Flap elevation is started with incision of anterior skin margin down to the deep fascia over the serratus anterior muscle; plane is developed between latissimus dorsi and serratus anterior muscle, using combined sharp and blunt dissection. The flap is divided inferiorly and medially, cauterizing large posterior perforators of the intercostal vessels, and then slowly lifted proximally to expose neurovascular pedicle. The amount of the harvested muscle tissue around the blood vessels depends on fat thickness – in slim patients more muscle is harvested and vice versa. The pedicle surrounded by fatty tissue is identified and dissected proximally up to the axillary vessels (Fig. 31.2). All major branches are identified and carefully ligated using monofilament ligatures, while smaller ones are cauterized. The thoracodorsal nerve is identified and isolated proximally from vessels for the length of 5–6 cm, taking care to preserve its vascularization. During dissection, care is taken to avoid injury of the long thoracic nerve which can cause winging of the scapula. A neophallus is created while the flap is still perfusing on its vascular pedicle: the flap is tubularized fully, leaving 3–4 cm-wide muscle surface exposed ventrally, which is grafted with split-thickness skin graft (STSG) taken from some available skin, most often from the labia minora (Fig. 31.3a, b) but, sometimes, from the long skin flap from clitoral and labia minora skin (Fig. 31.3c). Heparin is administered intravenously, and few minutes later neophallus is detached from the axilla after clamping and dividing the subscapular artery, vein, and thoracodorsal nerve at its origin, in order to achieve maximal pedicle length and wider blood vessel diameter. Donor site defect is closed directly using one or two local rotational flaps (Fig. 31.4a, b). Previously, we used STSG for donor site closure when it was not possible to close it directly, but due to non-satisfactory esthetic result, we started to use rotational flaps instead. In the second stage, the surgical team prepares the recipient site simultaneously – superficial femoral artery, saphenous (or some other local) vein, and ilioinguinal nerve are dissected and mobilized through the oblique inguinal incision. Another, a Y incision is made on the pubis for neophallus attachment, and a wide tunnel is created between two incisions for pedicle placement. After neophallus transfer and its fixation to the recipient area, microsurgical anastomoses are done between the subscapular and femoral artery (latero-terminal) and between the subscapular and saphenous vein (terminoterminal) using operative loops (Fig. 31.5). The epineural microneurorrhaphy is then completed between the ilioinguinal and thoracodorsal nerve (Fig. 31.6). Previously extended proximal urethra is joined to the neourethral plate on the ventral side of the flap. The clitoris with preserved neurovascular bundle is mobilized and fixed at the base of the neophallus for its better stimulation during sexual intercourse. A Foley catheter is inserted for one 2–3 weeks. The neophallus is fixed in an elevated position for 7–10 days to the specially constructed dressing, which is important to prevent pedicle kinking. Flap viability is assessed by clinical examination (i.e., skin color, turgor, and capillary refill).

The second stage includes tubularizing urethroplasty over 14 Ch silicone Foley catheter and is performed at least 6 months after first surgery; in the majority of patients penile urethra was joined with proximal part of the neourethra, but in some, which were on the risk for urethral stricture, small fistula was leaved for voiding at their junction, while penile part is dilated for few months and then joined in the next stage (Fig. 31.7). Care is taken to avoid overlapping of urethral and skin suture lines. The neophallus is created by tubularization, with glans designed and created over the distal 4–6 cm of the flap by tangential skin cutting and joined subdermally with the proximal part (Fig. 31.7b). In this stage, testicular implants are usually implanted. Suprapubic catheter is placed for 3–4 weeks. Patients start to void 3–4 weeks after completion of urethroplasty. After healing is finished, neophallus already will have its definitive shape (Fig. 31.8a–c).