These are great reliable flaps that can be configured to create a wonderful phallus with chimeric opportunities but leave behind extensive donor site and require skin grafts like the two flaps above.
Thus these techniques are avoided unless specifically requested by the patient.
The full spectrum of microsurgical and local phalloplasty options are available at The Maercks Institute. However, Dr. Maercks' preference is to use an advanced technique described below that maximizes safety, efficacy, form and function called the MAERCKS Phalloplasty. Each technique is described below and a highlight of advantages and disadvantages is included. Dr. Maercks prefers to avoid conventional techniques because of extensive scar burden, long term complications, poor sensation, the need for implants, staged procedures and revisionary procedures.
The SCIP flap has the advantage of leaving only an abdominoplasty scar-like donor site, unlike the extensive morbidity of the flaps listed previously. It is a wonderfully reliable flap that if harvested from both sides can be used as a double flap that has many advantages functionally and aesthetically over the two former flaps.
This flap however has been drastically improved upon through Dr. Maercks’ studies and experience leading to the two flaps listed below.
The Maercks phalloplasty is the result of Dr. Maercks’ dissatisfaction with the amount of morbidity associated with female to male phalloplasty techniques and the relatively poor function, need for foreign bodies and the vast complication profile.
Dr. Maercks goal was to design a transgender phalloplasty that would be aesthetically pleasing with crucial anatomical features, leave behind no stigmata of transgender surgery, provide more analogous innervation to a natural penis with independent clitoral sensation to the glans, obviate the need for secondary procedures including implants or pumps, provide robust independent flap tissue for the urethra to avoid the common problems of urinary fistulas and strictures and limit recovery time for the patient.
Maercks visited multiple international centers and brainstormed with colleagues and did extensive anatomical research and cadaver study to bring this ultimate phalloplasty to fruition. The first step was to prove that the novel vascularized nerve supply was attainable. The CIS Phalloplasty was developed and successfully demonstrated this concept.
By taking a flap in the groin crease of both sides the patient is left with a straight line scar that resembles an abdominoplasty scar and does not clearly declare reconstructive efforts. An independent flap is used for the urethra and the second flap is used for the penile shaft. This methodology allows independent innervation of a true glans that actually appears like a shapely natural glans without additional stages.
The Maercks phalloplasty is the only transgender phalloplasty technique with three modes of innervation, the glans, the shaft and the internal base of the flap are fed by three independent nerves making it the most innervated phalloplasty to date. By virtue of this separated innervation, the perception of kinaesthesia and more natural sexual feedback is possible. By nature of its double flap construction and tissue quality, implants and pumps are not necessary for penetrative intercourse. Size and girth are not restricted and truly customized phallus can be designed. Some patients require a condom for penetrative sex however there is an option to include natural cartillagenous structure again in one stage to avoid the need for a condom, The MAERCKS-s Phalloplasty which stands for structurally supported.
Lattisimus Perforator & Parascapular Flaps
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The MAERCKS Phalloplasty
The Multifocal Anatomic Emulating Reconstructive Clitoral Kinaesthetic SCIP flap
CIS phalloplasty flap Clitorally innervated SCIP flap
Anterolateral Thigh Flap (ALT Flap)
The anterolateral thigh flap has the advantage of being less conspicuous than a radial forearm flap and yielding much more tissue to work with. It is also harvested with a nerve and has enough tissue to provide a ureter but can be difficult to sculpt when used this way and typically appears unnatural.
The donor site is large and like the radial forearm flap a secondary defect for skin graft harvest is necessary leaving behind a thigh covered in scarring.
SCIP flap Superficial Circumflex Iliac Perforator flap
Conventional Transgender Phalloplasty
The CIS flap is a breakthrough developed by Dr. Maercks and brought to reality by his collaboration with international colleagues. The advantages of the CIS phalloplasty include: no need for skin grafting and only a single closed scar that resembles that of an abdominoplasty. Innervation from the clitoral nerve is concentrated near the head of the phallus, more closely approximating natural anatomy and the base can be innervated by local nerves in the groin. The glans is thicker than the shaft in a single stage and a secondary urethral design is not necessary, reducing chances of complications of the two techniques mentioned under Conventional Transgender Phalloplasty.
Radial Forearm Flap
This is the most commonly used phalloplasty technique. The advantages are: it is a very straight forward reliable procedure with enough pliable tissue to create a urethra and penis of sufficient length with a nerve supply. The disadvantage are: the large and obvious donor site, scarring both on the wrist and forearm and additionally on the leg or back where a skin graft must be taken to cover the wrist defect.
Furthermore as a significant portion of the blood supply is removed from the hand, patients may experience pain and cold intolerance later in life. The flap is also generally thin which can often limit girth of the penis resulting in a less than ideal length to width ratio.
The radial forearm flap also requires an expensive secondary procedure of placing an implant or pump in order to be sexually functional. Also creating a glans, or a head of the penis is an additional procedure and results typically look surgically created or unnatural.
Whereas standard procedures use Conventional Flaps which are the standard techniques used by most phalloplasty surgeons, Dr. Maercks prefers to avoid them because of unnecessary donor site morbidity and complication profiles. We do offer these techniques to patients that specifically request them, however recommend the procedures listed under modern histiocentric phalloplasty.
Female to Male (FTM) Phalloplasty
Modern Histiocentric Phalloplasty