For trans men interested in phalloplasty, one of the hardest decisions is deciding what donor site is the most appropriate. In general, there is no wrong decision for this, but there is a personalized best decision based on the patient’s surgical goals and body type. In the video link below, Dr. Crane discusses in detail the risks and benefits of each donor site: the radial forearm (RF), the anterior lateral thigh (ALT), and the musculocutaneous lattisumus dorsi (MLD) flap.
Delayed ALT Flap (tissue lifted from a donor site and moved to a recipient site).
Delaying a flap is a technique that has been used in plastic surgery for thousands of years. The technique was first used to reconstruct noses that were amputated as a form of punishment. The basic principle of the delayed flap is that all blood vessels to the tissues that are supposed to be transported to another part of the body are cut, except for the one or two main blood vessels that the tissue will rely on for oxygen once the flap is in the intended place. The act of cutting all the blood vessels except for the one or two main blood vessels gives the tissue time to get used to surviving on a minimal blood supply before going through the stress of transporting the tissue to where the surgeon eventually wants it to reside. Waiting about six months between delaying the flap and transposing the tissue gives the blood vessels time to quadruple or quintuple in size and it allows for swelling to resolve.
After a patient wakes up from a flap delay surgery, he will notice a large rectangular incision on his thigh that will outline the future tissue that will become the phallus. The time period between the flap delay surgery and the phalloplasty surgery is a great opportunity to continue laser hair removal. You will know exactly what tissue will be taken and hair removal can be continued up to two weeks before the day of phalloplasty surgery. Two drains are placed for 4-8 days to drain any fluid that accumulates post-operatively. Once the drains are removed, it is possible that more fluid builds up under the flap. As long as the fluid does not get infected, which is rare, there is no reason to drain it unless it is causing discomfort. Draining all the fluid usually takes multiple attempts a few weeks apart as the body can keep producing the fluid for some time. You can also choose not to drain the fluid is as it will be drained when your phalloplasty is performed.
It is ok to return to work a week or two after a flap delay procedure, and showering is permitted 2-3 days after the surgery.
Below are templates for hair removal prior to surgery. The areas shown should be done on the donor site forearm or thigh. Hair removal can be a lengthy process (varies slighly depending on size of area and hair density of the area to be treated).