Dr. Mang Chen, MD is a highly experienced Reconstructive Urologist in San Francisco who specializes in bottom surgery procedures for transmasculine individuals. He has performed hundreds of Phalloplasty, Metoidioplasty and related procedures, and has deep expertise in urological repair surgeries.
Ring Flap Metoidioplasty
Alysen Demzik, Liem Snyder, Solomon Hayon, Mang Chen, Bradley D. Figler. Urology,
Volume 158, December 2021, Page 243.
In a ring flap metoidioplasty, the urethra is created from bilateral anteriorly based labia minora and vestibular flaps. This technique is combined with Ghent scrotoplasty, vaginectomy (distal mucosal excision and proximal mucosal fulguration followed by cavity closure) and perineal masculinization. Suprapubic tube is placed for urinary diversion. To avoid disrupting the anteriorly based urethral pedicles, we do not perform monsplasty, division of the suspensory ligament, or resection of the labial folds adjacent to the penis at the time of ring flap metoidioplasty. Typically, resection of labial folds adjacent to the penis and testicular prosthesis insertion are performed 4-6 months after metoidioplasty.
Immediate Lymphovenous Bypass Treated Donor Site Lymphedema during Phalloplasty for Gender Dysphoria [FULL TEXT]
Walter Lin, Bauback Safa, Mang Chen, Ming-Huei Cheng. Plast Reconstr Surg Glob Open. Sept 17 2021;9(9):e3822.
The extended radial forearm flap phalloplasty remains one of the most commonly performed gender-affirming phalloplasty techniques. One potential morbidity that has emerged is postoperative donor site lymphedema, which was susceptible to develop after harvest of extended radial forearm flap. In the setting of preventative or immediate lymphovenous bypass (LVB) with axillary lymph node dissection for the treatment of breast cancer, it is possible that a subset of patients undergoing gender-affirmation surgery would benefit from immediate lymphatic reconstruction at the time of primary phalloplasty. Lymphography showed no dermal backflow at 5 months follow-up; at 13 months, the patient demonstrated no signs or symptoms of lymphedema in the left forearm or hand.
Transgender Scrotoplasty and Perineal Reconstruction With Labia Majora Flaps: Technique and Outcomes From 147 Consecutive Cases
Travis J Miller, Walter C Lin, Bauback Safa, Andrew J Watt, Mang L Chen. Ann Plast Surg. Sept 1 2021; 87(3):324-330.
We retrospectively reviewed the outcomes of phalloplasty patients who underwent either primary or secondary labia majora flap scrotoplasty and perineal reconstruction from October 1, 2017, to December 1, 2019. Bilateral elevation and rotational flap advancement from the posterior to anterior position formed a pouch-like scrotum. Perineal reconstruction involved multilayered closure with apposition of the inner thigh skin. Minor wound complications are common and frequently heal with conservative management. Wounds that do not heal may be associated with urethral complications.
Infrapubic Insertion of Penile Implants in Transmen After Phalloplasty
Mang L Chen, Darshan P Patel, Rachel A Moses, Isak A Goodwin, Bauback Safa, Andrew J Watt, James M Hotaling. Urology. Jun 2021; 152:79-83.
Our infrapubic prosthesis insertion after phalloplasty technique with modifications to commercially available implants may help reduce the risk of postoperative complications.
Neourethra Creation in Gender Phalloplasty: Differences in Techniques and Staging
Jens U Berli, Stan Monstrey, Bauback Safa, Mang Chen. Plast Reconstr Surg. May 2021; 147(5):801e-811e.
The creation of a sensate, aesthetic, and functional phallus for transmasculine individuals has high reported complication rates. Neourethra reconstruction is the most challenging aspect of this surgery, with widely varying techniques and staging between providers. In this expert opinion article, the authors strive to give an overview of the principles behind, and a detailed explanation of, the technical details of creating the penile and bulbar urethra during phalloplasty. The authors focus on the three most common strategies: single-stage phalloplasty; two-stage phalloplasty with a metoidioplasty-first approach; and two-stage phalloplasty with a phalloplasty-first (Big Ben method) approach. It is not the authors’ intent to establish the “best” or “only” way, but rather to compile different options with their respective pros and cons.
An abnormal clinical Allen’s Test is not a contraindication for free radial forearm flap [FULL TEXT]
Travis J Miller, Bauback Safa, Andrew J Watt, Mang L Chen, Walter C Lin. Clin Case Rep. Jul 15 2020. ;8(11):2191-2194.
An abnormal clinical Allen’s test is not a definitive exclusion criterion for free radial forearm flap use. A surgical Allen’s test may be useful to determine whether flap harvest is feasible in patients with an abnormal clinical Allen’s test.
Mang L Chen, Bauback Safa
Urol Clin North Am, Nov 2019, 46(4):567-580.
Single-stage phalloplasty may be accomplished by having both the microsurgical and the reconstructive urology team operate simultaneously. Phalloplasty with pars pendulans urethroplasty is completed by the microsurgeons, and pars fixa urethroplasty, vaginectomy, scrotoplasty, and perineal reconstruction are performed by the reconstructive urologist.
Overview of surgical techniques in gender-affirming genital surgery [FULL TEXT]
Mang L Chen, Polina Reyblat, Melissa M Poh, Amanda C Chi. Transl Androl Urol. Jun 2018; 8(3):191-208.
Gender related genitourinary surgeries are vitally important in the management of gender dysphoria. Vaginoplasty, metoidioplasty, phalloplasty and their associated surgeries help patients achieve their main goal of aligning their body and mind. These surgeries warrant careful adherence to reconstructive surgical principles as many patients can require corrective surgeries from complications that arise. Peri-operative assessment, the surgical techniques employed for vaginoplasty, phalloplasty, metoidioplasty, and their associated procedures are described. The general reconstructive principles for managing complications including urethroplasty to correct urethral bulging, vaginl stenosis, clitoroplasty and labiaplasty after primary vaginoplasty, and urethroplasty for strictures and fistulas, neophallus and neoscrotal reconstruction after phalloplasty are outlined as well.
Phalloplasty with Urethral Lengthening: Addition of a Vascularized Bulbospongiosus Flap from Vaginectomy Reduces Postoperative Urethral Complications.
Massie JP, Morrison SD, Wilson SC, Crane CN, Chen ML. Plast Reconstr Surg. 2017 Oct;140(4):551e-558e.
This study examined the effects of vaginectomy and the addition of extra layers of vascularized vestibular tissue on phalloplasty complication rates. Of 224 total phalloplasty patients, 215 underwent vaginectomy and nine underwent vaginal preservation. Urethral complications occurred in 27 percent of patients with vaginectomy and in 67 percent of patients with vaginal preservation (OR, 0.18; p = 0.02). Vaginectomy was associated with decreased urethral stricture (OR, 0.25; p = 0.047) and urethral fistula formation (OR, 0.13; p = 0.004). Non-urethra-related complications occurred in 15 percent of vaginectomy patients but were not statistically significant (OR, 3.37; p = 0.41). Vaginectomy is associated with a significant decrease in urethral stricture and fistula formation, most likely because vaginectomy affords additional horizontal urethroplasty suture line coverage of labia minora flaps with vascularized vestibular tissue.
Outcomes of Single-Staged Phalloplasty by Pedicled Anterolateral Thigh Flap versus Radial Forearm Free Flap in Gender-Confirming Surgery [FULL TEXT]
Ascha M, Massie JP, Morrison SD, Crane CN, Chen ML. J Urol. 2017 Jul 29.
This study examines outcomes between transmales who had phalloplasty with vaginectomy and full-length urethroplasty utilizing the anterolateral thigh pedicled flap (pALT) or radial forearm free flap (RFFF). There were 213 patients included: 149 RFFF and 64 pALT phalloplasties. RFFF patients had a significantly higher body mass index (BMI) than pALT patients. The overall urethral complication rate for RFFF phalloplasty was 31.5%; the overall pALT rate was 32.8%. The rate of partial or total neophallus loss was 7.8% for pALT and 3.4% for RFFF. Patients in the pALT cohort experienced significantly greater odds of urethral fistula (OR=2.50, p=0.024), non-urethral complications (OR=2.38, p=0.027), and phallus wound dehiscence (OR=5.03, p=0.026). pALT phalloplasty was associated with overall greater odds of urethral and other complications at six months follow-up.
An overview of female-to-male gender-confirming surgery
Morrison SD, Chen ML, Crane CN. Nat Rev Urol. 2017 May 16.
Phalloplasty, with a resultant aesthetic and sensate phallus along with implantable prosthetic, can take upwards of a year to accomplish, and is associated with a considerable risk of complications. Urethral complications are most frequent, and can be addressed with revision procedures. A number of scaffolds, implants, and prostheses are now in development to improve outcomes in FtM patients.