title: Immediate pedicled gracilis flap in radial forearm flap phalloplasty for transgender male patients to reduce urinary fistula.
abstract: OBJECTIVE
  Radial forearm phalloplasty is accompanied by high rates of fistula formation. We examined the effect of placing a pedicled gracilis myofascial flap around the urethral anastomosis at the time of radial forearm flap transfer on the development of postoperative urethrocutaneous fistula.
  
  
  METHODS
  Fifteen patients underwent phalloplasty with urethroplasty between June 2012 and October 2015, and they met the inclusion and exclusion criteria for the study. We retrospectively reviewed patients' medical records and extracted patient demographic data, prelamination technique used (mucosa, skin graft, both, or neither), and whether or not a gracilis myofascial flap was harvested at the time of flap transfer and used to reinforce the native-neourethral anastomosis. The chi-squared test was used to evaluate the association between the presence of a gracilis flap and fistula formation.
  
  
  RESULTS
  Four patients received a gracilis flap as part of their primary phalloplasty operation. None of these patients developed a fistula. Eleven patients did not receive a gracilis flap at the time of initial surgery and seven developed a fistula.
  
  
  CONCLUSIONS
  In our patient series, inclusion of a pedicled myofascial gracilis flap at the time of radial forearm phalloplasty with urethroplasty was associated with an absence of fistula formation. Therefore, we have since made inclusion of this flap a standard practice for all transmales undergoing phalloplasty with urethroplasty.
authors.affiliation: Division of Plastic Surgery, Gender and Sexual Health Program, Department of Surgery, University of Miami, 1120 NW 14th St., 4th Floor, Miami, FL 33136, USA. Electronic address: csalgado2@med.miami.edu.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Salgado
authors.affiliation: Division of Plastic Surgery, Gender and Sexual Health Program, Department of Surgery, University of Miami, 1120 NW 14th St., 4th Floor, Miami, FL 33136, USA.
authors.forename: Ajani G
authors.initials: AG
authors.lastname: Nugent
authors.affiliation: Division of Plastic Surgery, Gender and Sexual Health Program, Department of Surgery, University of Miami, 1120 NW 14th St., 4th Floor, Miami, FL 33136, USA.
authors.forename: Alison M
authors.initials: AM
authors.lastname: Moody
authors.affiliation: Division of Plastic Surgery, Gender and Sexual Health Program, Department of Surgery, University of Miami, 1120 NW 14th St., 4th Floor, Miami, FL 33136, USA.
authors.forename: Harvey
authors.initials: H
authors.lastname: Chim
authors.affiliation: Division of Plastic Surgery, Gender and Sexual Health Program, Department of Surgery, University of Miami, 1120 NW 14th St., 4th Floor, Miami, FL 33136, USA.
authors.forename: Alejandra M
authors.initials: AM
authors.lastname: Paz
authors.affiliation: China Medical University Hospital, Department of Plastic Surgery, North District, Taichung City 404, Taiwan.
authors.forename: Hung-Chi
authors.initials: HC
authors.lastname: Chen
mesh_terms: D000328:Adult; D000368:Aged; D015992:Body Mass Index; D017577:Cutaneous Fistula / Q000601:surgery*; D000071976:Gracilis Muscle / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010413:Penis / Q000601:surgery*; D019651:Plastic Surgery Procedures; D012189:Retrospective Studies; D016038:Skin Transplantation / Q000379:methods; D013524:Surgical Flaps; D063106:Transgender Persons; D016896:Treatment Outcome; D014521:Urethra / Q000601:surgery*; D014548:Urinary Fistula / Q000601:surgery*; D013521:Urologic Surgical Procedures, Male / Q000379:methods*; D005260:Female
keywords: Gracilis flap; Phalloplasty; Radial forearm flap; Transgender; Urethrocutaneous fistula; Urethroplasty