Scrotal reconstruction after Fournier's Gangrene using the superficial circumflex iliac artery perforator (SCIP) propeller flap: A case report.

INTRODUCTION: Fournier's gangrene, a rare infectious condition affecting the external genitalia, often requires aggressive medical-surgical interventions, resulting in variable scrotal tissue loss. Despite numerous proposed reconstruction techniques, achieving a consensus on the most effective approach that balances aesthetics and function remains elusive. This case report presents a one-year follow-up on scrotal reconstruction using a pedicled Superficial Circumflex Iliac Artery Perforator (SCIP) propeller flap. CASE REPORT: A 56-year-old patient with significant scrotal tissue loss due to Fournier's gangrene underwent scrotal reconstruction using a pedicled SCIP propeller flap. Optimal placement was ensured through a subcutaneous tunnel, with a thin thigh skin graft applied to cover the penile skin defect. DISCUSSION: The SCIP flap is distinguished by its thin and pliable characteristics, rapid harvesting and featuring a discreet donor site. It stands as a compelling alternative to skin grafts, providing advantages in sensory restoration, color congruence, and resilience against tension. Considering the thickness of the reconstruction helps both in recovering testicular function and improving the appearance by restoring the natural contour. CONCLUSION: The utilization of the pedicled SCIP propeller flap for scrotal tissue loss resulting from Fournier's gangrene has demonstrated both aesthetic and functional success, underscoring its potential as an effective reconstructive option.

Surgical rhinoplasty after prior hyaluronic acid based nose remodeling.

BACKGROUND: Medical rhinoplasty by hyaluronic acid injection (HA) has become nowadays a common practice. The number of patients requesting surgical rhinoplasty and having already undergone one or more injections of HA is increasing. However, the literature lacks publications regarding the management of these patients. OBJECTIVES: The aim of this study is to discuss the management of patients who have been treated with previous nasal HA injections and who seek surgical rhinoplasty, and elaborate a treatment protocol and algorithm to standardize surgical plans. METHODS: We are reporting case studies based on our clinical experience. We also reviewed the literature to suggest perioperative management for rhinoplasty with previous HA injections. RESULTS: Hyaluronidase injection preoperatively allows to carry out an accurate preoperative analysis of the nasal deformities to treat, in order to make an adapted treatment plan. Postoperative course is similar to other rhinoplasty cases without the use of this enzyme. CONCLUSION: Hyaluronidase should be used in all patients with nasal injections of HA (unless contraindications), who are willing to undergo a surgical rhinoplasty. The operation can be undertaken at one-week interval as soon as the edema subsides and no further treatments are necessary.

[Vulvoplasty after gender-affirmating genital surgery]. / Vulvoplastie chez les patientes en incongruence de genre.

Functional and aesthetic results after vaginoplasty in sexual reassignment surgery have improved in recent years. Improved surgical techniques, well-established expert teams and a growing demand for and interest in this type of surgery are some of the reasons for these results. However, there is a growing demand for genital cosmetic surgery, not only among cis women, but also among trans women. The main shortcomings in results are therefore presented and listed. The aesthetic revision surgery techniques specifically indicated are described. Labiaplasty and clitoridoplasty appear to be the two main requests for secondary surgery following trans vaginoplasty.

[Scapular flap, an alternative to the radial forearm flap in phalloplasty: Advantages and limitations]. / Lambeau scapulaire, une alternative au lambeau antébrachial en phallopoièse : avantages et inconvénients.

INTRODUCTION: Antebrachial phalloplasty is considered as the standard technique in total penile reconstruction. This technique allows the creation of a phallus and a neourethra in one step at the cost of significant sequelae of the donor site. Thus, this technique has been replaced in some centers by other techniques such as the MSLD flap or the ALT flap. However, in Western populations, these techniques require the addition of a technique dedicated to the urethroplasty. The scapular flap is a technique that is not widely described in the literature and, like the antebrachial flap, allows the creation of a phallus and a urethra in one step according to the "tube within tube" technique. AIM: The aim of the study was to detail this technique, to study its vascularization and to adapt the measurements of the flap to a western population. PATIENTS AND METHODS: Six cadaveric dissections were performed in the laboratory. Intravascular injection of colored latex allowed easier identification of the vessels of interest and study of the subcutaneous vascular tree. Scapular flaps of variable size were raised to adapt the size to a Western population. RESULTS: Six dissections were performed in Caucasian subjects. The scapular circumflex artery was constant and had a mean diameter of 3.5mm (3.3mm-3.8mm). The mean pedicle length was 7.3cm (6.8cm-8.1cm). The size of the flaps was adapted to the subcutaneous tissue and flaps of at least 14×16cm allowed the "tube within tube" technique to be performed. CONCLUSION: The scapular flap has the advantage of allowing phalloplasty with urethroplasty to be performed at the same time. The pedicle is constant and of good diameter. In addition, the sequelae of the donor site are minimal. On the other hand, the pedicle used is short and the flap cannot be surgically reinnervated. Nevertheless, the restoration of a protective sensitivity allows the implantation of a penile prosthesis.

The bilateral scrotal flap: Anatomical study and it's use for the management of inflammatory granulomas following custom-made injections.

INTRODUCTION: The management of 10 cases of penile inflammatory granulomas following a subcutaneous injection of non-absorbable substance for the purpose of penile augmentation is presented. We subsequently used the bilateral scrotal flaps to cover the post-excision skin defect. A simple decision aid chart outlining the management of penile foreign body injections is proposed. METHODS: A total of 10 patients were included in this study. All required surgical management by penile degloving, followed by complete excision of the inflammatory granuloma and overlying skin. The dissection of 14 cadavers was carried out to study the blood supply to the anterior scrotal flap. Penile reconstruction was then performed using a bilateral scrotal flap in all but two cases. Post-operatively, the patients were followed up for a 1 year period. RESULTS: We obtained good results in terms of the aesthetic outcome with all of our ten patients with the area covered having similar color to penile skin. There were no major post-operative complications. There were two minor complications involving wound healing. Sensory function was maintained and no penile shortening or curvatures were noted, in addition all patients were satisfied with both the shape and function of the penis. CONCLUSION: Although much rarer, penile augmentation related complications are still seen in western countries. The treating doctor should be aware of its management. We had achieved acceptable outcomes in our experience with the bilateral scrotal flap. We believe it is a good and simple option for soft tissue coverage of the penis in cases following the complete inflammatory granuloma excision. It can achieve satisfactory aesthetic and functional results for this group of patients.

A new gastric impedancemeter for detecting the development of a visceral edema: a proof-of-concept study on an experimental endotoxemic shock.

Visceral congestion and edema are important features of advanced heart failure. Monitoring the evolution of fluid content in the gastric wall might provide an index of the development of this phenomenon and therefore constitute an innovative marker to early detect acute decompensated heart failure episodes. The evolution of the fluid content in the gastric wall is measured using a device implanted in the submucosa layer of the fundic region of the stomach. The device composed of two electrodes measures the bioimpedance values that reflects the water content of the tissue.An in-vivo experiment in a pig was carried out to validate the feasibility of detecting the gastric bioimpedance variations during the development of an experimental acute visceral edema caused by an endotoxemic shock. Our preliminary results confirm the possibility to monitor the bioimpedance variations due to moderate changes in tissue water content (10%) with a two-electrode configuration device implanted in the submucosa of the stomach.

Tick-borne diseases in the Union of the Comoros are a hindrance to livestock development: Circulation and associated risk factors.

Tick-borne diseases (TBD) occur in many temperate countries and are economically important in most tropical and subtropical areas, affecting dairy and beef cattle, as well as small ruminants. Four major tick-borne diseases have been detected in eastern and southern Africa: East Coast fever (ECF) caused by Theileria parva, Theiler 1904, anaplasmosis caused by either Anaplasma marginale, Theiler 1910, Anaplasma centrale, Theiler 1911, or Anaplasma ovis, Bevan 1912, babesiosis caused by Babesia bovis, Babes 1988 and Babesia bigemina, Smith & Kilborne 1893, and heartwater caused by Ehrlichia ruminantium Cowdry 1925. A cross-sectional survey was undertaken to determine the antibody prevalence of these TBDs and to identify the risk factors for TBD infections in the Union of the Comoros. In 2016 and 2017, 903 individual animal serum samples were collected from 429 separate farms, where the farmers answered individual questionnaires. The antibody prevalence of anaplasmosis, babesiosis (B. bigemina) and heartwater was determined by enzyme-linked immunosorbent assays (ELISA) and the antibody prevalence of ECF was assessed using an immunofluorescence antibody test (IFAT). The relationship between TBD seropositivity and livestock-related variables was assessed by multivariate analyses with standard logistic regression models. The results showed that these four TBDs were present in the Union of the Comoros with a global antibody prevalence of 15% (95% CI [12.7%; 17.3%]) for anaplasmosis, 9.2% (95% CI [6.5%, 11.9%]) for B. bigemina babesiosis, 5.3% (95% CI [3.2%, 7.4%]) for ECF and 4.6% (95% CI [3.2%, 6%]) for heartwater. We compared these findings with the abundance and distribution of several tick species known to be TBD vectors and we found a significant correlation between Rhipicephalus appendiculatus and ECF, and between Amblyomma variegatum and heartwater. We also found that two major variables were significantly correlated with B. bigemina antibody prevalence ("island" and "breeding area"), four variables were significantly correlated with anaplasmosis antibody seroprevalence ("island", "number of cattle per farmer", "number of farmers per village" and "breeding area"), two were significantly correlated with ECF antibody prevalence ("number of farmers in village" and "presence of ticks"), and three were significantly correlated with heartwater ("island", "number of cattle per farmer" and "number of farmers in the village"). Our findings confirmed livestock exposure to the four targeted TBDs of major concern for livestock development. Consequently, raising farmers' awareness and setting up a period of quarantine should be considered a priority.

An anatomic study of deep inferior epigastric artery diameters at the origin from external iliac and at the lateral border of rectus abdominis muscle by computed tomographic angiography from autologous breast reconstruction patients.

BACKGROUND: Autologous breast reconstruction by means of microsurgical abdominal flaps is an very well described technique. The flap harvest dissection under inguinal ligament would cause the risk of parietal weakening in this zone and postoperative bulging. The goal of our study is to investigate whether the deep inferior epigastric artery diameter remains constant from its exit of the external iliac artery to its entrance in the rectus muscle sheath. PATIENTS AND METHOD: One hundred arteries were studied on fifty preoperative computed tomographic angiographies made before a DIEAP flap for breast reconstruction. We measured the caliber of the left and right deep inferior epigastric arteries at these two landmarks. The length of this artery between these was also calculated. This data were collected with specific angiography reconstruction. RESULTS: At the caudal landmark, the mean DIEA diameter was 2.1±0.27mm on the left side and 2.1±0.31mm on the right side. At the cephalic landmark, the mean DIEA diameter was 2.0±0.28mm on the left and 2.0±0.27mm on the right side (P=0.00035 at left side; P=0.0089 at right side). The mean pedicle length between the two landmarks was 22.3±2.85mm on the left side and 22.2±2.98mm on the right side. CONCLUSION: This computed tomographic angiography study showed that the diameter of DIEA is equivalent at its origin and at the lateral border of muscle. Flap harvest without dissection under inguinal ligament provides sufficient pedicle length and caliber to allow for comfortable and reliable sutures.

Mandibular angle resection using cervicofacial lifting surgical approach: Technical note.

Facial feminization surgery brings a set of surgical procedures that address the three thirds of the face and aims to give feminine characteristics to a masculine face. The characteristics of the lower third of a male face are a long, broad chin, a prominent mandible with sharp angles (in connection with the insertions of the masseter muscles). Mandibular angle reduction is an important procedure of the male-to-female transformation. It allows to modify the appearance of the lower third of the face, reducing the bi-mandibular distance in the coronal plane and opening the mandibular angle in profile. The classical procedure uses trans-oral surgical approach. However, patients undergoing male-to-female sexual transformation frequently present a mixed indication of cervicofacial lift and angular resection. We present an innovative surgical technique associating cervicofacial lifting and mandibular angle resection using the same cutaneous surgical approach. We describe its advantages and discuss its disadvantages.

[Profunda femoral artery perforator flap: Anatomical study]. / Le lambeau perforant de l'artère fémorale profonde : une étude anatomique morphométrique.

BACKGROUND: Within the framework of mammary reconstruction, since 2012 when Allen first described it, the profunda femoral artery perforator flap (PAP) takes an important place in the current therapeutic options. OBJECTIVE: This anatomical study aims to analyze the anatomy and morphologic consideration of the PAP : position of the perforating artery; length of the pedicle, area and volume of vascularization. METHODS: Sixteen flaps were harvested on fresh subjects at the University Department of Anatomy of Rockfeller, Lyon. The first direct cutaneous branch from the deep femoral vessels was located between or through the adductor magnus and gracilis muscles. Pedicle location, diameter, length and position regard to the great saphenous vein were recorded. A flap based on this vessel was designed. Height, width, and surface of the skin paddle were recorded. Three-dimensional computed tomographic angiography was used to analyze the area and volume of cutaneous territory supplied by the studied perforator. RESULTS: On the 16 analyzed flaps, localization of the perforating artery is on average to 8.2cm of the pubic tuber and 3.7cm behind a line connecting the pubic tuber to the internal femoral condyle. The length of the pedicle is on average of 11.7cm and the average area of skin perfused was 94,68cm2. The way of this perforating arterty is primarily through the adductor magnus. On the radiological images of the 8 flaps, the analysis shows an average surface of 111,25cm2 and a mean volume of 325.3cm3. DISCUSSION: PAP is an interesting therapeutic choice within the framework of a mammary reconstruction. Its surface and its volume associated with a discrete scar make a valid indication within the framework of this surgery.

[French adaptation of a new score for global assessment of psoriasis severity: The Simplified Psoriasis Index (SPI)]. / Adaptation française d'un nouveau score destiné à l'évaluation globale de la sévérité du psoriasis : l'Indice Simplifié du Psoriasis (Simplified Psoriasis Index, SPI).

OBJECTIVE: Although several scores exist to assess psoriasis severity, most have marked limitations that rule out their use in routine clinical practice. A new score, the Simplified Psoriasis Index (SPI), has recently been developed and validated in adults in Britain for such use. It has separate components for current severity (SPI-s), psychosocial impact (SPI-p) and past history and interventions (SPI-p), and it is suitable for either professional assessment or patient self-assessment. The aim of this work was to produce a validated translation of SPI into French (as spoken in France). METHODS: The index was translated and validated using a strict methodology comprising respectively five and eight phases for the professional (proSPI) and self-administered instruments (saSPI). Translation of the saSPI instrument also involved a cognitive debriefing with five psoriasis patients. RESULTS: Linguistic discrepancies and subtle differences of meaning arising during the process were closely examined. The developer of the instrument ensured conceptual accuracy. A panel of health experts guaranteed that medical terms were correctly translated. Five patients with plaque psoriasis (two female and three male of median age 45 years [range: 31-78]) tested the SPI-p version during cognitive interviews and found the questionnaire clear and easy to understand. CONCLUSION: Validated French translations of both SPI instruments are now available for use in routine clinical practice. Further investigations are currently underway to validate the psychometric properties of the instrument.

Cadaver models for cardiac arrest: A systematic review and perspectives.

AIM: To provide an overview of cadaver models for cardiac arrest and to identify the most appropriate cadaver model to improve cardiopulmonary resuscitation through a systematic review. METHODS: The search strategy included PubMed, Embase, Current contents, Pascal, OpenSIGLE and reference tracking. The search concepts included "heart arrest", "cardiopulmonary resuscitation" and "cadavers". All studies, published until February 2019, in English or French, on research or simulation in the field of cardiac arrest and using cadaver models were eligible for inclusion. RESULTS: Overall, 29 articles out of the 244 articles located were selected. The characteristics of the studies and the cadaver models were heterogenous. Indeed, 31% of the studies lacked a proper description of the model used and its specificities. Fresh cadavers were used in 55% of the studies and chest compressions were performed in 90%. This model was appreciated for its realism in terms of mechanical properties and tissue conservation. Thiel-embalmed cadavers also showed promising results concerning lung and chest compliance. The lack of circulation stood out as the strongest limitation of all types of human cadaver models. CONCLUSION: Four types of cadaver models are used in cardiac arrest research. The great heterogeneity of these models coupled with unequal quality in reporting makes comparisons between studies difficult. There is a need for uniform reporting and standardisation of human cadaver models in cardiac arrest research.

Impact of East Coast fever on Grande Comore: assessment taking a participatory epidemiology approach.

East Coast fever (ECF), one of the most serious tick-borne diseases in sub-Saharan and eastern Africa, was introduced to the island of Grande Comore in 2002 through zebu import from Tanzania, resulting in at least a 10% loss of livestock. A participatory epidemiology initiative was launched in 2015 to gain a better understanding of ECF epidemiology. Thirty-six villages were investigated involving 36 focus group sessions and 120 individual questionnaires. Farmers' knowledge of ECF and of priority diseases affecting the country was assessed, and the impacts of ECF and other major diseases were compared by a scoring method. The results showed that 69.4% (95% CI [51.3, 87.5%]) of the farmers had good to very good knowledge of ECF. The most important cattle diseases on Grande Comore were considered to be East Coast fever, heartwater, babesiosis, and cutaneous diseases. About 58% of the farmers (95% CI [49.2, 66.8%]) use curative treatments when cattle were sick. Between January and September 2015, the ECF incidence was estimated at 18.5% (95% CI [15.5, 21.4%]), and 87.5% (95% CI [72.7, 100%]) of the cattle infected by ECF died. The ECF incidence estimated in our study was found to be less when compared to that observed in Tanzania even though the climatic conditions in the Union of the Comoros are suitable for the biological vector of ECF, the tick species Rhipicephalus appendiculatus. Access to chemical treatment and its effectiveness against ECF, as well as controlling borders and organizing quarantine, are discussed.

[Breast reconstruction with Muscle-Sparing Latissimus Dorsi flap combined to a Thoraco-Abdominal advancement flap and fat grafting]. / Reconstruction mammaire par lambeau dorsal épargnant le muscle grand dorsal (Muscle-Sparing Latissimus Dorsi, MSLD) associé à un lambeau d'avancement thoraco-abdominal et greffe de tissu adipeux autologue.

The Latissimus Dorsi flap (or LD flap) was first described by the Tansini in 1896 and published in 1906. It concerned a case of chest wall reconstruction after breast amputation. The use of the LD flap in all its variants is very frequent in breast reconstruction. In these indications, the muscle is harvested for skin paddle vascularization and/or for bringing volume to the reconstructed breast. When all or most of the muscle is taken, its motor function is completely lost. The functional sequelae due to the loss of the latissimus dorsi muscle are then definitive. Tobin et al. showed that the LD muscle can be separated into two flaps based on the division of the thoracodorsal artery; the concept of muscle-sparing was then posed (Muscle-Sparing Latissimus Dorsi [MSLD]). The MSLD as we perform now, concerns only a thin muscle strip and preserves 95% of the LD muscle with its vascularization and motor innervation. This technique is quick with very low donor site morbidity. The functional sequelae and postoperative complications appear limited compared to the harvest of a total LD whatever the posterior scar. The volume of the breast to be reconstructed is obtained by several sessions of fat grafting. We present here the anatomical bases and the surgical technique of the muscle-sparing latissimus dorsi associated with a thoracoabdominal advancement flap and fat grafting in breast reconstruction.

Inductive plethysmography in rats: towards a new standard for longitudinal non-invasive cardiac output monitoring in preclinical studies.

OBJECTIVE: Cardiovascular function assessment is most often a mandatory requirement in preclinical studies in all industrialized countries. The invasiveness and impact of the monitoring devices used on animals have to be reduced as far as possible for scientific as well as ethical reasons. In humans, inductive plethysmography (IP) is a commonly used wearable non-invasive technology based on volume recordings. The innovative target of the present work is to transfer the IP technology to cardiac output (CO) measurement in rodents. APPROACH: A new IP device specifically designed for rodents was developed and compared with the gold standard equipment for CO assessment in rodents. CO was monitored in anesthetized rats equipped with both the IP device and an ultrasonic flow probe during a hemodynamic challenge (volume overload). MAIN RESULTS: Cardiac blood flow measurements with the new IP device are significantly correlated with those obtained with the ultrasonic probe throughout the volume overload procedure (r = 0.97, p < 0.001). SIGNIFICANCE: Our results clearly show that the IP device has adequate technological characteristics to allow accurate CO measurement and can therefore be used for longitudinal non-invasive monitoring in rats.

Reconstruction of soft tissue defects of the distal third of the arm using a muscle-sparing latissimus dorsi musculocutaneous flap.

Use of a latissimus dorsi (LD) flap has been widely described for upper limb reconstruction. However, donor site sequelae have led to the development of muscle-sparing techniques for the LD flap. We present the technical principles of a muscle-sparing LD flap and its use as a pedicled flap to reconstruct the distal third of the arm.

[Fasciocutaneous flap reliable by deep femoral artery perforator for the treatment of ischial pressure ulcers]. / Lambeau fasciocutané sous fessier fiabilisé par une perforante de l'artère fémorale profonde en reconstruction d'escarre ischiatique.

INTRODUCTION: The surgical management of pressure ulcers in the paraplegic or quadriplegic population is marked by the high risk of recurrence in the long-term. In the current era of perforator flaps, newer reconstructive options are available for the management of pressure ulcers, decreasing the need to use the classically described muscular or musculocutaneous locoregional flaps. The coverage of ischial sores described in this article by a pedicled flap based on a deep femoral artery perforator, appears to be an effective first-line reconstructive option for the management of limited size pressure ulcers. PATIENTS AND METHOD: A number of fifteen paraplegic or quadriplegic patients having at least one ischial bed sore with underlying osteomyelitis were included in this series. The approximate location of the deep femoral artery perforator was initially identified using the "The Atlas of the perforator arteries of the skin, the trunk and limbs", which was confirmed, with the use of a Doppler device. A fasciocutaneous transposition flap was elevated, with the pivot point based on the cutaneous bridge centered on the perforator, and then transposed to cover the area of tissue loss. The donor site was closed primarily. RESULTS: A total of fifteen patients were operated from November 2015 to November 2016. The series comprised of 16 first presentations of a stage 4 pressure ulcers associated with underlying osteomyelitis that were subsequently reconstructed by the pedicled deep femoral artery perforator flap. The healing rate and functional results were both satisfactory. CONCLUSION: Fasciocutaneous flap reliable by deep femoral artery perforator appears to have a promising role in the treatment of ischial pressure sores. It is an attractive option to spare the use of musculocutaneous flaps in the area. Thus this flap could be used as a first-line option to cover ischial pressure ulcers of limited size.

[Incisions and baseline operative technique of cervicofacial lifting]. / Incisions et technique opératoire de base du lifting cervicofacial.

Cervicofacial lifting is one of the most iconic procedure of plastic surgery and is about hundred years old. In the following chapters of this report, numerous technical points will be specify. A baseline reliable and reproducible technique, appealing to the largest possible audience is presented in order to begin this surgery in optimum conditions. Pre- and postoperative management is also exposed. The aim of this chapter is to precise incisions and baseline operative technique of cervicofacial lifting, with description of SMAS and platysma suspensions as well as complementary procedures like liposuccion and lipofilling. This chapter will lay the foundation of more complex elements that will be described in the various following chapters.

Hospitalisation for lower respiratory tract infection in children in the province of Quebec, Canada, before and during the pneumococcal conjugate vaccine era.

Streptococcus pneumoniae is an important cause of community-acquired pneumonia and pneumococcal conjugate vaccines (PCVs) may reduce this burden. This study's goal was to analyse trends in lower respiratory tract infections (LRTI) hospitalisations before and during a routine vaccination programme targeting all newborns with PCV was started in the province of Quebec, Canada in December 2004. The study population included hospital admissions with a main diagnosis of LRTI among 6-59 month-old Quebec residents from April 2000 to December 2014. Trends in proportions and rates were analysed using Cochran-Armitage tests and Poisson regression models. We observed a general downward trend in all LTRI hospitalisations rate: from 11·55/1000 person-years in 2000-2001 to 9·59/1000 in 2013-2014, a 17·0% reduction, which started before the introduction of PCV vaccination. Downward trends in hospitalisation rates were more pronounced for all-cause of pneumonia (minus 17·8%) than for bronchiolitis (minus 15·4%). There was also a decrease in the mean duration of hospital stay. There was little evidence that all-cause pneumonia decreased over the study period due mainly to the introduction of PCVs. Trends may be related to changes in clinical practice. This study casts doubt on the interpretation of ecological analyses of the implementation of PCV vaccination programmes.

[Phalloplasty: Microsurgical options and management algorithm]. / Phalloplastie : options microchirurgicales et algorithme décisionnel.

The free radial forearm flap is considered as the gold standard in penile reconstruction for good functional and aesthetic results. The scar on donor site could be considered as pathognomonic of their situation by transsexual patients. The development of microsurgical flaps provides new therapeutic options. This options are discussed and a therapeutic algorithm is presented. The main techniques used are the pedicled anterolateral thigh perforator flap and free muscle sparing latissimus dorsi flap. Principal criteria are listed, the choice of patient and the local anatomical conditions are the most important. Antebrachial flap stay the first choice. In case of non-feasibility of this flap, phalloplasty with pedicle ALT flap or free MSLD flap will be proposed. Urethral reconstruction will be done by a narrow free forearm flap or by a delayed thin skin graft or buccal mucosa graft. Microsurgical phalloplasty options are not limited to the forearm flap. Satisfactory results can be obtained using alternative procedure. The use of a therapeutic algorithm allows to choose the most optimal solution for each patient.