: Alternative approaches to female-to-male gender affirming surgery**
The pursuit of a gender-affirming surgery that aligns with one's identity can be both transformative and anxiety-provoking. For many individuals, the ideal is a surgery that provides a realistic and sensitive tool to facilitate penetration and satisfaction during sexual activity. Historically, the standard approach for female-to-male (FTM) gender affirmation has involved a large approach from the wrist combining skin, fat, nerves, and blood vessels to create a larger phallus. The alternative to this approach could be the anterolateral thigh (ALT) flap, a less invasive method for creating a phallus while maintaining the integrity of the donor site.
The Anterolateral Thigh Phalloplasty (ALT) Approach:
TheALTphalloplasty technique uses skin, fat, and fascia from the anterolateral aspect of the thigh to construct the penile shaft. The benefit of this approach is that it preserves anatomic structure for potential future surgical revision or reoperation. The skin is moved as a nonautologous (donor) skin with blood supply from the descending branch of the lateral femoral circumflex vessels and innervation from the lateral femoral cutaneous nerve. The technique does, however, require microsurgical reanastomosis of the blood supply to establish a good flow to the neophallus.
Indications and Conditions:
Candidates for the ALT phalloplasty typically have a body type that does not yield significant amounts of fat or skin from the posterior aspect of the thigh and are looking for a less invasive approach. Candidates may also have had previous unsuccessful procedures, such as vein bypass, augmentation mammaplasty, or a nonautologous tissue phalloplasty with a nonautologous approach.
Contraindications:
Contraindications for ALT phalloplasty can include a history of medical conditions that affect coagulation, such as known clonidine (Catapres) or beta-blockers use, active smoking, and conditions such as deep infection at the ALT donation site. Additionally, patients with significant scarring or significant skin laxity may be poor candidates for the surgery.
Reconstruction Techniques:
Reconstruction with the ALT phalloplasty can involve multiple approaches, including primary phalloplasty (a one-stage procedure), secondary phalloplasty (a two-stage procedure), and a combination of procedures such as with the nonautologous partial thickness approach for the scrotum or metoidioplasty techniques to create the clitoris and penile skin.
Postoperative Care and Outcomes:
术后护理和结果因个体而有很大差异。常见的并发症包括血肿、感染、淋巴水肿和神经病变。在术后康复期间，建议患者避免剧烈运动和重体力劳动。术后恢复可能需要长达一年或更长时间。总体而言，与传统手术相比，ALT手术的风险可能更低。
Discussion:
The development and adoption of the ALT approach represent a shift away from the historical use of the radial forearm free flap (RFFF) with the goal of reducing surgical burden and maintaining better cosmesis. However, the decision to pursue the ALT approach must be carefully considered in light of the potential risks and benefits. Careful selection of patients based on medical history, physical examination, and discussion with a gender affirming plastic surgeon can lead to optimal surgical outcomes and improved quality of life.:
ALT phalloplasty represents a viable alternative for individuals seeking gender affirming surgery. It presents decreased surgical time, the potential to preserve natural anatomic structures, and the ability to maintain sensation. The technique necessitates meticulous preoperative planning, microsurgical skills, and attentive postoperative care to optimize outcomes, which may approach that of traditional approaches.
