Free forearm flap penile reconstruction

Indications for penile reconstruction are mainly penile defects, hermaphroditism and female degenerative patients. Penile defects are caused by trauma, tumor resection, penile gangrene, congenital dysplasia and other factors, forcing male urinary tract dysfunction. This physiological defect causes a serious mental trauma. Penile reconstruction of such patients is of great significance. In addition, in patients with hermaphroditism and feminine susceptibility, the former often has a short penis and cannot meet the normal sexual needs. The latter has no male genitalia, so penile reconstruction is also required. The ideal standard for penis reconstruction is: 1 re-construction of the penis has a good shape and a certain sensory function; 2 unobstructed urethra opening in the penis head, and can stand urinating; 3 penis support is tough, soft and hard moderate, can flex and straight; 4 Has close to normal sexual function and healthy sexual psychological quality. One-stage surgery with free flaps with blood vessels and nerve pedicles is an ideal method for penile reconstruction. The best way to meet these criteria is to use the forearm flap, which is accompanied by a radial artery that ensures an effective blood supply. Forearm free flap transplantation for penile reconstruction is a convenient method for operation and good postoperative morphology. Different types of penile defects are indications, especially after radical resection of penile cancer. The flap is moderately thick, the reconstructed penis is moderately sized, and has a long vascular pedicle and sensory nerves, making it a good material for reconstituting the penis. However, the new wounds left in the supply area are unsightly. From the long-term follow-up data analysis, some showed that the penile reconstructed flap was thinner, and there was more atrophy in the penis body and penis head 2 years after reconstruction, accounting for about 10% of the penis circumference. Although the sensory nerve anastomosis was performed during penile reconstruction, the sensory function of the distal penis was still lacking. The reason is that the lateral forearm cutaneous nerve only occupies 1/4 to 1/3 of the entire flap. Treatment of diseases: penile breaks and penis fracture Indication Forearm free flap grafting penis reconstruction is applicable to: 1. Penile defects caused by various reasons. 2. The penis is severely stunted and cannot be used for normal sexual intercourse. 3. Women turn to masculine gender convertors. Contraindications 1. The skin of the donor area has abnormalities such as inflammation and scarring. 2. The collateral circulation between the ulnar artery and the radial artery of the forearm is not good. 3. Older patients with atherosclerosis. 4. Jackson's stage II-III penile malignant tumor, there may be recurrence and metastasis after surgical resection. Preoperative preparation 1. Allen's experiment detects collateral circulation between the ulnar artery and the radial artery of the forearm. 2. Perform skin preparation for the right quarter rib and pubic area. 3. Smoking is prohibited 1 week before surgery. Surgical procedure The operation was performed in two groups: one group cut the ribs for the recipient area; the other group cut the forearm flaps for the penis body prefabrication. 1. Urine flow changes the pubic bladder puncture stoma. 2. Preparation of penile support The eleventh rib and costal cartilage were cut in the chest, and the length was 9.0 to 10.5 cm and the width was 1.0 to 1.5 cm. 3. Forearm flap design; from the superior iliac crest to the intersection of the radial artery and the wrist transverse line, forming the longitudinal axis of the forearm flap. The surface markers of the radial artery and the cephalic vein are drawn. The reconstructed flap of the penis is designed on both sides of the longitudinal axis, and the radial artery and the cephalic vein are included in the flap. 4. The design of the penile reconstructed flap and the reconstruction of the penis include reconstruction of the penis and reconstruction of the urethra. The forearm flap is divided into: 1 ft side portion: 13 to 14 cm in length and 3.5 to 4.0 cm in width. As a flap formed by the urethra, it is preferable to leave a precious vein in the pedicle. 2 side part: length 12 ~ 14cm, width 10 ~ 12cm, the pedicle of the flap has radial artery, iliac vein and cephalic vein, as a flap reconstructed by the penis. Cut the skin and subcutaneous tissue to the superficial sarcolemma according to the design line, and make a sharp separation on the sarcolemma from the iliac and ulnar sides, respectively, to the space between the diaphragm and the iliac crest muscle, so that the radial artery is sent to the flap. A small skin branch is included in the flap. The distal median vein, cephalic vein, radial artery and accompanying vein were cut off at the distal end of the flap, and the end was sutured. In the radial artery, the vein is deeply separated from the proximal end, and the muscle branch of the radial artery is ligated one by one, and the flap is lifted from the intermuscular groove, but it is not broken. The vascular pedicle of the flap includes the radial artery, the iliac vein, the median vein, the cephalic vein, etc., and the lateral cutaneous nerve of the forearm should also be included in the pedicle. The vascular pedicle should be at least 10 cm long. 3 intermediate part: between the urethral and penile body reconstruction flaps, the 1 cm wide epidermis and dermis were excised to form the epithelial zone, which was used as a suture band formed by the urethra and the penis. Be careful not to damage the subdermal vascular network during resection and suturing. 5. The penis body forms the anterior and posterior pedicle flaps. The skin of the ulnar side flap was turned inward, wrapped around a 16F silicone catheter, and the 5-0 absorbable line was sutured continuously to form a urethra. The skin of the temporal side flap was everted, and the ribs and urethra were embedded in the flap in parallel. The lateral skin edge and the suture band were sutured with a 3-0 absorbable thread to make the penis body. The flap at the distal end of the reconstructed penis is sutured intermittently with the flap at the distal end of the urethra to form the penis head and the external urethra. 6. The affected area is ready to dissect the transplanted bed of the urethral opening and the prefabricated penis body. 1 5mm from the urethral opening of the stump, make a circular incision in the skin, dissipate outward, enlarge the wound, in order to match the urethra and the penis. 2 In the femoral artery beating area below the inguinal ligament, dissect the branches of the femoral artery and femoral vein. The deep femoral artery, the superficial peritoneal artery or the superficial temporal artery and the radial artery can be used for end-to-end or end-to-side anastomosis; the branch of the saphenous vein is associated with the venous anastomosis of the cephalic vein, the venous vein and the radial artery. 3 The sneak free from the inferior horn of the inguinal ligament incision communicates with the perineal incision to form a tunnel for the vascular pedicle of the graft flap. 7. Precast penile body transplanted penis reconstruction The forearm flap prefabricated penis body is freely transplanted to the perineum, together with the forearm lateral cutaneous nerve to disconnect the vascular pedicle, and the vascular pedicle passes through the tunnel to the femoral artery pulsation area below the inguinal ligament. The reconstructed urethral stent tube is inserted into the bladder through the external urethra. Firstly, the prefabricated penis body and the perineum are positioned and sutured; then the arteries and veins are respectively anastomosed under the microscope, and the vascular tract is confirmed after the vascular anastomosis is good; the cutaneous nerves of the forearm are connected with the erectile nerve of the penis or clitoris, so that the reconstructed penis is good. a feeling of. The penile support and the perineal tissue are sutured and fixed, and the penis is reconstructed. 8. Close the wound of the front arm to repair the free skin. Close the wound of the root of the penis and the wound of the groin area of the groin. The latter two wounds should be placed at the same time.