikolaos A.; Schaff, Juergen; Biemer, Edgar (Journal of Plastic and Reconstructive Surgery, Volume 109 Issue 3, March 2002)

Fibula free flap phalloplasty: modifications and recommendations. [Full PDF]
Hage JJ, Winters HA, Van Lieshout J. Microsurgery. 1996;17(7):358-65.

One-stage total penile reconstruction with a free fibula osteocutaneous flap.
Sadove RC, Sengezer M, McRoberts JW, Wells MD. Plastic and Reconstructive Surgery 92:1314–1323, 1993.

Total phallic reconstruction with the free fibula osteocutaneous flap.
Sadove RC, McRoberts JW. Plastic and Reconstructive Surgery 89: 1001, 1992.

Last updated: 12/12/19



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