Minority vote: expanders actually make sense, as far as any of this makes sense. Being able to tolerate lookin' weird for the expanders is going to remove some of the hideous scarring afterward.
It seems like the usual phalloplasty technique is to plan for multiple revisions, but to always be reactive in those revisions. Tissue expanders speak to some well-intentioned premeditation. Less bad.
If you scroll back some pages you will see that somebody found an article that announced "Mr and Mrs X from *insert address* welcome the birth of their twin girls". I heard about parents announcing the birth of their kid in a local newspaper before, but putting the address out there too seems quite reckless, it's strange that they didn't even write their full surname but this was okay.
Anyway, there was no need to post her address here for all to see especially since she's a 20 yo autistic kid. Sure, she's promoting mutilating surgeries for other kids but not even that justifies putting her at risk like this,
So the situation is that a cow's dox is findable by anyone autistic enough to put the puzzle together. You can't delete it. They can't, either. You can't stop them from sharing too much. What can be done?
you could:
A. Keep it to yourself.
B. Tell the target directly
C. Tell everyone
Option A leaves the cow open to whatever harm you are imagining, since anyone intent on harming the target wouldn't warn them first.
B helps the cow (maybe if you can get ahold of them), but doesn't stop anyone else who is making the exact same mistakes.
C helps the cow and also other people who might otherwise be careless with their privacy
A person with bad intent would not warn them. Posting dox publicly is a warning to non-retards to keep themselves anonymous, if they care about that. Because her dox was posted here, elephant dick now knows that any weirdo could locate her, and she probably bought some mace. she probably pays more attention to her surroundings.
There is no known risk. No one has been harmed because their address was posted on kiwi farms. People who wish to harm strangers based solely on internet activity are a rarity. In fact, people have to make shit up about kiwi farms to make it look harmful or dangerous because there isn't any obvious example of harm perpetrated. The worst thing that happens is it makes people scared, I suppose, but that could be said about literally anything. It isn't anyone elses problem.
Also, why is there a scar running along the top of the rot dog? Usually the stitches are placed on the underside, you know, to keep them from showing. Did the bologna literally burst open (like some of them do from the pressure) and need to be reassembled/restitched? Questions, questions.
The study I'm aware of is from 2019, which "concluded that the potential advantages of preexpansion do not outweigh the high risks of complications and lack of success."
There's a newer one from 2021 that says "Pre-expended SPP is a feasible and safe surgical procedure, involving a stepwise approach. Vascular complications are reduced as no total phalloplasty loss is reported in this series. Non-urethral complications are mainly low-grade. When performed in additional procedures, urethroplasty remains a limitation. It brings along a high amount of urethral complications, as for all phalloplasty techniques."
The thigh one is from this article from 2016. There's an arm flap one from 2017 also.
2 articles, one from 2014 and one from 2021 explain pre-expansion in males with penile loss. (not troons but the expander method is relevant). As a bonus, a short article from 1989 is the oldest I can find. (still in males). This other one from 2014 shows a type I only seem to see in natal males.
There's some juicy images and details so sharing (going through the articles chronologically):
Beginning with the 1989 one, the patient was a guy who "suffered a catastrophic motor vehicle accident. He had extensive injuries that required a hemipelvectomy with resulting loss of his penis and a major portion of his scrotum. Only one of his testicles remained intact. He also sustained severe urethral injury; a subsequent perineal urethrostomy and construction of an artificial sphincter were done."
This has a lot of observations that show a care by the surgeons I've never seen in an SRS butcher, the whole expander is to get non-hairy donor skin, as the article notices "otherwise urethral strictures most likely will occur" (so they've known that for years, and many of our guys still go ahead and use hairy skin).
In our case, the flap of choice was the lateral arm flap. The reasons for this choice are: 1. It is a sensate
flap. 2. It is relatively hairless, especially in our patient who has hairy forearms and abdomen. The limited surface area of this flap was the major drawback. To overcome this difficulty, we elected to expand the flap prior to its transfer. The technique of skin expansion described earlier allowed us to harvest a flap measuring 18 cm by 20 cm, which was adequate for simultaneous total penile and urethral reconstruction. Although the donor site required a skin graft for closure, our main reason for expansion was to obtain a flap of adequate size from the nonhairy skin for reconstruction. This we have achieved.
Total penile and urethral reconstruction was requested by the patient for both urinary continence and psychologic benefits. Preoperatively, psychiatric evaluation was obtained and surgery was recommended. The operation was planned as a free tissue transfer using microsurgical technique.
Because of the patient's hairy forearm, the radial forearm flap was not a suitable choice. The lateral arm was then chosed as the donor site. Because of the anticipated limited size of this flap, expansion of the flap prior to its transfer was performed. A 350 cc quadrangular skin expander was inserted subfascially, medial to the lateral intermuscular septum, through a 5-cm skin incision. Full expansion was accomplished in three months (Fig. 2).
Figure 1. Patient preoperatively with total absence of penis and urethra. Figure 2. At two years post accident, lateral arm flap at time of harvest.
In the second stage, an 18 cm x 20 cm lateral flap was harvested and transferred to the perineum as a free flap. Total reconstruction of the penis and urethra was then performed (Fig. 3).
The technique used was similar to that reported by Chinese microsurgeons. Two epithelialized and connected portions were created out of the lateral arm flap by deepithelialization of a 1-cm wide skin strip near one edge of the flap. The urethra was then formed by tubing the smaller portion
(measuring 2.5 cm x 20 cm) over a No. 12 French catheter. The remaining larger portion of the flap, 14.5 cm x 20 cm, was then wrapped around the neourethra in a reverse direction to form the penis (Fig. 4).
Figure 3. Recipient site with outlining of the location of reconstructed penis and recipient vessels (inferior epigastric artery). Figure 4. The smaller flap was tubed over a catheter to form the urethra; the larger flap was then wrapped around to form the neopenis.
A semirigid prosthesis was inserted at the same time to maintain rigidity and to create a potential space for future insertion of an inflatable prosthesis. The inferior epigastric artery was isolated, rerouted to the groin, and reanastomosed to the inferior radial collateral artery of the flap. Similarly, venous anastomosis was performed on the superficial internal pudendal vein. For innervation, the lateral cutaneous nerve of the arm was anastomosed to the internal pudendal nerve. The donor site was closed with a skin graft measuring 7.5 cm x 20 cm.
At eight months, the patient reported further sensory recovery in his neopenis (Fig. 5). At this time, an inflatable penile prosthesis was also inserted. Because of recurrent infections in his urinary tract and artificial sphincter, the restoration of the perineal urethra was postponed until a future time.
Figure 5. Eight months postoperatively, a semirigid prosthesis has been inserted in preparation for an inflatable penile prosthesis. A glans penis was created with a split-thickness skin graft.
The 2009 article is relatively short, but has some gory pics of the process:
Two female-to-male transsexual patients underwent total penile reconstruction with preexpanded
radial forearm fasciocutaneous free flap 2 months after bilateral mastectomy with free nipple-areola grafting, hysterectomy, and oophorectomy. During this first phase of gender reassignment surgery, a 300-mL oval-shape tissue expander was implanted under the fascia of the planned fasciocutaneous radial forearm free flap, which was partially dissected (Fig. 1A). A forearm fascia was incised distally and ulnarly to allow expansion (Fig. 1B). The tissue expander was gradually inflated with normal saline twice a week for 2 months on an outpatient basis (Fig. 1C).
Figure 1 (A) Oval-shaped expander prepared for implantation. (B) Expander implanted under the incised fascia of planned radial forearm free flap. (C) Expansion performed on an outpatient basis once a week. (D) Operative design for total penile reconstruction.
After the desired expansion was accomplished (Fig. 1D), the expander was removed (Fig. 2A) and one-stage total penile reconstruction was performed with simultaneous urethral reconstruction
(Fig. 2B) and silicone prostheses implantation in both patients (Fig. 2C and D). A 7-cm-long, knitted Dacron vascular graft normally used for femoral artery bypass procedures was used as silicone rod holder. We used the graft, which was 5 mm less in diameter than the silicone rod, to obtain a strong hold of the prostheses, which was inserted 7 cm inside the graft lumen (Fig. 2E, F, and G).
Figure 2 (A) Extraction of the expander. (B) Reconstruction of the urethra and (C) implantation of penile silicone prostheses in the same procedure. (D) Flap sutured before microvascular transfer. (E) Insertion of the silicone rod into graft holder. (F) Prostheses inserted 7 cm inside the graft lumen. (G) Close-up view at the most distal part of graft holder.
The proximal edge of the graft holder was sutured to the symphysis pubis with 2–0 nonresorbable sutures subperiosteally. Both flaps were anastomosed to the superficial and deep epigastric vessels, and the lateral antebrachial nerve, harvested within the flap, was coapted to the dorsal clitoris branch from the pudendal nerve for flap sensation. Healing was uneventful, and both flaps survived completely, showing excellent aesthetic and functional results, including micturition and sexual activity (Fig. 2H and I). Donor site morbidity was acceptable.
After 18 months, both patients demonstrated satisfactory long-term final results (Fig. 2J and K). Preexpanded radial forearm fasciocutaneous free flap may enable one-stage total penile reconstruction, allowing simultaneous urethral reconstruction and prostheses implantation with
satisfactory aesthetic and functional results.
Moving on to 2014, the patient was a male burn victim, expanders were used to acquire non-scared donor site
Our case is a 31-year-old patient who sustained a 19% total burn surface area by electrical burn in August 2011. The burn area involved both forearms, abdominal region, both femoral regions, and perineum including genitalia loss. Most of the burn wounds were skin grafted shortly after the injury. Due to the nature of the burn, regular donor sites for penile reconstruction were unavailable. Before surgery, we went through a detailed plan for phalloplasty with the patient and his family. The patient consented to the 2-stage surgery for the penile reconstruction.
The first stage was insertion of a 600-mL soft tissue expander in the scapular region. After 4 months of expansion, the second stage of free scapular flap transfer was performed in March 2012.
The surgical procedure can be divided into 2 stages. First is the expansion phase followed by the second stage of penile reconstruction performed 4 months later. At the first surgery, we implanted a rectangular 600-mL soft tissue expander at the scapular region. Before surgery, using the ultrasound Doppler survey, the pedicle is mapped out on the skin surface (Fig. 1).
FIGURE 1. A, The area of implantation pocket was determined by the size of expander. B, The surface markings of the scapular cutaneous vessels. The top one was not included in the flap planning because of its inappropriate distribution. Another 2 branches were contained by the area of implant pocket. C, Four months after expansion.
The pocket for implantation should be determined by the size of expander and the location of vasculature. The appropriate tissue layer is dissected out. The pocket is created parallel to the scapular spine and the lateral border being 4 cm away from the pedicle. An 8-cm incision was made 3 cm away from the medial border of the pocket.
The expander was implanted deep to the deep fascial layer, whereas the filling port was placed in a separate pocket lateral to the expander. During surgery, the expander was prefilled with 100-mL saline. Serial expansion was started 10 days after surgery at the interval of 3 to 4 days for 4 months, reaching a final volume of 800 mL.
At the second stage of reconstruction, the flap was designed in 5 parts (Fig. 2), 15 cm in length and 18.5 cm in width. Vasculature was once again determined by ultrasound Doppler. The emerging point of the circumf lex scapular vessel from the trilateral space along the lateral border of the scapular as well as distribution of its 3 major branches is mapped on the skin.
Flap parts A and C were planned for reconstructing the body of penis, whereas parts D and E for glans penis. Flap part B is to be curled inward around a folly’s catheter placed inside, and the 2 small deepithelialized gaps by both sides of part B were sutured together, to form the new urethra. The side of the neourethra was designed to be the ventral surface side of the reconstructed penis.
Another deepithelialized gap perpendicular to the macroaxis of the flap is also curled inward and sutured together to form the corona of the glans penis, whereas the other 2 deepithelialized gaps with ‘‘V’’ shape used for external orifice of neourethra. When the new urethra was completed, flap parts A and C were rotated backward and sutured together to form the dorsal side of the penis.
FIGURE 2. Flap planning. A, Five parts of the f lap marked out. Vascular anatomy is mapped out yet again. B, Flap after dissection and deepithelialization. C, Formation of neourethra. D, The reconstructed penis.
The reconstructed penis achieved good esthetic appearance and satisfactory stiffness. However, a urinary fistula developed. The fistula was repaired 8 months later. The final appearance and function were quite satisfying, with the donor site of the flap also undergoing good recovery (Figs. 3 and 4).
FIGURE 3. A to C, Perineum region before surgery. D to F, Reconstructed penis 8 months later. Urinary fistula repair and lipectomy were also performed.
FIGURE 4. A, Donor site of f lap after expansion. B, Donor site covered by split-skin graft 8 months later after reconstruction.
Now we get to 2017, with the thigh expander you were asking about. The article goes into detail about it.
The anterolateral thigh (ALT) perforator flap for phalloplasty is gaining popularity because it avoids the well-known scars of the radial forearm flap. However, scars are not eliminated, just moved to a different location, the thigh, that can for some patients be of great sexual value. Preexpansion of the ALT flap allows primary donor site closure, thus avoiding not only the unsightly appearance of a skin grafted ALT donor site, but also the skin graft donor site scar. Preoperative perforator location by means of computed tomography angiography allows safe expander placement through 2 small remote incisions.
Very large flaps are needed for a phalloplasty and the donor site subsequently needs skin grafting. As a result, the donor site is quite noticeable because a hairless skin graft with a depression is left at the donor site. If the donor site is located in the forearm, it is not only quite visible and difficult to conceal unless long sleeves are worn, but also a recognizable sign of the operation performed (Fig. 1).
If an ALT flap is used for phalloplasty, the RFF donor site scars are avoided. However, a donor site scar will be present in the thigh, combined with the scars needed for skin graft harvest (Fig. 2). With the RFF and ALT, there is not only the flap donor site scar, but also the split thickness skin graft donor site, which is often more painful than the flap donor site itself.
Fig. 1. Postoperative result of a radial forearm flap (RFF) phalloplasty showing the typical scar at the
donor site. Because this is the only application for use of such a large RFF, this scar has become a recognizable sign of the operation, which not all patients like to have. Scars in the thigh are also present due to harvest of STSGs for coverage of the RFF donor site. Fig. 2. Postoperative result of an anterolateral thigh (ALT) and superficial circumflex iliac perforator flaps phalloplasty. Although concealable with regular clothing, when naked the scars in the thigh, owing to both ALT and split thickness skin graft harvest, are apparent.
There is a particular subset of patients who want to avoid both scars because, although the thigh scars can be easily concealed whit a pair of shorts while dressed, they cannot be concealed when naked and are very close to the genital area. These patients would rather avoid disfigurement of the area that is the center of their masculinity and intimacy. Preexpansion of the ALT allows donor site scarring to be minimized in these patients (Fig. 3).
Fig. 3. Expanded anterolateral thigh and superficial circumflex iliac perforator flaps phalloplasty donor site, 5 months postoperatively. For comparison, here is an early postoperative image of a phalloplasty after expansion. The donor site has been closed with an inverted “Y” scar and no skin graft donor site is present in the thigh. The scars are still red but already much less disfiguring than those in Fig. 2.
PREOPERATIVE PLANNING AND PREPARATION
Preoperative location of the perforator is crucial to flap planning. A CT angiography is used for this purpose. The CT angiography allows the most distal perforator with the largest caliber, the longest (to comfortably reach the pubis), with the best subcutaneous branching and the most convenient intramuscular or septal course, providing a preoperative navigation that cannot be obtained by simple Doppler location.
The radiologist provides distances from the anterior superior iliac spine based on an x–y axis (Fig. 4) drawn on the thigh and the position of the perforator is marked on the patient’s skin. The flap is drawn accordingly with the perforator lying along its midline and close to its proximal margin. Then the expander’s base (20 7 cm) is drawn outside of the flap’s borders (Fig. 5) because, as described, placing the expanders in the flap will squeeze the fat toward the midline, which is not desirable in this case.
Fig. 4. An example of a preoperative computed tomography angiography. The sagittal (upper left), coronal (upper right), and axial (lower right) views of the perforator course together with a 3-dimensional reconstruction of the skin with the projection on the skin of the point of emergency from the fascia of the perforator (lower left), are provided. In the upper right coronal view, the distances measured from the anterior superior iliac spine are provided. Thus in a single image information about the course and position of the perforator are provided.
Fig. 5. Same patient as Fig. 4. A line is drawn connecting the anterior superior iliac spine (ASIS) to the upper lateral border of the patella. Using the angiographic computed tomography measurement in Fig. 4, the projection on the skin of the perforator is marked with a black, circled X, exactly 222 mm below and 32 mm laterally from the ASIS. Afterward the flap is drawn (black rectangle). The skin projection of the 2 expander pockets is drawn just lateral and medial to the flap to have little overlapping with the flap once the expanders are inflated. The expander base and remote ports are drawn in green. The ports are placed in an easily reachable position when the patient is lying supine. The “W” incisions (black) are placed in between.
PATIENT POSITIONING
The patient is placed in the supine position. The ipsilateral arm can be abducted or adducted based on the surgeon’s preference. Abduction will provide greater room for the placement of the lateral expander because the hand, with the arm adducted, comes in close proximity to the lateral incision and pocket.
PROCEDURAL APPROACH Expander Placement
Two remote “W” incisions 16 are performed some centimeters caudal to the inguinal ligament (see Fig. 5) and deepened to the deep fascia. Then the 2 pockets are dissected, bluntly or with the cautery, with the aid of a lighted retractor to obtain hemostasis. Care must be taken not to deepen the plane too much because the sensory nerves lie on top of the fascia and they must not be damaged. Once the pocket is complete, a superficial (3–5 mm of fat left on the skin flap) pocket is dissected cranially to the incision to allow for remote port placement in a position that shall be as easily accessible as possible (Fig. 6). Before expander placement, two 12-F suction drains are placed in the pocket. The air is emptied from the expanders and they are partially filled with methylene blue–tinted saline, which allows easy visualization of the fluid coming out of the expanders during ambulatory postoperative expansion. Partial inflation keeps the expander distended and allows easy placement without folding (Fig. 7). Once the expander and ports are in position, easy accessibility of the ports is double checked before closure (Figs. 8 and 9).
Fig. 6. Medial view of a right thigh (the knee is on the left hand side of the picture) at the time of expander placement. The pocket has already been dissected through the “W” incision, which allows wider exposure with the same length compared with a linear incision. The drain is in place. Saline (150 mL) colored with methylene blue is injected in the expander after all air has been removed. The expander is placed on the skin in the same position that it will eventually have inside the pocket.
Fig. 7. Same view as in Fig. 6. The partial inflation of the expander facilitates insertion by keeping it distended and avoiding folding.
Fig. 8. Same view as in Figs. 6 and 7. The remote port is inserted last. The pocket for the port is dissected in a different – more superficial – plane and with a bottle-neck to prevent the port from slipping back toward the incision once inserted.
Fig. 9. Bird’s eye view, knee on the left hand side. The figure shows the 2 expanders with the procedure completed for the lateral one and to be completed for the medial one, to show the 2 moments of placement of the needle in the port. The syringe on the right is connected to the medial port before closure. At this point, the port is probed to verify easy access before closure, for eventual replacement. The syringe on the right has been used for a final inflation of the expander after closure, to ensure obliteration of dead space within the pocket to avoid fluid collection.
Donor Site Closure
At the time of flap transfer (Fig. 10), the flap is harvested first, with the expander left in place to maintain skin stretch and inflated with extra 100 to 150 mL to obtain some intraoperative expansion. Donor site closure begins with expander and valve removal through the easy access of the defect left by the flap. Dissection is suprafascial and then on the plane of the deep capsule of the expander, which will result in division of the capsule into a superficial and a deep part. While the deep part is not touched, the superficial is scored extensively to maximize the advancement of the skin flaps, extending the capsular incision to the superficial fascia in a way very similar to galeal scoring in the scalp (Fig. 11). Then the flaps are brought together and temporarily held together with skin staples. Two big dog ears will form distally that are eventually resected, resulting in inverted “Y” or “T” scars (Figs. 12–16). Suction drains are placed underneath the flaps.
Fig. 10. Bird’s eye view, knees on the right hand side. Preoperative markings of a right pre-expanded anterolateral thigh flap. The CT scan showed 2 septal perforators coming close to each other in this case. This picture shows how the expanders, although placed laterally to the flap, eventually – with inflation – do expand underneath the flap as well, causing some peripheral thinning.
Fig. 11. Intraoperative, bird’s eye view after flaps transfer. Knees on the right hand side. The anterolateral thigh flap is wrapped around the ipsilateral superficial circumflex iliac perforator flap (not visible) that has been used for urethral reconstruction and whose donor site is clearly visible. The thigh flaps for closure has been dissected and the capsular scoring is clearly visible on the lateral flap, held in the bottom of the picture by 2 skin hooks. Fig. 12. Same view as in Fig. 11. The wound edges have been temporarily approximated with skin taples and 2 dog ears form distally.
Fig. 13. Close up view of the distal dog ears. The midpoint is brought proximally with forceps to show the correction needed to eliminate the 2 dog ears. Fig. 14. Lateral view of the wound on the right thigh (knee on the right hand side). The skin resection is drawn in blue. Fat resection will extend further to avoid residual dog ears. The forceps are kept in the same position as Fig. 13 to allow for comparison.
Fig. 15. Donor site after closure. The resulting scar is an inverted “Y”. Fig. 16. Four years postoperative result. Despite some scar widening in the middle, the scar is little visible. No skin graft harvest scars are present. The inverted “T” can be seen distally above the knee.
POTENTIAL COMPLICATIONS AND THEIR MANAGEMENT
There are no specific complications of ALT flap preexpansion; potential complications are those
commonly related to tissue expansion. Like any specific body region, the anatomy accounts for
some peculiarities. In the thigh, the subcutaneous fat is quite dense, fibrous, and thick, and skin
perforation and exposure is very unlikely.
We have observed 2 leaks from the inflation ports that needed replacement likely owing to puncture with an exceedingly large needle. Infection can be a complication and can be prevented with appropriate technique. We have had an infection when we associated liposuction to expander placement. Infection is treated with expander removal, culture-guided antibiotic therapy and expander re-placement once the infection is cured. Placement without the aid of an CT angiography carries the risk of discontinuation of the procedure because the right perforator is missed.
POSTPROCEDURAL CARE
Patients are immediately mobilized and discharged after drain removal. Expansions are begun after 2 weeks and are usually performed weekly. The whole process usually takes 4 to
6 months. It is thus initiated approximately 6 months before phalloplasty.
Overexpansion is usually performed and is stopped until a circumference gain of at least 14 cm has been obtained. During this period, especially when the expanders are fully inflated, physical activity is limited because the volume of the expanders restricts movement. Sports and activities that involve lower limb movements and that are at risk for trauma to the thighs are restricted. The patients comply well and wear larger trousers to accommodate the inflated expanders.
REHABILITATION AND RECOVERY
Once the expanders are removed and the flap transferred, recovery is relatively fast and no specific rehabilitation is needed. Because of the phalloplasty, the patients stay in bed for 10 days. When allowed to walk, no specific problems have been observed.
OUTCOMES
The charts of 91 pedicled ALT flap phalloplasties performed between 2004 and 2016 were retrospectively reviewed. Nine patients (10%) underwent pre-expansion of the ALT flap in preparation for a pedicled ALT flap phalloplasties. Seven patients were operated for female-to-male sex reassignment surgery, 1 for reconstruction after penile amputation, and 1 for reconstruction after bladder extrophy (Table 1). Six patients had a preoperative CT scan.
Seven of 9 patients underwent eventual phalloplasty with an ALT flap (see Table 1). In 1 patient (case 2 in Table 1) who had no preoperative CT angiography, no suitable perforator was identified and the procedure was converted in a free RFF phalloplasty. Another patient (case 8 in Table 1) had an infection that eventually forced removal of the implants. Because of this delay and of a significant weight gain that caused fat thickening in the thigh, we abandoned the ALT flap phalloplasty and performed an RFF phalloplasty instead.
In cases 2 and 3, there was a leak from the expander inflation ports that required their replacement. The expanders did not deflate. The leak was probably due to the use of a large needle for inflation.
The only infection was observed in the patient in whom we performed flap liposuction for thinning purposes in the same operation as expander placement (case 8 in Table 1). Because it is only 1 case, we cannot conclude that liposuction might be related to infection. More data are needed, although it seems that performing the 2 procedures simultaneously is better avoided if possible.
Donor site closure was primary with a double dog ear resection distally that resulted in an inverted “T” or “Y” appearance in 6 cases and with 2 opposed advancement flaps in 1 case. After flap harvest, all donor sites but one healed uneventfully. This case (case 6 in Table 1) had 2 advancement flaps for donor site closure, the medial of which had a partial necrosis with a wound dehiscence that eventually required skin grafting. We would discourage use of these 2 flaps for donor site closure and we would use 2 big rotation flaps—if flaps are needed because primary closure is not possible—instead.
There were no flap-related complications like partial or total necroses.
In 2 cases (cases 1 and 2 in Table 1) lipofilling was performed twice for correction of a contour deformity in the thigh.
CASE EXAMPLES Case 1
A 36-year-old female to male transgender patient was admitted for phalloplasty with a pre-expanded ALT flap combined with a free RFF for urethral reconstruction (Figs. 17–19; see Table 1, Case 5). Two rectangular expanders of 750 mL each were implanted on the left thigh and expanded with 1000 mL until a 14-cm circumference gain was achieved, which took 11 weeks. Seven months after expander placement, phalloplasty was performed with the pre-expanded ALT flap combined with a free RFF. The RFF was anastomosed end to side to the femoral artery and end-to-end to the greater saphenous vein.
The pedicled ALT flap was transferred as a pedicled flap with 2 sensory nerves that were anastomosed to 1 ilio-inguinal nerve and to one of the dorsal clitoral nerves. The ALT flap donor site was closed primarily. Coronaplasty was performed 6 weeks after the initial operation. Erectile and testicular implants were placed 3 years after the operation. One year later, a minor correction was performed to reduce the penile size. At 5 years follow-up the patient is doing fine.
Fig. 17. Case 1 (see text for details). Three-quarters preoperative view of the expanded thigh. Fig. 18. Case 1 (see text for details). Postoperative view before penile correction. The linear thigh scar has widened, probably owing to some residual tension.
Fig. 19. Case 1 (see text for details). Postoperative view after volume reduction of the phallus by narrowing the base with a wedge resection on the ventral side.
Case 2
A 29-year-old female-to-male transgender patient (see Table 1, Case 9) was admitted for a phalloplasty with a pre-expanded ALT flap and a superficial circumflex iliac perforator flap for urethral reconstruction because he wanted no scars in his forearm (Figs. 20–23). Two 750-mL rectangular expanders were placed in his right thigh and inflated, over 13 weeks, with 1000 and 775 mL.
Four months after the operation, the patient underwent a phalloplasty with a pedicled ALT flap combined with a pedicled superficial circumflex iliac perforator flap for urethral reconstruction. Two lateral femoral cutaneous nerve branches harvested with the ALT flap were connected to 1 ilio-inguinal nerve and 1 dorsal clitoral nerve. The procedure was uncomplicated and the donor sites were closed primarily. Coronaplasty has not yet been performed. The patient had a postoperative urinary infection that was treated with antibiotics and, 1 year after the operation, is voiding well and waiting for coronaplasty and placement of erectile and testicular implants.
Fig. 20. Case 2 (see text for details). Intraoperative view after completion of vaginectomy and reconstruction of the fixed part of the urethra, before phalloplasty.
Fig. 21. Case 2 (see text for details). Postoperative frontal view showing 2 dog ears that will fade over
time and the contour deformity of the right thigh. Fig. 22. Case 2 (see text for details). The left lateral view shows the linear scar of the superficial circumflex iliac perforator flap that extends far laterally to obtain an adequate pedicle length to reach the pubis.
Fig. 23. Case 2 (see text for details). Close up view of the external urinary meatus, made of the suture of the superficial circumflex iliac perforator and the anterolateral thigh flaps.
Case 3
A 43-year-old patient (see Table 1, case 4) came to our attention for penile reconstruction after amputation for a squamous cell carcinoma (Figs. 24–2. Two 750-mL rectangular tissue expanders were placed in the right thigh based on perforator location with a CT angiography. Because the superficial circumflex iliac perforator flap was unavailable due to scarring from the previous groin sentinel node biopsy, a pre-expanded RFF was planned as well and another 750-mL expander placed in the left forearm.
The RFF was anastomosed end to side to the femoral artery and end-to-end to the greater saphenous vein and the pedicled ALT flap wrapped around it with its cutaneous sensory nerves connected to 1 ilio-inguinal nerve and to one of the dorsal nerves of the glans. Coronaplasty was performed 1 week later. One year after the operation, an erectile implant was placed.
Fig. 24. Case 3 (see text for details). Preoperative view after completion of tissue expansion in the forearm and thigh.
Fig. 25. Case 3 (see text for details). Left lateral intraoperative view. The belly is on the right hand side. The free radial forearm flap is wrapped around the drain placed into the bladder through the urethra and the anterolateral thigh (ALT) flap is ready to be wrapped around it. The nerves ready for coaptation can be seen coming from the ALT flap.
Fig. 26. Case 3 (see text for details). Intraoperative view before expander removal. The fascia has been closed.
Fig. 27. Case 3 (see text for details). Three-quarters right postoperative view shows some widening and discoloration of the scar, not uncommon in people with dark skin. Fig. 28. Case 3 (see text for details). Widening and discoloration are observed also in the forearm skin.
CLINICAL RESULTS IN THE LITERATURE
The first case report of a pre-expanded free ALT came from Tsai, who visualized the perforators through a large incision and placed a subfascial expander. Other reports followed of its use as a free flap in burn wounds with the dual advantages of thinning the flap and closing the donor site primarily or reducing the skin graft and potentially increasing vascularity. As described above, the increase in vascularity is not needed and the usefulness of thinning the flap cannot be applied to phalloplasty. When the flap is thinned by expansion, the flap above the expander thins out but the part where the pedicle enters the flap stays thicker.
There are also some reports of pre-expanded flaps in phalloplasty surgery with the RFF, 22 the suprapubic flap,23 or scapular flap. 24 In these cases, just a reduction of the area to be grafted and an insensate phallus are obtained, whereas a pre-expanded ALT flap always allows preservation of flap’s innervation.
Over the years, we have refined our technique to optimize outcomes. A CT angiography is used routinely to accurately locate perforators and expanders are placed accordingly. This way the unfortunate occurrence observed in patient 3 of Table 1 is avoided (Fig. 29).
Fig. 29. This schematic drawing shows how incisions, expander, and valves shall be placed once the perforator is located by means of a CT scan. For more information, see Figs. 4 and 5 and the relative legends, and the “preoperative planning and preparation” and “procedural approach: expander placement” sections.
Expansion is routinely carried out until a circumference gain corresponding to the flap’s width is achieved. Closure is performed directly and a dog ear usually forms distally, which is excised resulting in an inverted “T” or “Y” design. Patient are instructed on wearing large trousers to accommodate the bulk of the expanders.
The flap can be farther thinned to the level of the suprascarpal fat provided that the regions were the nerves and the perforator lie are avoided. This thinning might sometimes result in a temporary venous congestion (fast capillary refill) that normally subsides within 30 minutes. The ALT flap is harvested without any fascia and is best tunneled underneath the rectus femoris and sartorius muscles, and then through a wide subcutaneous tunnel, to reach the pubic area.
If an appropriate perforator is chosen based on CT angiography studies, the perforator is long enough to transfer a pedicled flap and avoid microsurgical anastomoses. The patient is kept with his thigh slightly bent to avoid any traction on the pedicle for the first 3 days. Once the flap is tubed, any tension must be avoided. If there is any tension that might cause flap compression with postoperative edema, a skin graft is best placed ventrally to relieve this tension and avoid vascular compromise.
The presence of the expanders is cause of discomfort, especially toward expander completion, because the expanders hold a considerable volume. Patients try to partially conceal the expanders by wearing very large trousers. It is indeed a procedure for a small group of patients (10%) in our series, who accept the presence of the expanders and the additional operation and ambulatory inflations needed to reduce the donor site scarring. These patients must be very well-informed and have sufficient motivation because they have to put extra effort to go through a longer process, additional operations, and extra costs.
Also, it has to be pointed out that in this cases reduction of scars is achieved at the expenses of contour. It has to be discussed with the patient that indeed the patch like scars due to skin grafting will be avoided. But avoidance of scars comes at the expenses of contour because the thinned expanded skin will cause a depression and a contour deformity in the thigh that will need future lipofilling sessions to be corrected.
This got pretty long, so I will post the rest in another post.
I'm back on my ADHD meds so back on my hobby of searching for gory SRS on pubmed
So the situation is that a cow's dox is findable by anyone autistic enough to put the puzzle together. You can't delete it. They can't, either. You can't stop them from sharing too much. What can be done?
you could:
A. Keep it to yourself.
B. Tell the target directly
C. Tell everyone
Option A leaves the cow open to whatever harm you are imagining, since anyone intent on harming the target wouldn't warn them first.
B helps the cow (maybe if you can get ahold of them), but doesn't stop anyone else who is making the exact same mistakes.
C helps the cow and also other people who might otherwise be careless with their privacy
A person with bad intent would not warn them. Posting dox publicly is a warning to non-retards to keep themselves anonymous, if they care about that. Because her dox was posted here, elephant dick now knows that any weirdo could locate her, and she probably bought some mace. she probably pays more attention to her surroundings.
There is no known risk. No one has been harmed because their address was posted on kiwi farms. People who wish to harm strangers based solely on internet activity are a rarity. In fact, people have to make shit up about kiwi farms to make it look harmful or dangerous because there isn't any obvious example of harm perpetrated. The worst thing that happens is it makes people scared, I suppose, but that could be said about literally anything. It isn't anyone elses problem.
Imo the horror and terror experienced by these kids when they're doxed is a direct result of witnessing their actual everyday real-life self collide with their internet fantasy persona. It probably actually does feel threatening and terrifying, but the call is coming from inside the house, as they say.
All the operations, the complications, the pain, the pissing in a bag for months, the scarring, the life on medication…to end up with that. I’d say it was tragic, but as the saying yet again goes, play stupid games, win stupid prizes - in this case a foot-long flopsausage that is useless for anything except maybe pissing out of (badly).
Imagine having to walk around with that ridiculous dangler hanging off you for the rest of your life. Lass is going to have to wear those giant wrap-around yoga pants to be able to walk down the street without people staring at the weird long bulge down one leg.
And she’ll never be able to have sex with a gay man. Physically impossible as a top, and as a bottom, wtf would a gay guy want with a female asshole? Especially a deluded one hell-be t on forcing them into sex with her.
It’s just sad. Hilarious and sad. Girls who’ve never interacted with an actual penis showing off their insane facsimiles, in the belief that they’re totally like the real thing. And they claim it’s not a mental illness?
"All the operations, the complications, the pain, the pissing in a bag for months, the scarring, the life on medication…to end up with that."
"Trans people are like... so totes brave"
"And she’ll never be able to have sex with a gay man."
It never fails to amuse me seeing TIFs get rebuffed by gays, like so many women they fetishise and objectify gay men just as TIMs objectify women and seeing how both react with the inevitable crying in the bathroom for the former and autistic male rage for the latter is always deeply amusing.
Physically impossible as a top, and as a bottom, wtf would a gay guy want with a female asshole?"
Maybe if the faggot was really desperate, what's the difference between male and female assholes?
I remember when the internet first crashed the normie world in the 90s. As a kid, we were inundated with a second wave of “stranger danger” info, this time about not sharing a/s/l, not chatting with strangers because that fellow girl really into Smashing Pumpkins and Buffy might in fact be some degenerate adult dude whacking off to the photos you shared. Why aren’t kids taught that shit anymore? /rhetorical
Pic tax: Tissue expanders for phalloplasty. I know tissue expansion is the norm for some reconstructive procedures, but of course phalloplasty is cosmetic and I hadn’t seen how it works on FTMs before now and thought it worth sharing.
Apart from paraphiliacs that only want to have sexual contact with a certain body part (like feet) it's about the body that is attached to the parts you have sex with. TIFs will never ever have a functioning dick that can get hard, and gay men, top, bottom or versatile practically always want to interact with functioning male equipment during sex. Hypothetically, if an unusually masculine and ripped TIF that doesn't look like the Pillsbury dough girl managed to get a gay dude into bed with her, seeing a scarred mess where her now sown-up twat used to be instead of balls would most definitely kill the gay dude's boner. That shit's just vile.
Maybe one of our resident surgeons can explain the placement of the surgical guide markings in her thigh there. Why is the tissue not being taken from the part that has been expanded or the part where the expansions could easily be rejoined to leave a line scar?
I’ll link to the report here where they explain at least in part how this method is done. Apologies, I’m not a medical kiwi so I’m not sure if the link will answer your question. Warning to anyone clicking— NSFL medical gore. Seriously, this is some gnarly shit.
According to faggots I know they're really into male bodies which includes the stuff dumb TIFs think they can replicate but also things like having a real hard dick to give a reach around to and the ability to give the other guy's prostate one helluva drum solo.
I honestly don't know why women (it's mostly inexperienced girls, let's be honest) fantasize about the gays so much. I've been called a fag hag plenty of times, thanks, just because I have gay relatives I'm close to. But being close to them meant getting an uncensored view of gay males and their shenanigans. I want nothing to do with their unfettered male sexuality. Some of them are very, very attractive at first glance, not going to lie, but being sober of mind around them for any length of time will cure you of pining for them.
I follow this thread pretty religiously and haven't seen this expander 'technique" used yet. Is there a reddit post or anything for context?
. Two 750-mL rectangular tissue expanders were placed in the right thigh based on perforator location with a CT angiography. Because the superficial circumflex iliac perforator flap was unavailable due to scarring from the previous groin sentinel node biopsy, a pre-expanded RFF was planned as well and another 750-mL expander placed in the left forearm.
