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Anterolateral Thigh (ALT) Pedicled Flap Phalloplasty

Anterolateral Thight (ALT) phalloplasty is acceptable for patients wanting/needing a neophallus who do not want to or cannot use their arm as the donor site.


PREOP REQUIREMENTS for ALT phalloplasty include:

  • Understanding that the complication rate for ALT phallo is higher than that for RF phallo.

  • Three letters (2 from mental health professionals, 1 from a hormone provider or primary care doctor)
  • Hair removal: laser or electrolysis; electrolysis is preferred. Photo is of area for hair removal; the area inside the  rectangle lines should be where the hair is removed. Generally it's better to go a little wider than the markings. The rectangle with the "U" is the urethral portion and hair should be preferentially removed here first.
  • Overall good health
  • Hysterectomy
  • No smoking, nicotine use, or inhalational products (including vaping, marijuana, and 2nd hand smoke) around 3 months before and after surgery (ideally 6 months before and after surgery). This includes chewing tobacco and nicotine free inhalational products. Use of these products can cause about a 5-fold increase in complications. Use within this 3-6 month window before surgery may prompt rescheduling of the surgery to a later time when then the patient has reliably stopped smoking.
  • Perioperative assistance (friends, family, hired help)
  • A very thin thigh
  • No hanging mons/pannus


General information:

  • Team members: Microsurgeons, Reconstructive Urologist, associated surgical and perioperative care staff

  • Duration of surgery: 6-8 hours

  • Hospital stay: 5 days on average

  • In town stay: 4 weeks on average

Reconstructive urology portion:

  • Cystoscopy, SP tube insertion: camera that looks into bladder with placement of a catheter through the lower abdomen skin.

  • Vaginectomy: removal/fulguration of the mucosa with closure of the canal.

  • Urethral lengthening: minora tissue is used to extend the urethra from where it is currently to the head of the native phallus.

  • Nerve dissection: one of the two dorsal nerves (sensory and erotic sensation) are dissected free for future connection with the sensory nerve of the arm.

  • Transposition of native phallus: the outer skin of the glans and shaft are removed and the native phallus with the lengthened urethra at the tip are moved to just underneath the pubic bone. The native phallus (clitoris) is buried beneath the skin at the base of the new phallus to help align the urethra and nerves.

  • Scrotoplasty: the majora tissue is dissected free and folded into a pouch that lies more anteriorly about 10 cm away from the anus.

  • Perineal reconstruction: the perineum is the area between the anus and the back of the scrotum. This is reconstructed with inner thigh skin and neighboring genital tissue.

Microsurgeon portion:​

  • Flap harvest: the rectangular ALT flap (skin and fat) is dissected free along with its nerve and blood supply. The muscles require occasional dissection to locate the flap blood supply and the tendons are left alone.

  • Neophallus/neourethra creation: the urethral component of the rectangular flap is rolled into a tube; the remainder of the flap is then rolled into the phallus.

  • Glansplasty: NOT performed as there is insufficient blood supply.

  • Nerve coaptation: the dorsal nerve is microscopically connected to the ALT flap sensory nerve.

  • Vessel Anastomosis: on occasion, groin blood vessels are microscopically connected to the ALT flap blood vessels; however, most ALT phalluses are pedicled, meaning they do not require a vessel connection.

Joint portion:

  • Urethral anastomosis: the tip of the native phallus urethra is connected to the back of the ALT flap neophallus urethra.

  • Donor site closure: the leg donor site is closed with a split thickness skin graft that is taken from the other thigh.

  • Skin closure: the groin and base of phallus skin is closed with several layers of absorbable suture.

Note: This is a generalized description of the procedures, and steps vary depending on patient anatomy, medical/surgical history, and surgical goals.

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