Big Ben Method Phalloplasty: Step by Step.

Gender-affirming phalloplasty is an amalgam of procedures that can be combined and staged differently to achieve individual patient goals. The most described version of gender-affirming phalloplasty is a single “tube-within-tube” (TWT) flap to allow for standing urination. At our institution, we perform the TWT in a staged approach, referred to as the “Big Ben method,” coined after the city of its inventors.1 The creation of the phallic shaft and urethra occurs first, followed 5 months later by creation of the perineal urethra, transposition of erogenous clitoral tissue, colpectomy/colpoclesis, glansplasty, and scrotoplasty. In this video, we demonstrate the key principles of the Big Ben phalloplasty as performed at Oregon Health & Science University. (See Video [online], which shows key steps of Big Ben phalloplasty.) Specific nuances of phalloplasty are the focus here, as the principles of microsurgery and flap harvest are robustly discussed in the plastic surgery literature. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"This video displays Key Steps of Big Ben Phalloplasty as performed at Oregon Health \u0026 Science University.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_n3iavz64"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} STAGE 1: CREATION OF PHALLUS AND PHALLIC URETHRA The TWT flap is harvested from either forearm or anterolateral thigh (ALT). Meticulous flap templating is critical to factor in patient goals for length and girth, while balancing flap perfusion and donor-site morbidity.2,3 The ALT flap is pedicled whenever possible; the radial forearm is taken free with the radial pedicle in addition to the cephalic vein.4 The deep inferior epigastric vessels and saphenous vein are used as recipient vessels. The flap is harvested with two sources of innervation whenever possible. The posterior and lateral antebrachial cutaneous nerves in the radial forearm and the lateral femoral cutaneous nerve ± a femoral perforating nerve in the ALT.5,6 The donor nerves used are the dorsal nerve of the clitoris and the ilioinguinal nerve. A 4–4.5 cm proximal urethral extension of flap is incorporated to bring the phallic urethra into a pre-pubic position and shorten distance needed for urethral lengthening at stage 2. An opening is made to marsupialize the urethral extension just lateral to clitoral shaft in nonhair-bearing skin of the vulva. The ipsilateral labia minora are excised to create a flat surface between the native urethra and marsupialized proximal neo-urethra. STAGE 2: VAGINECTOMY, URETHRAL LENGTHENING, CLITOROPLASTY, SCROTOPLASTY, PERINEOPLASTY, GLANSPLASTY A formal vaginectomy with mucosal excision is performed.7 A 16 Fr catheter is inserted through the penis and into the bladder. A u-shaped urethroplasty is designed with a width of 23–25 mm. Labia majora flaps are raised, urethroplasty incisions are made, and the remaining mucosal tissue is de-epithelialized from the clitoris and remaining labia minora. The urethroplasty is performed; the denuded clitoris is then transposed superiorly against the pubic bone at the base of the penis. Robust, multi-layer closure is performed using the labia minora and perineal tissues to eliminate dead space and reinforce the urethroplasty. The labia majora flaps are rotated and advanced to create an anteriorly positioned scrotum. The perineum is closed in the midline, and if needed minor tissue rearrangement is performed at the most inferior aspect to avoid a perineal pit. The phallus glansplasty is performed raising a coronal flap and using two full-thickness skin grafts and quilting sutures to maintain coronal ridge projection long term.8 The patient will have a penile catheter for 5 days and a suprapubic catheter for 4 weeks. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. ACKNOWLEDGMENTS This work conforms to the Declaration of Helsinki put forth by the World Medical Association. The authors would like to acknowledge the significant contributions and expert care provided to our phalloplasty patients by Carley Putnam, PA and Lizzandra Trueba-Mejia, MA.