Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 1200e1203

A free scapular skin ap for penile reconstruction

H. Wang, S.K. Li*, M.Y. Yang, Y.Q. Li, Q. Li, W. Chen, Y.Q. Wang
Plastic Surgery Hospital, PUMC & CAMS, Beijing, China Received 2 July 2006; accepted 5 March 2007

KEYWORDS
Free scapular skin ap; Penile reconstruction

Summary Introduction: There are many possible methods for penis reconstruction, among them, pedicled aps, myocutaneous aps, combined osseocutaneous aps, and free skin aps. This study evaluated the free scapular skin ap method for penile reconstruction. Methods: Fifteen men aged 20 to 48 underwent the procedure between March 2000 and February 2006, with follow-up examinations from 6 months to 5 years. Results: Fourteen of the reconstructions were successful, with patients enjoying good cosmetic results as well as functionality. Conclusion: The free scapular skin ap technique is a good method for penile reconstruction. 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Penis reconstruction using a free scapular skin ap is a practical method with a simple technique, excellent conguration, good function and less secondary deformity of the donor site. Between March 2000 and February 2006, 15 patients underwent penis reconstruction by transferring a scapular free ap with implanting a malleable penile prosthesis. Good cosmetic and functional results were achieved.

Methods
Before surgery, the ap must be designed. First, the circumex scapular artery must be marked. The ap is

* Corresponding author. Address: Department of South 2, Plastic Surgery Hospital, PUMC & CAMS, BaDaChu Road, ShiJingShan Borough, 100041 Beijing, Peoples Republic of China. Tel.: 86 10 88703902; fax: 86 10 68864137. E-mail addresses: wanghao1117@sina.com, lisenkai@yahoo. com.cn (S.K. Li).

designed to be 12e14 cm in length and 14e16 cm in width, with the artery and its branch for axis. It includes three parts; part A ap is 3.0e3.6 cm wide and is used for urethral reconstruction. Part B ap is 0.5e1.0 cm wide and is designated for the de-epidermis. Part C ap is 9e 14 cm wide and is used to reconstruct the penis shaft (Fig. 1A, B). The scapular skin is incised to the deep fascia according to the preoperation design. The ap is then lifted between the fascia and muscular membrane to triangular space (Fig. 2). To make locating the scapular artery easier, it is important to cut the branch to the muscle and scapula. The scapular vessel should be dissected until the pedicle is 7 cm in length. The vessels are cut, the ap taken out, and the wound is covered by a split thickness skin graft transplantation. Now the operation begins on the recipient site. The inferior epigastric vessel should be examined, and should be cut near the rectus abdominis as distal as possible. The adventita and periadventitial tissue should be excised sharply.

1748-6815/$ - see front matter 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.03.003

A free scapular skin ap for penile reconstruction

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Figure 2

Scapular skin ap.

Postsurgical procedures include 2 weeks of bed rest with the penis elevated, frequent inspection of the ap, anticoagulation medication and prevention of infection. In obese patients, free skin graft or scrotal septum ap can be used for urethral reconstruction to prevent a big shaft or insufcient blood ow to the new urethra. Reconstruction of the glans is achieved by split thickness skin graft transplantation in the distal part of penis.

Clinical results
Of the 15 procedures that were included in this study, 14 were successful, with favourable cosmetic and functional results. One patient experienced failure due to venous thrombus, which was probably due at least in part to his 20year smoking habit (Table 1).

Case 1
The patient, a 30-year-old, was burned 2 years ago by electric shock. His penis was completely severed but his scrotum, testicles and varicosity were left intact. It was readily apparent that the scar on his perineum had already become soft (Fig. 5). One year after undergoing penis reconstruction with free scapular skin ap and a malleable penile prosthesis implantation, he has satisfying erections and good cosmetic results, but he has not married (Figs. 6 and 7).

Figure 1

Design of ap.

Discussion
The advantages of the free scapular ap include ample tissue, invariable vessel direction, abundant blood supply and less deformity. The scapula may be used for penis

The part B ap is used as de-epidermis for the gap between the reconstructed urethra and the penis body. The part A ap is overturned for the inner skin, and the part C ap is also overturned for the penis shaft (Fig. 3). The distal edge of the part A ap is then sutured to that of the part C ap to form a new urethral orice. The new glans is reconstructed by local shaping (Fig. 4). The next step is anastomosis of the new partial urethra to the old urethral orice with a Follys catheter in it. A malleable penile prosthesis with silver silica gel is inserted into the reconstructed penis. Its proximate part is xed to the pubic periosteum. The donor vessel and receipt vessel are anastomosed using a microsurgical technique. This closes the incision.

Figure 3

Urethra reconstruction.

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H. Wang et al.

Figure 4

Penis shaping.

Table 1

Clinical information Cases Success 2 1 8 3

Micropenis Infection Burn Self-inicted penis cutting

2 1 8 4

Figure 7

Postoperation 12 months.

Figure 5

Preoperation.

Figure 6

Postoperation 12 months.

support, but this study opted instead for a malleable penile prosthesis because of the difculty of shaping bone. The inferior epigastric vessel has a long pedicle, adequate diameter and invariable vessel direction, therefore it was selected as the recipient vessel. The sensory nerves of the scapular ap are the inner branches of the posterior branches of two to four pectoral nerves. It is difcult to transfer the scapular ap with sensory nerves because they are detached from the vessel with several branches. But this study revealed the ap regained sensitivity after 6 months. The extent of recovery of sensitivity after was 3e4 cm below the top of the ap. The testing included perception of pain, feelings and twopoint discrimination. Exploration is under way for a method of scapular ap transplantation with neurovascular pedicle. There are many methods for penis reconstruction.1e10 The forearm ap method, which is similar to the free scapular ap, is common but has some disadvantages, such as thin subcutaneous tissue, less tissue for transfer, thin reconstructed penis, lost forearm trunk vessel and reduction of muscular power. It is also inadequate for the patient with more hair on the forearm. The advantage of the forearm ap is that it has good sensory nerves for its neurovascular pedicle.

A free scapular skin ap for penile reconstruction Another method, the combined inguinal osseocutaneous ap, which is applied with a ap of pedicled supercial circumex iliac vessel combining iliac bone piece, has the advantages of a hidden donor site and a simple procedure with no microsurgical technique. But the combined ap has decient blood supply for its vessel variation. The complications include fat uidity, infection and bone exposure. Therefore the authors conclude that the free scapular ap is the preferred method for penile reconstruction.

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3. Felici N, Felici A. A new phalloplasty technique: the free anterolateral thigh ap phalloplasty. J Plast Reconstr Aesthet Surg 2006;59:153e7. 4. Hester TR, Hill HL, Jurkiewicz MJ. One-stage reconstruction of the penis. Br J Plast Surg 1978;31:279e85. 5. Chang TS, Huang WY. Forearm ap in one stage reconstruction of the penis. Plast Reconstr Surg 1984;74:251e8. 6. Biemer E. Penile construction by the radial arm ap. Plast Reconstr Surg 1988;15:425e30. 7. Gilbert DA, Winslow BH, Gilbert DM, et al. Transsexual surgery in the genetic female. Clin Plast Surg 1988;15:471e87. 8. Castro RB, Oliveira AB, Favorito LA. Utilization of skin ap for reconstruction of the genitalia after an electric burn. Int Braz J Urol 2006;32:68e9. 9. Seftel A. Penis reconstruction using three different operative methods. J Urol 2005;174:2299. 10. Hu ZQ, Hyakusoku H, Gao JH, et al. Penis reconstruction using three different operative methods. Br J Plast Surg 2005;58: 487e92.

References
1. Yang Mingyong, Li Shiyin, Li Senkai. Anatomical study for ascending branch of circumex scapular artery. Zhong Hua Zheng Xing Shao Shang Wai Ke Za Zhi 1996;12:293e5. 2. Dabernig J, Shelley O, Cuccia G, et al. Urethral prelamination in penile reconstruction with an osteo-cutaneous free bular ap. J Plast Reconstr Aesthet Surg 2006;59:561e2.