An Alternative Recipient Vessel for Free Flap Phalloplasty

Goals/Purpose: Free flap phalloplasty and genital reconstruction have advanced significantly since the first reported phalloplasty in 1982. Over time, various flaps such as the radial forearm, anterolateral thigh (ALT), and ulnar forearm flaps have become key players in both phalloplasty and pelvic reconstruction. However, a limited focus exists on the selection of recipient vessels, despite their critical role in surgical outcomes. This study explores the descending branch of the lateral circumflex femoral artery (DLCFA), commonly used in ALT flap surgeries, as a viable recipient vessel. We aim to assess its reliability, advantages, and comparison with other commonly used vascular systems such as the deep inferior epigastric artery (DIEA) and femoral artery.

Methods/Technique: In this cadaveric dissection, an incision was made on the thigh to expose the rectus femoris and vastus lateralis muscles, revealing the DLCFA and its accompanying veins. The DLCFA pedicle was carefully dissected and transposed to the pubic region, simulating the surgical approach used in free flap surgeries. The procedure also included dissection of the great saphenous vein (GSV) for venous supercharging and other relevant nerves (e.g., superior perforator nerve, median perforator nerve) for sensory coaptation.

Results/Complications: Our dissection demonstrated that the DLCFA is accessible, reliable, and offers a low-risk alternative for recipient vessel anastomosis in phalloplasty, genital, and pelvic reconstructions. The DLCFA pedicle was successfully transposed with minimal risk of injury. Compared to other recipient vessels such as the DIEA, femoral artery, and EPA, the DLCFA system showed easier dissection, fewer complications, and a more consistent arterial supply. The relative superficial location of the DLCFA further simplified the dissection, making it a promising candidate for future clinical use in reconstructive surgeries. The DLCFA offers several advantages over other vascular systems commonly used in free flap phalloplasty, including the femoral artery and DIEA. The risk of complications, such as intra-abdominal injury, hernia, and pedicular compression, is lower with the DLCFA, particularly when compared to the more invasive DIEA. Additionally, the DLCFA’s anatomical location allows for end-to-end anastomosis, which is technically less demanding than the end-to-side technique required for larger vessels. This simplifies the procedure, reduces microsurgical challenges, and enhances overall surgical safety. Moreover, its potential for venous supercharging with the GSV and nerve coaptation for sensory innervation further improves its suitability for genital reconstruction.

Conclusion: The descending branch of the lateral circumflex femoral artery (DLCFA) represents a highly reliable and practical recipient vessel for free flap phalloplasty, genital reconstruction, and pelvic soft tissue reconstruction. It offers significant advantages over other traditional recipient vessels due to its accessibility, consistent arterial supply, and lower risk of complications. The DLCFA should be considered as a preferred recipient vessel in the absence of contraindications, offering a simpler and safer alternative to more commonly used vessels such as the DIEA and femoral artery.