title: Modification of the tube-in-tube pedicled anterolateral thigh flap for total phalloplasty: the mushroom flap.
abstract: BACKGROUND
  Malformation or absence of the penis can lead to physical and psychological problems for male patients. Reconstruction of the phallus should optimally be completed in a single procedure, be aesthetically pleasing, retain erogenous and tactile sensation, enable micturition in the standing position, and allow for penetrative sexual intercourse. The tube-in-tube flap was described nearly 30 years ago and forms both a urethra and an outer penile shaft with a single flap. Here we present our modification of the original tube-in-tube design with the pedicled anterolateral thigh (ALT) flap and an extension for the neoglans, which we have termed the "mushroom flap" because of its shape and design.
  
  
  METHODS
  The flap is based on the ALT flap; however, the area that will become the neoglans is shaped with a semicircular extension, resembling the head of a mushroom. When the flap is tubularized, the neoglans has the proper anatomic landmarks such as the corona and more closely approximates a circumcised penis. When used in conjunction with the tube-in-tube design, the neophallus, neoglans, and neourethra can all be constructed in a single stage with a single flap.
  
  
  RESULTS
  We have performed total phalloplasties in three patients using the pedicled ALT flap, and the mushroom flap design evolved as we sought to improve the aesthetics of the neoglans. In comparing the aesthetic results among our patients as well as those published in the literature, the mushroom flap design seems to provide the most natural and aesthetically pleasing appearance.
  
  
  CONCLUSIONS
  The pedicled ALT flap can be used to reconstruct an entire penis, as well as a urethra, without the need for microsurgery. By modifying the original tube-in-tube design to include a semicircular extension (a.k.a. the "mushroom flap"), we feel that we have been able to achieve a more natural-appearing neoglans.
authors.affiliation: From the *Stanford University School of Medicine, Palo Alto, CA; †Department of Plastic Surgery, University Hospitals Case Medical Center, Cleveland, Ohio; ‡Wonkwang University School of Medicine, Iksan, South Korea; §Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Palo Alto, CA; and ∥Department of Urology, University of Miami/Jackson Memorial Medical Center, Miami, FL.
authors.forename: Shane D
authors.initials: SD
authors.lastname: Morrison
authors.forename: Ji
authors.initials: J
authors.lastname: Son
authors.forename: Jeonghoon
authors.initials: J
authors.lastname: Song
authors.forename: Aaron
authors.initials: A
authors.lastname: Berger
authors.forename: Johanna
authors.initials: J
authors.lastname: Kirby
authors.forename: Michael
authors.initials: M
authors.lastname: Ahdoot
authors.forename: Gordon K
authors.initials: GK
authors.lastname: Lee
mesh_terms: D058752:Free Tissue Flaps / Q000637:transplantation*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010409:Penile Diseases / Q000601:surgery*; D010413:Penis / Q000601:surgery*; D019651:Plastic Surgery Procedures / Q000379:methods*; D013848:Thigh; D014521:Urethra / Q000601:surgery*