RU2148964C1 - Method for carrying out phalloplastic repair with bound cellulocutaneous flap - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves cutting out cellulocutaneous flap from thigh having vascular pedicle on the anteroexterior surface of the thigh. Descending branches of the lateral arteries and veins enveloping the femur are used with thigh skin nerve retained. Zone the transplant is taken from, is determined from formulas taking into account distance between the anterosuperior spine of the iliac bone and outer point of the superior edge of the knee pan. EFFECT: improved anatomic and physiologic results. 6 dwg

Description

 The invention relates to medicine, in particular to urology and andrology, and can be used in reconstructive surgery for the purpose of partial or complete phalloplasty.

 Phalloplasty methods determine the functional aesthetic and cosmetic results of surgical interventions, which is important for the social and domestic adaptation of patients. At the same time, preservation of skin sensitivity is of no small importance.

 A known method of phalloplasty developed by N. A. Bogoraz, which is based on the method of creating a migrating round skin stalk according to Filatov / N. A. Bogoraz, 1936 /.

 However, the viability of this flap depends on strict adherence to the proportions / ratio of width and length 1: 2 /. The sequential intersection of the legs of the skin stem, necessary for moving the flap, leads to loss of sensitivity and impaired blood supply, which leads to trophic disorders, failure of sutures. It should be noted that another disadvantage of this method is multi-stage, as a result of which the operation is stretched for many months. Therefore, at present, the use of this method is unacceptable.

 There is also a method of phalloplasty with a skin-fat inguinal flap formed along the surface envelope of the ilium of the artery and vein / C.X. Kichemasov et al., 1990.

 Cutting and transposition of this flap on the vascular pedicle to the pubic joint involves the intersection of the vascular pedicle, loss of skin sensitivity, and phalloplasty in this way is carried out in two stages. Despite the reduction of the time and stages of the operation, cutting off the flap from the donor site leads to poor nutrition and loss of skin sensitivity. These significant disadvantages impede the widespread implementation of the method.

 The purpose of the invention is to reduce the invasiveness of the operation, leading to post-plastic complications, and to improve the anatomical and physiological results of phalloplasty due to the movement of the tissue complex while maintaining blood supply and skin innervation.

 The goal is achieved by isolating a skin-fat flap on the anterolateral surface of the thigh and transplanting it on a constant vascular pedicle - descending branches of the lateral envelope of the femoral artery, vein and lateral cutaneous nerve of the thigh - into the pubic joint with the formation of neofallus.

 The lack of information in the patent and scientific literature on the possibility of phalloplasty by transposition of a skin-fat islet flap on a constant vascular pedicle — the descending branches of the lateral envelope of the femur of the artery and vein with the preservation of the sensory nerve — indicates that the claimed technological solution meets the “novelty” criterion.

 Phalloplasty by means of transposition of an islet skin-fatty flap on a constant vascular pedicle - the descending branches of the lateral envelope of the femur of the artery and vein has never been undertaken by anyone. The possibility of forming such a skin-fat flap on the front-lateral surface of the thigh and moving it to the pubic joint with the formation of neofallos on the aforementioned vascular pedicle was proved as a result of medical topographic and anatomical studies performed on 47 lower limbs of 25 unfixed corpses.

In FIG. 1 - 6 presents the proposed method of phalloplasty:
FIG. 1 - preparation of the left thigh after injection of the arterial bed with black latex. The rectus muscle is removed. A descending branch of the lateral envelope of the femur of the artery is visible, forming skin branches (1);
FIG. 2 is a diagram with coefficients for calculating the boundaries of the zones of location of skin vessels from the descending branches of the lateral envelope of the femur of the artery and vein emerging from the intermuscular gap between the rectus and lateral wide muscles of the thigh;
FIG. 3 - on the right thigh, a line was drawn between the HPAI and the LCI, zone I and zone II were calculated and shaded, in which the localization of blood vessels and nerves is assumed;
FIG. 4 - the rectus muscle of the thigh with a plate hook raised up. The descending branches of the lateral envelope of the femur of the artery and vein (1) and cutaneous nerve (2) are taken on holders;
FIG. 5 - a skin-fat non-free hip flap (1) was isolated on the vessels supplying it (2), innervated by the cutaneous nerve (3). The rectus femoris muscle (4) was taken onto the holders and raised to transpose the graft under it;
FIG. 6 - a skin-fat tube was formed - neofallos (1), the donor wound was sutured, in the proximal part it was covered with a split graft (2).

 It was found that in the intermuscular space, between the rectus and lateral wide muscles of the thigh, 2 to 6 skin arteries with a diameter of 0.5 - 1.4 mm / fig. 1/. Each artery is accompanied by two veins of approximately equal caliber. These skin vessels extend from the descending branches of the lateral envelope of the femur of the artery and vein / Fig. 1/. The sensitivity of the skin of the outer surface of the thigh is provided by the lateral cutaneous nerve of the thigh, penetrating the broad fascia of the thigh downward and somewhat inward from the anterior superior iliac spine.

 Statistical processing of the measurement results on the preparations made it possible to calculate the coefficients / Fig. 2 /, by which the detection of these skin vessels is most likely. For this, it is necessary to measure in a particular patient the distance from the upper anterior iliac spine / VPPO / to the lateral edge of the patella / LKN / and multiply by the diagrams shown in the diagram / Fig. 2 / odds.

 For example, if the distance from the HPLA to the LCS is 50 mm, the upper boundary of zone I will be 50 cm • 0.45 = 22.5 cm from the HPLA and the lower boundary of zone II by 50 cm • 0.58 = 29 cm. The width of zone II, located above the intermuscular gap between the rectus and lateral wide muscles of the thigh, will be 29 - 22.5 cm = 6.5 cm. Studies have shown that the detection rate of large skin vessels in zone I is 75.3%, and in zone II - 100%.

 Thus, it was proved that on the descending branches of the lateral envelope of the femur of the artery and vein and their anatomical permanent skin vessels, the formation of islet skin-fat flaps is possible, while maintaining skin sensitivity due to cutaneous nerve branches.

 The size of such flaps can reach 28 x 15 cm with a thickness of 1.0 - 2.5 cm, and the length of the supply vessels with a nerve is 15 cm. This allows you to move these flaps to the pubic joint on a permanent vascular pedicle and form a neofallos skin-fat tube .

Isolation of a skin-fat flap on the anterolateral surface of the thigh on the descending branches of the lateral envelope of the femur of the artery, vein and lateral cutaneous nerve of the thigh and its transposition on the permanent vascular pedicle to the pubic joint with the formation of neophallus helps to achieve a qualitatively new effect:
reducing the invasiveness of the operation, reducing stages, maintaining the skin sensitivity of the neophallus with satisfactory anatomical and functional results.

 Thus, the proposed technical solution meets the criterion of "significant difference".

The method is as follows: before the operation on the skin of the thigh, a projection of the intermuscular gap between the rectus and lateral wide muscles is outlined, from which the skin vessels and nerve that feed the flap come out. This projection practically coincides with the straight line drawn between the upper and anterior iliac spine / VPPO / and the upper lateral point of the patella / VLTN /. Then, the border is determined and marked on the skin, within which the blood supplying flap vessels and the innervating cutaneous nerve are localized. They are calculated according to the following formulas:
L1 = L • K1 and L2 = L • K2,
where L is the distance from VPPO to VLTN, measured for each particular patient, K1 = 0.45 and K2 = 0.58 are constant coefficients, and the obtained digital values L1 and L2 show the distance that needs to be measured from VPPO towards VLTN along the intended projection of the intermuscular gap, respectively, to the upper / L1 / and lower / L2 / boundaries of the desired zone. Then the skin with the designated boundaries of the found zone must be included in the composition of the skin-fat flap, the contours of which are indicated on the anterolateral surface of the thigh in accordance with the shape and size of the neophallus. The maximum possible size of such a flap is 25 x 15 cm / Fig. 3 /.

 Flap cutting begins with a bordering incision of the skin and subcutaneous tissue inward from the intended projection of the intramuscular gap. Then, the flap is separated laterally from the broad fascia with scissors and, within the designated area, the vessels and nerve that feed it are found that extend to the skin between the rectus and lateral broad muscles of the thigh. A wide fascia is dissected along the gap between these muscles and plate hooks and the rectus muscle is retracted inward. Next, the neurovascular leg of the flap is distinguished - the descending branches of the lateral envelope of the bone arteries and veins, as well as the branches of the lateral cutaneous nerve of the thigh upward and inward for 10-15 cm up to the main trunks of the lateral envelope of the femoral vascular bundle and lateral cutaneous nerve of the thigh / Fig. 4/.

 At the same time, all muscle branches extending from the indicated vascular leg are bandaged and crossed. Finish the formation of the islet skin-fat flap, separating it from the wide fascia outwards from the intermuscular space and preserving only the nourishing vessels and nerve / Fig. 5/. Then, an isolated complex of tissues is carried out under the rectus femoris muscle and the skin covering it in the pubic joint area, preserving the vascular pedicle and nerve and preventing its twisting or significant excesses. A skin-fat tube is formed from a skin-fat flap - a neophallus, which is sutured to the edges of a previously prepared wound bed in the pubic joint area. The donor wound is sutured / Fig. 6 /, and if not possible, close with a split skin graft.

 The proposed method of phalloplasty allows you to form or restore the penis while maintaining skin sensitivity, which allows for adequate sexual adaptation of patients and to improve the quality of sexual life.

 An example of practical use.

 1. Patient K., 24 years old. Diagnosis: transsexualism is a true nuclear type, surgical correction of gender from female to male. At the stage of phalloplasty, it was decided to perform the formation of neofallos from the skin-fat islet flap of the thigh on the descending branches of the lateral envelope of the femur of the artery, veins with the preservation of the lateral cutaneous nerve of the thigh by the proposed method.

 Before the operation on the skin of the right thigh, a dashed line outlined the intermuscular gap between the rectus and lateral broad muscles of the thigh, from which the vessels feeding the flap and the lateral cutaneous nerve of the thigh innervating it exit to the skin / Fig. 3 /. Next, the zone of the supposed localization of these vessels and nerves was calculated and shaded. Its limits were calculated by the formulas: for the upper border of the zone L1 = L • K and for the lower border L2 = L • K2, where the distance from HPL to VLTN measured in patient K, and K1 = 0.45 and K2 = 0.58 - constant coefficients shown in the diagram / Fig. 3 /. The obtained digital values L1 and L2 were used to determine the distance from the HPL along the intended dashed line, respectively, to the upper and lower boundaries of the desired zone. Next, contours of a skin-fat flap measuring 18 x 8 cm were applied to the thigh, which included the found area / Fig. 3 /. Flap cutting began with dissection of the skin and subcutaneous tissue inward from the dashed line. Next, the flap was separated from the wide fascia outward to the detection of the skin vessels and nerve supplying it within the calculated zone.

 All three flap-feeding skin arteries and their accompanying veins departed from the descending branches of the lateral envelopes of the femur of the vessels. Between the sheets of the superficial fascia of the thigh, a lateral cutaneous nerve of the thigh was found, penetrating the broad muscle of the thigh downward and somewhat inward from the anterior superior iliac spine and extending between the rectus and lateral thigh muscles / Fig. 4/.

 After dissection of the wide fascia, the vascular leg of the flap with the nerve was isolated upward and inward into the intermuscular gap between the rectus and lateral wide muscles of the thigh for 12 cm.All the muscle branches that departed from it were ligated and crossed. Then completed the formation of the islet skin-fat flap by separating it from the wide fascia outward from the indicated intermuscular gap / Fig. 5/.

 After that, a skin-fat flap, which was adequately supplied with blood through the preserved vascular pedicle, was performed without crossing the vessels supplying it and the cutaneous nerve under the rectus femoris muscle and the skin covering it to the pubic joint.

 From the skin-fat islet flap, a skin-fat tube is formed - a neophallus, which is then sutured to the edges of the wound bed formed in the pubic joint area / Fig. 6 /.

 The donor wound was partially sutured, in the proximal part it was closed with a dermatome graft taken from the medial surface of the same thigh. After surgery, complete engraftment of the flap was noted.

 The patient was examined after 6 and 12 months, had no complaints, skin sensitivity of the flap was preserved, neophallus was used for sexual intercourse.

 An example of clinical application N 2. Patient S., 38 years old, was admitted with a diagnosis of amputation of the penis due to cancer of his head. The proposed method produced cutting a skin-fat flap on the vascular pedicle - the descending branches of the lateral envelope of the femur of the artery and vein while maintaining skin sensitivity due to the branches of the lateral cutaneous nerve of the thigh. After moving it to the pubic joint and forming the skin-fat tube, the neophallus is sewn into the previously prepared wound of the penis stump. The donor wound is sutured completely. There was a complete engraftment of the flap.

 The patient was examined after 6 months. No complaints. Aesthetic and functional results satisfied.

 The proposed method of phalloplasty can be used in adult patients both for replacing wound defects of the penis resulting from injuries, cancer, and for reconstructive operations during surgical correction of sex pathology.

References
1. Bogoraz N.A. On the complete plastic restoration of the male penis, capable of copulation. Soviet surgery. - 1936, N 8, p. 303 - 309.

 2. Bogoraz N.A. Reconstructive surgery. - M .: Medgiz, 1948, v. 2, part 1, p. 264.

 3. Guicemasov Z. S.Kh., Alexandrov V.P., Lipkin A.Yu. et al. Use of an inguinal stem to restore the integument of the penis after Fournier gangrene. Urology and Nephrology. - 1990, N 4, p. 66 - 68.

Claims (1)

The method of phalloplasty with a non-free skin-fatty flap of the thigh on the vascular pedicle, characterized in that the flap is cut out on the anteroposterior surface of the thigh on the descending branches of the lateral envelope of the femoral artery and veins with preservation of the lateral cutaneous nerve of the thigh in the area between points L 1 and L 2, which are determined by the formulas
L 1 = L x 0.45 and L 2 = L x 0.58,
where L is the distance between the anterior superior iliac spine and the external point of the superior margin of the patella.

Images