Long-Term Follow-Up of Total Penile Reconstruction with the Sensate Osteocutaneous Free Fibula Flap

Surgical reconstruction of the penis is challenging because of the many cosmetic and functional requirements that must be addressed. Since 1994, 18 biologically male patients with total penile losses for various reasons were treated with free sensate osteocutaneous fibula flaps. The ages of the patients ranged between 20 and 26 years (mean: 22.2 years). The average follow-up period was 5.4 years (range: 1–9 years). Patient satisfaction was evaluated by a questionnaire regarding both quality of orgasm and daily activities. Conventional radiographic imaging, magnetic resonance imaging, and bone mineral densitometry were performed to evaluate the fate of the bony component. Sensibility was evaluated by bulbocavernous reflex and penile somatosensory evoked potentials.

Six patients married, and five of them had six children. Most patients and their partners reported pleasurable sexual intercourse and orgasm. Conventional radiographs of the fibular bone in the neophalluses showed robust, calcified, bone structure without any evidence of bone resorption or fracture. The magnetic resonance images showed the cortical substance and spongiosum of bone marrow, which are characteristic signs of bone viability. Viability of the neophallus bone was shown even at 9-year follow-up (the longest follow-up in the literature). Dual energy x-ray absorptiometry measurements of the penile bone grafts showed that the fibular components in the penis had bone mineral density values that were close to normal subjects.These results were considered evidence of viability of the bone grafts. Neural integrity was found between the nerves of the neophallus and the residual penile bodies.

Free sensate fibula flap phalloplasty provides the cosmetic and functional requirements that an ideal penis should have. All results ended the discussion whether the fibular component of the neophallus could resorb. The re-constitution of neural integrity is important in terms of pleasurable sexual intercourse.