Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

Bioengineered dermal matrix (Integra®) reduces donor site morbidity in total phallic construction with radial artery forearm free-flap

International Journal of Impotence Research (2023)Cite this article

Subjects

Abstract

Total phallic construction with radial artery forearm free-flap (RAFFF) is widely regarded as the gold standard approach for phalloplasty. However, donor-site morbidity remains a significant concern, which is typically managed by using a full-thickness skin graft (FTSG) on the forearm. Split thickness skin grafts (STSG) have been proposed as an alternative, along with the use of an acellular dermal matrix substitute. A retrospective comparative analysis was performed to assess the differences in operative, functional and cosmetic outcomes between FTSG (Group A) and the combination of acellular dermal matrix with STSG (Group B). A retrospective cohort study was conducted on all patients who underwent total phallic construction with RAFFF, between 2016 and 2021. Post-operative surgical and functional outcomes were evaluated using validated tools. A total of 34 patients were included in the study, with 18 patients (52.9%) in Group A and 16 patients (47.1%) in Group B. Group B demonstrated a significant advantage in terms of healing time (24 days vs. 30 days, p = 0.003) and complete graft take (93.8% vs. 27.8%, p = 0.001). Group B also had significantly shorter operative times (310 min vs. 447 min, p = 0.001) and a reduced median hospital stay (8 days vs. 10 days, p = 0.001). Satisfaction with cosmesis was significantly higher in Group B (93.8% vs. 66.7%, p = 0.048).

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

References

  1. Wirthmann A, Finke JC, Giovanoli P, Lindenblatt N. Long-term follow-up of donor site morbidity after defect coverage with Integra following radial forearm flap elevation. Eur J Plast Surg. 2014;37:159–66. https://doi.org/10.1007/s00238-013-0918-0.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Falcone M, Blecher G, Anfosso M, Christopher AN, Ralph DJ. Total phallic reconstruction in the genetic male. Eur Urol. 2021;79:684–91. https://doi.org/10.1016/j.eururo.2020.07.025.

    Article  PubMed  Google Scholar 

  3. Monstrey S, Hoebeke P, Selvaggi G, Ceulemans P, Van Landuyt K, Blondeel P, et al. Penile reconstruction: is the radial forearm flap really the standard technique? Plast Reconstr Surg. 2009;124:510–8.

    Article  CAS  PubMed  Google Scholar 

  4. Doornaert M, Hoebeke P, Ceulemans P, T’Sjoen G, Heylens G, Monstrey S. Penile reconstruction with the radial forearm flap: an update. Handchir Mikrochir Plast Chir. 2011;43:208–14.

    Article  CAS  PubMed  Google Scholar 

  5. Selvaggi G, Dhejne C, Landen M, Elander A. The 2011 WPATH standards of care and penile reconstruction in female-to-male transsexual individuals. Adv Urol. 2012;2012:581712.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Van Caenegem E, Verhaeghe E, Taes Y, Wierckx K, Toye K, Goemaere S, et al. Long-term evaluation of donor-site morbidity after radial forearm flap phalloplasty for transsexual men. J Sex Med. 2013;10:1644–51.

    Article  PubMed  Google Scholar 

  7. Kovar A, Choi S, Iorio ML. Donor site morbidity in phalloplasty reconstructions: outcomes of the radial forearm free flap. Plast Reconstr Surg Glob Open. 2019;7:e2442.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Ito O, Igawa HH, Suzuki S, Muneuchi G, Kawazoe T, Saso Y, et al. Evaluation of the donor site in patients who underwent reconstruction with a free radial forearm flap. J Reconstr Microsurg. 2005;21:113–7.

    Article  PubMed  Google Scholar 

  9. Lutz BS, Wei FC, Chang SCN, Yang KH, Chen IH. Donor site morbidity after suprafascial elevation of the radial forearm free flap: a prospective study in 95 consecutive cases. Plast Reconstr Surg. 1999;103:132–7.

    Article  CAS  PubMed  Google Scholar 

  10. Selvaggi G, Monstrey S, Hoebeke P, Ceulemans P, Van Landuyt K, Hamdi M, et al. Donor-site morbidity of the radial forearm free flap after 125 phalloplasties in gender identity disorder. Plast Reconstr Surg. 2006;118:1171–7.

    Article  CAS  PubMed  Google Scholar 

  11. Milcheski DA, Chang AA, Lobato RC, Nakamoto HA, Tuma P Jr, Ferreira MC. Coverage of deep cutaneous wounds using dermal template in combination with negative-pressure therapy and subsequent skin graft. Plast Reconstr Surg Glob Open. 2014;2:e170.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Menn ZK, Lee E, Klebuc MJ. Acellular dermal matrix and negative pressure wound therapy: a tissue-engineered alternative to free tissue transfer in the compromised host. J Reconstr Microsurg. 2012;28:139–44.

    Article  PubMed  Google Scholar 

  13. Lee JW, Jang YC, Oh SJ. Use of the artificial dermis for free radial forearm flap donor site. Ann Plast Surg. 2005;55:500–2. https://doi.org/10.1097/01.sap.0000183789.00146.c6.

    Article  CAS  PubMed  Google Scholar 

  14. Yu P, Qi Z. Prospective randomized comparison of scar appearances between cograft of acellular dermal matrix with autologous split-thickness skin and autologous split-thickness skin graft alone for full-thickness skin defects of the extremities. Plast Reconstr Surg. 2016;137:906. https://doi.org/10.1097/PRS.0000000000001518.

    Article  CAS  Google Scholar 

  15. Lee YJ, Park MC, Park DH, Hahn HM, Kim SM, Lee IJ. Effectiveness of acellular dermal matrix on autologous split-thickness skin graft in treatment of deep tissue defect: esthetic subjective and objective evaluation. Aesthetic Plast Surg. 2017;41:1049–57. https://doi.org/10.1007/s00266-017-0891-2.

    Article  PubMed  Google Scholar 

  16. Cheshire PA, Herson MR, Cleland H, Akbarzadeh S. Artificial dermal templates: a comparative study of NovoSorbTM biodegrad- able temporising matrix (BTM) and Integra® dermal regenera- tion template (DRT). Burns. 2016;42:1088–96.

    Article  PubMed  Google Scholar 

  17. Zuidam JM, Coert JH, Hofer SOP. Closure of the donor site of the free radial forearm flap: a comparison of full-thickness graft and split-thickness skin graft. Ann Plast Surg. 2005;55:612–6.

    Article  CAS  PubMed  Google Scholar 

  18. Moiemen NS, Vlachou E, Staiano JJ, Thawy Y, Frame JD. Reconstructive surgery with Integra dermal regeneration template: histologic study, clinical evaluation, and current practice. Plast Reconstr Surg. 2006;117:160S–74S. https://doi.org/10.1097/01.prs.0000222609.40461.68.

    Article  CAS  PubMed  Google Scholar 

  19. De Angelis B, Orlandi F, Fernandes Lopes Morais D’Autilio M, Scioli MG, Orlandi A, Cervelli V, et al. Long-term follow-up comparison of two different bi-layer dermal substitutes in tissue regeneration: clinical outcomes and histological findings. Int Wound J. 2018;15:695–706. https://doi.org/10.1111/iwj.12912.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Müller-Richter UD, Driemel O, Mörtl M, Schwarz S, Zorger N, Wagener H, et al. The value of Allen’s test in harvesting a radial forearm flap: correlation of ex-vivo angiography and histopathological findings. Int J Oral Maxillofac Surg. 2008;37:672–4. https://doi.org/10.1016/j.ijom.2008.01.012.

    Article  PubMed  Google Scholar 

  21. Chang TS, Hwang WY. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg. 1984;74:251–8. https://doi.org/10.1097/00006534-198408000-00014.

    Article  CAS  PubMed  Google Scholar 

  22. Mitropoulos D, Artibani W, Biyani CS, Bjerggaard Jensen J, Rouprêt M, Truss M. Validation of the Clavien–Dindo grading system in urology by the European Association of Urology guidelines ad hoc panel. Eur Urol Focus. 2018;4:608–13. https://doi.org/10.1016/j.euf.2017.02.014.

    Article  PubMed  Google Scholar 

  23. Sullivan T, Smith J, Kermode J, McIver E, Courtemanche DJ. Rating the burn scar. J Burn Care Rehabil. 1990;11:256–60. https://doi.org/10.1097/00004630-199005000-00014.

    Article  CAS  PubMed  Google Scholar 

  24. Draaijers LJ, Tempelman FR, Botman YA, Tuinebreijer WE, Middelkoop E, Kreis RW, et al. The patient and observer scar assessment scale: a reliable and feasible tool for scar evaluation. Plast Reconstr Surg. 2004;113:1960–5. https://doi.org/10.1097/01.prs.0000122207.28773.56.

    Article  PubMed  Google Scholar 

  25. Gajdosik RL, Bohannon RW. Clinical measurement of range of motion: review of goniometry emphasizing reliability and validity. Phys Ther. 1987;67:1867–72. https://doi.org/10.1093/ptj/67.12.1867.

    Article  CAS  PubMed  Google Scholar 

  26. Ciesla N, Dinglas V, Fan E, Kho M, Kuramoto J, Needham D. Manual muscle testing: a method of measuring extremity muscle strength applied to critically ill patients. J Vis Exp. 2011;2632. https://doi.org/10.3791/2632.

  27. Gottlieb LJ, Levine LA. A new design for the radial forearm free-flap phallic construction. Plast Reconstr Surg. 1993;92:276–83.

    Article  CAS  PubMed  Google Scholar 

  28. Song C, Wong M, Wong CH, Ong YS. Modifications of the radial forearm flap phalloplasty for female-to-male gender reassignment. J Reconstr Microsurg. 2011;27:115–20. https://doi.org/10.1055/s-0030-1268210.

    Article  PubMed  Google Scholar 

  29. Wirthmann AE, Majenka P, Kaufmann MC, Wellenbrock SV, Kasper L, Hüttinger S, et al. Phalloplasty in female-to-male transsexuals by Gottlieb and Levine’s free radial forearm flap technique—a long-term single-center experience over more than two decades. J Reconstr Microsurg. 2018;34:235–41.

    Article  PubMed  Google Scholar 

  30. Garaffa G, Christopher NA, Ralph DJ. Total phallic reconstruction in female-to-male transsexuals. Eur Urol. 2010;57:715–22. https://doi.org/10.1016/j.eururo.2009.05.018.

    Article  PubMed  Google Scholar 

  31. Murray RC, Gordin EA, Saigal K, Leventhal D, Krein H, Heffelfinger RN. Reconstruction of the radial forearm free flap donor site using integra artificial dermis. Microsurgery. 2011;31:104–8. https://doi.org/10.1002/micr.20833.

    Article  PubMed  Google Scholar 

  32. Molteni G, Gazzini L, Bisi N, Nocini R, Ferri A, Bellanti L. et al. Donor site aesthetic and functional outcomes of radial forearm free flap: a comparison between full-thickness and split-thickness skin grafts. Eur J Plast Surg. 2022;45:583–90. https://doi.org/10.1007/s00238-021-01922-1.

    Article  Google Scholar 

  33. Davis WJ 3rd, Wu C, Sieber D, Vandevender DK. A comparison of full and split thickness skin grafts in radial forearm donor sites. J Hand Microsurg. 2011;3:18–24. https://doi.org/10.1007/s12593-011-0036-9.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Haslik W, Kamolz LP, Manna F, Hladik M, Rath T, Frey M. Management of full-thickness skin defects in the hand and wrist region: first long-term experiences with the dermal matrix Matriderm. J Plast Reconstr Aesthet Surg. 2010;63:360–4. https://doi.org/10.1016/j.bjps.2008.09.026.

    Article  CAS  PubMed  Google Scholar 

  35. Demiri E, Papaconstantinou A, Dionyssiou D, Dionyssopoulos A, Kaidoglou K, Efstratiou I. Reconstruction of skin avulsion injuries of the upper extremity with integra® dermal regeneration template and skin grafts in a single-stage procedure. Arch Orthop Trauma Surg. 2013;133:1521–6. https://doi.org/10.1007/s00402-013-1834-2.

    Article  PubMed  Google Scholar 

  36. Shores JT, Hiersche M, Gabriel A, Gupta S. Tendon coverage using an artificial skin substitute. J Plast Reconstr Aesthet Surg. 2012;65:1544–50. https://doi.org/10.1016/j.bjps.2012.05.021.

    Article  PubMed  Google Scholar 

  37. Wester JL, Pittman AL, Lindau RH, Wax MK. AlloDerm with split-thickness skin graft for coverage of the forearm free flap donor site. Otolaryngol Head Neck Surg. 2014;150:47–52. https://doi.org/10.1177/0194599813513713.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Urology, “A.O.U. Città della Salute e della Scienza”, Turin, Italy

    Marco Falcone, Mirko Preto, Federica Peretti, Anna Scarabosio, Lorenzo Cirigliano, Ilaria Ferro, Natalia Plamadeala, Martina Scavone, Massimiliano Timpano & Paolo Gontero

  2. Department of Orthopaedics and Traumatology, Hand and Microsurgery Unit, Orthopaedic Trauma Center CTO—“A.O.U. Città della Salute e della Scienza”, Turin, Italy

    Davide Ciclamini

  3. Department of Surgery, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia

    Gideon Blecher

  4. Department of Urology, The Alfred Hospital, Melbourne, VIC, Australia

    Gideon Blecher

  5. Monash Health, Bentleigh East, VIC, Australia

    Gideon Blecher

Authors
  1. Marco Falcone
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mirko Preto
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Davide Ciclamini
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Federica Peretti
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Anna Scarabosio
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Gideon Blecher
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Lorenzo Cirigliano
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Ilaria Ferro
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Natalia Plamadeala
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Martina Scavone
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Massimiliano Timpano
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Paolo Gontero
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conceived and/or designed the work that led to the submission, acquired data, and/or played an important role in interpreting the results: MF, MP, DC, FP, NP, and MS; LC and MT. Drafted or revised the manuscript: MP, MF, FP, IL, AS, and GB. Approved the final version: MF, MP, DC, PG, and GB. Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: MF, MP, and DC.

Corresponding author

Correspondence to Mirko Preto.

Ethics declarations

Competing interests

The authors declare no competing interests.

Ethics approval

The study was approved by the local institutional review board with protocol number: 201/2021.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Falcone, M., Preto, M., Ciclamini, D. et al. Bioengineered dermal matrix (Integra®) reduces donor site morbidity in total phallic construction with radial artery forearm free-flap. Int J Impot Res (2023). https://doi.org/10.1038/s41443-023-00775-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1038/s41443-023-00775-5

Search

Advanced search

Quick links