Clinical Anatomy 31:152–159 (2018)

ORIGINAL COMMUNICATION

The Anatomy of the Musculocutaneous

Latissimus Dorsi Flap for Neophalloplasty
M. DENNIS,1 A. GRANGER,2,3 A. ORTIZ,2 M. TERRELL,1
M. LOUKOS ,2 AND J. SCHOBER 4*
1
Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
2
School of Medicine, St. George’s University, West Indies, Grenada
3
Department of Neurology, NYU Langone Hospital - Brooklyn, Brooklyn, New York
4
Pediatric Urology, University of Pittsburgh Medical Center – Hamot Hospital, Erie, Pennsylvania

In transgender surgery, the ideal neophallus is one that: (a) is constructed using
a reproducible procedure, (b) possesses tactile and erogenous sensation, (c) is
large and rigid enough (naturally, or using a prosthesis) to permit penetrative
intercourse, (d) leaves acceptable donor site morbidity, (e) results in esthetically
satisfactory appearance, and (f) allows for voiding while standing. The musculo-
cutaneous latissimus dorsi (MLD) flap has favorable results in the area of neo-
phalloplasty. Among its advantages are acceptable donor site appearance,
stiffness sufficient for intercourse, and esthetically satisfactory genital appear-
ance. The anatomy of the MLD flap supports the creation of a neophallus for
transsexual anatomy revision. Herein, we give an overview of the advantages
and disadvantages of the procedure, and the anatomical details and surgical
steps involved. Novel illustrations were created from standard surgical text
descriptions to clarify this topic for surgical training and patient understanding
and decision making. A review of the relevant literature regarding the anatomy,
procedure development, and outcomes is presented. The MLD flap uses part of
the latissimus dorsi muscle with branches of the thoracodorsal vessels and nerve
to construct a neophallus. A thin strip of muscle around the pedicle is harvested,
resulting in a slightly curvilinear scar. The blood supply is connected to the femo-
ral artery and saphenous vein or the deep inferior epigastric artery and vein, while
the nerve is connected to the ilioinguinal nerve or the obturator nerve. The MLD
flap for neophalloplasty is a reliable graft with a well concealed scar and low donor
site morbidity. Clin. Anat. 31:152–159, 2018. VC 2017 Wiley Periodicals, Inc.

Key words: phalloplasty; latissimus dorsi flap; gender affirmation surgery;

neophallus

INTRODUCTION reassignment (Gorton and Erickson-Schroth, 2017).

Gender dysphoria is the distress experienced by an
individual when they feel their birth anatomy is incongru-
ous with their gender identity (American Psychiatric
Association, 2013). It is estimated that 0.6% of the U.S.
population identify as transgender (Flores et al. 2016).
As cultural awareness and acceptance of the transgender
population grows, it is likely that more patients will seek
gender affirming therapy. For patients identifying as
transgender, the process of medical gender affirmation
treatment can involve many steps including psychologi-
cal evaluations, hormonal therapy, and surgical
Surgical intervention represents only one option for
these patients; in view of the finality of the procedure,
other medical and psychological modalities should be
*Correspondence to: J. Schober, Pediatric Urology, University of
Pittsburgh Medical Center – Hamot Hospital, Erie, PA,
E-mail: Schobermd@aol.com
Received 13 November 2017; Accepted 22 November 2017
Published online 28 December 2017 in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/ca.23016

C
V 2017 Wiley Periodicals, Inc.
 Anatomy of the Musculocutaneous Latissimus Dorsi 153

explored first. In transgender males, or anatomical

females who identify as male, surgical gender reassign-
ment can include bilateral mastectomy, salpingo-
oophorectomy, hysterectomy, phalloplasty, scrotoplasty,
and urethroplasty (Sutcliffe et al. 2009).
As established by Gilbert et al. (1987) and Mon-
strey et al. (2001), the goals of phalloplasty include: a
single stage operation, an esthetically acceptable neo-
phallus with both erogenous and tactile sensation, a
competent neourethra that permits voiding while
standing, the ability to perform sexual intercourse,
acceptable donor site morbidity, and reproducibility.
Currently, a neophallus that meets all of these criteria
remains elusive. However, studies have demonstrated
that patient preferences are variable (Jacobsson et al.
2017; Hage et al. 1993) and highlight the importance
of doctor–patient communication in defining surgical
goals. Understanding the patient’s desired outcome
will allow the best surgical technique to be selected,
as each provides its own characteristic set of benefits
and drawbacks.
There are multiple options for the surgical creation
of a neophallus. The first phalloplasty was performed
in 1936 by Borgoras (Vesely et al. 2007), but a range
of options involving either pedicled or free flaps now
exists, and donor sites include the forearm, fibula,
abdomen, thigh, upper arm, scapula, and groin (Gor-
ton and Erickson-Schroth, 2017). Each technique
offers an individual set of advantages and disadvan-
tages. Currently, the most commonly-used approach
is the radial forearm free flap phalloplasty; however,
this technique is not without drawbacks including a
Fig. 1. The latissimus dorsi is a broad, large, triangu-
potentially stigmatizing donor site scar, postoperative
larly-shaped muscle located in the group of superficial
fistulae, and urological complications (Monstrey et al.
back muscles that receives its blood supply from the sub-
2009). The MLD flap offers an easily concealable
scapular artery while the subscapular vein provides out-
donor site, a neophallus with potential for intercourse
flow. Innervation is derived from the thoracodorsal nerve.
with or without implant, and the possibility of voiding
(Printed with permission from Angelica Ortiz 2017) [Color
while standing (Perovic et al. 2007). Herein, the surgi-
figure can be viewed at wileyonlinelibrary.com]
cal anatomy and technique of MLD phalloplasty will be
described and demonstrated with novel illustrations.
Outcomes, advantages, and limitations are discussed. processes of the 7th-12th thoracic vertebrae, the
thoracolumbar fascia, and the iliac crest (Drake et al.
2010). The muscle subsequently decreases in width
MATERIALS AND METHODS superiorly and laterally as it narrows into a tendinous
apex that inserts into the floor of the intertubercular
The literature was reviewed using numerous search groove of the humerus. The primary actions of the
terms related to latissimus dorsi flap phalloplasty. muscle include adduction, extension, and internal
Articles written in English that were relevant to the rotation of the arm (Drake et al. 2010).
MLD flap were selected and considered. Original illus- The oxygenated blood supply for the latissimus
trations were created highlighting the anatomical dorsi arises from the thoracodorsal branch of the sub-
structures important for the surgical sites. scapular artery. After diverging from the subscapular,
the thoracodorsal artery travels inferiorly and posteri-
orly along the surface of the serratus anterior muscle
RESULTS toward the latissimus dorsi (Drake et al. 2010). This
is the dominant vessel supplying the MLD flap (Perovic
Anatomy
et al. 2007). Venous drainage from the area is pro-
The anatomy of the back and latissimus dorsi vided by two concomitant veins that subsequently join
region is well understood and has been extensively to form the thoracodorsal vein, which empties into the
studied. Many properties of the MLD flap make it a subscapular vein. Innervation of the latissimus dorsi is
useful candidate for female-to-male transsexual provided by the thoracodorsal nerve, which arises
patients. from the ventral rami of cervical nerve roots 6–8 in
The latissimus dorsi is a large, broad, triangular the posterior cord of the brachial plexus. The nerve
muscle located in the superficial group of back begins posterior to the subscapular artery, and as it
muscles (Fig. 1). The fibers originate from the spinous descends to reach the latissimus dorsi it comes to lie
154 Granger et al.
anterior the thoracodorsal artery (Drake et al. 2010).
The neurovascular hilum is located 8–9 cm from the
axillary artery and courses 1.5–3.0 cm from the ante-
rior edge of the muscle (Perovic et al. 2007).
After the MLD flap is harvested, the arterial blood
supply is anastomosed to the femoral artery and the
venous drainage to the saphenous vein, and micro-
neurorrhaphy is performed between the ilioinguinal
and thoracodorsal nerves (Perovic et al. 2007). The
femoral artery is a continuation of the external iliac
artery past the inguinal ligament. The saphenous vein
is located medial to the femoral artery, and it courses
up the medial aspect of the leg before joining the
common femoral vein in the region of the femoral tri-
angle (Drake et al. 2010). The ilioinguinal nerve is
derived from the ventral ramus of the first lumbar
nerve root and travels obliquely anterior to the quad-
ratus lumborum and iliacus muscles. After traversing
the transversus abdominus and internal oblique
muscles, it enters the inguinal canal and emerges
from the superficial ring to provide sensory innerva-
tion to the groin and superomedial thigh (Drake et al.
2010).
Surgery
The surgical technique for MLD phalloplasty was
described by Perovic et al. (2007), who used the pro-
cedure for patients with congenital anomalies and
penile trauma. Herein, the surgical steps are adapted
from their method and the technique is characterized
by novel anatomical illustrations.
In the months preceding the MLD procedure, the
donor site can be prepared with an ointment to
improve tissue elasticity and facilitate direct closure at
the time of surgery. Furthermore, in patients consid-
ered overweight or obese, liposuction can be per-
formed in the donor area to allow for an improved
graft (Perovic et al. 2007).
At the time of surgery, the patient must be posi-
tioned to allow simultaneous access to both the axil-
lary and groin regions. This is accomplished by placing
the patient in the lateral decubitus position with the
upper torso oriented 90 degrees to the table while the
pelvis is rotated an additional 20–30 degrees to
ensure groin exposure (Trombetta et al. 2015). The
course of the thoracodorsal artery should be outlined
and the borders of the flap marked. The dimensions
of the flap should be determined by penile size,
patient wishes, and the amount of subcutaneous fat in
the donor location (Vesely et al. 2007). The average
dimensions range from 11 to 15 cm wide and 13 to
18 cm long. The glans of the neophallus is repre-
sented by the distal 5 cm of the flap (Perovic et al.
2007).
Simultaneously, the recipient vessels are exposed
by another surgical team. Two incisions are made to
permit visualization, including a Y-shaped incision at
the mons pubis and an incision in the inguinal region
(Fig. 2). A tunnel is created between these two areas
to provide space for the vascular pedicle (Fig. 3). The
Y-shaped incision at the mons pubis will serve as the
attachment site for the MLD neophallus. The
Fig. 2. Three separate incisions are made to permit
MLD phalloplasty. A Y-shaped incision is made along the
mons pubis which will serve as the attachment site for the
neophallus (A). An additional inguinal incision provides
visualization of the femoral artery and saphenous vein
(B). Finally, one incision is made for flap harvest (C).
(Printed with permission from Angelica Ortiz 2017) [Color
figure can be viewed at wileyonlinelibrary.com]
ilioinguinal nerve is also identified and freed via this
window (Fig. 3). The inguinal lazy-S incision provides
access to the saphenous vein and femoral artery,
which are subsequently isolated for the anastomosis
(Perovic et al. 2007).
Once the recipient vessels are exposed and iso-
lated, the graft can be harvested. An incision is cre-
ated along the anterior skin margin that extends to
the deep fascia. A plane must be developed between
the serratus anterior and the latissimus dorsi muscles
using sharp and blunt dissection. During this step,
care must be taken to avoid injury to the long thoracic
nerve. The flap should be divided along the inferior
and medial edges, with cautery for hemostasis
throughout the dissection and division. The neurovas-
cular pedicle is visualized by lifting the newly-created
flap (Fig. 4). Subsequently, the hilum is proximally
dissected to the point of the axillary vessels. The thor-
acodorsal nerve is also identified and its vasculature
should be preserved. A 1 cm strip of the flap should
be de-epithelialized between the future shaft and
glans, as this area will represent the corona of the
glans. The flap is left on the pedicle so its blood supply
is retained while it is tubularized by approximating the
dorsal and ventral edges (Perovic et al. 2007) (Fig. 5).
The newly-constructed neophallus is then removed
from the axilla after the subscapular artery, vein, and
thoracodorsal nerve have been clamped at the origin
for optimal length. The donor site can be directly
closed or a split-thickness skin graft can be applied to
 Anatomy of the Musculocutaneous Latissimus Dorsi 155

Fig. 3. A tunnel is created between the Y-shaped and inguinal incisions. The Y-
shaped incision will allow for visualization of the ilioinguinal nerve (A), while the ingui-
nal incision provides access to the femoral artery and saphenous vein (B). (Printed
with permission from Angelica Ortiz 2017) [Color figure can be viewed at wileyonlineli-
brary.com]

Fig. 4. As the newly harvested flap is lifted, its neurovascular pedicle may be
clearly visualized. (Printed with permission from Angelica Ortiz 2017) [Color figure can
be viewed at wileyonlinelibrary.com]
156 Granger et al.
Fig. 5. A 1-cm strip of the flap should be de-epithelialized to subsequently repre-
sent the corona of the glans. The flap is left on its neurovascular pedicle and is tubular-
ized by approximating the dorsal and ventral edges to create the neophallus. (Printed
with permission from Angelica Ortiz 2017) [Color figure can be viewed at wileyonlineli-
brary.com]
facilitate re-approximation of the defect. The neophal-
lus is transferred to the groin region and attached at
the Y-shaped incision site. The subscapular artery is
anastomosed to the femoral artery, the subscapular
vein to the saphenous vein, and the thoracodorsal
nerve to the ilioinguinal nerve (Perovic et al. 2007)
(Fig. 6). An alternative option is epineural microneur-
rhaphy between the thoracodorsal nerve and the
anterior branch of the obturator nerve (Vesely et al.
2007)
Following the surgery, a Foley catheter is left to
drain the bladder for at least one week. Furthermore,
dressings are constructed that keep the neophallus
elevated to prevent kinking of the pedicle during the
first 7–10 postoperative days. Clinicians should moni-
tor flap survival by routinely checking skin color and
capillary refill (Perovic et al. 2007).
After the neophallus has been constructed, further
procedures can be performed including urethroplasty
and penile prosthesis implantation. Urethroplasty is
performed for patients who wish to be able to stand to
urinate. It is often carried out using a buccal mucosal
graft inlay at least three months after the initial sur-
gery. For those desiring a neophallus functional for
sexual intercourse, options for a penile prosthesis can
be implemented after healing from the initial proce-
dure (Perovic et al. 2007).
Outcomes and Complications
Phalloplasty techniques and complications were
comprehensively reviewed by Morrison et al. (2016).
A total of 121 articles were assessed and reviewed on
the basis of type of phalloplasty. In their evaluation of
the MLD phalloplasty, patient satisfaction was reported
at 93.8% overall. The neophallus length ranged from
seven to 17 cm, circumference from 10 to 20 cm, and
diameter averaged 3.5 cm. Sensory function was
reported for 17 patients, and 100% noted tactile sen-
sation. Similarly, urinary function was reported for 17
patients, with 100% maintaining the ability to void
(Morrison et al. 2016). In articles discussing sexual
function, a total of three patients described them-
selves as unable to have intercourse (4.9%). Compli-
cations included seven urethral fistulae (13.2%),
seven flap hematomas (13.2%), one partial flap loss
(1.9%), two vascular thromboses (3.8%), three cases
of excessive neophallic swelling (5.7%), and one
instance of skin graft loss at the donor site (1.9%)
(Morrison et al. 2016). Notably, this review considered
patients who had received MLD phalloplasty for multi-
ple indications and did not isolate transgender men.
To the author’s knowledge, satisfaction has yet to be
assessed specifically for patients receiving the MLD
phalloplasty due to gender dysphoria.
DISCUSSION
A recent study examined the priorities of trans-men
with the diagnosis of gender dysphoria. Patient prefer-
ence was variable, and it differed significantly on the
basis of self-identification of gender (“male” vs. “mostly
male” vs. “inter-gender” vs. “nonbinary”) (Jacobsson
et al. 2017). In general, the most significant attributes
requested by patients seeking gender affirmation sur-
gery were preserved orgasm ability and tactile sensa-
tion; less significant attributes included vaginectomy,
minimal scarring, and size. The importance of ability to
urinate while standing was highly variable among the
 Anatomy of the Musculocutaneous Latissimus Dorsi 157

Fig. 6. Arterial supply to the flap is provided as the subscapular artery is anasto-
mosed to the femoral artery. Venous outflow is established as the subscapular vein is
anastomosed to the saphenous vein. Finally, neurorrhaphy is performed between the
thoracodorsal and ilioinguinal nerves. (Printed with permission from Angelica Ortiz
2017) [Color figure can be viewed at wileyonlinelibrary.com]

patients studied, some giving it high priority and others
assigning low importance to it (Jacobsson et al. 2017).
Currently, the most commonly used surgical tech-
nique in gender affirmation surgery for transgender
men is the free radial forearm flap phalloplasty. His-
torically, this surgery has provided a neophallus with
adequate length, a competent neourethra, and sexual
function (Monstrey et al. 2009). However, the result-
ing forearm scar is difficult to conceal and is fre-
quently viewed as stigmatizing (Fig. 7). Furthermore,
urological complications following the surgery are fre-
quent. Monstrey et al. (2009) reviewed 287 radial
forearm phalloplasties performed by a single surgical
team, and they found urological complications in
approximately 41% of patients. The most commonly-
reported urethral complication following the procedure
is urethrocutaneous fistula, with rates ranging as high
as 22–75% (Nikolavsky et al. 2017). While this
technique has produced favorable results, the multi-
tude of drawbacks has left gender surgeons seeking
alternative options for their patients.
In contrast, the MLD phalloplasty results in a phal-
lus with acceptable esthetics, the possibility for ure-
throplasty, and a scar that can easily be concealed
with everyday clothing (Perovic et al. 2007). Further-
more, the musculature contained within the graft pro-
vides an environment for penile prosthesis insertion if
sexual function is a high priority for the patient; how-
ever, no studies specifically examining the efficacy of
penile prostheses in MLD phalloplasty have yet been
performed to this author’s knowledge.
As stated, a benefit of MLD phalloplasty is the
option for subsequent penile prosthesis implantation
(Perovic et al. 2007). The large size and musculature
incorporated into the graft could make a prosthesis
implantation more likely to be successful. There are
158 Granger et al.
Fig. 7. The concealable surgical scar left by the MLD
phalloplasty as compared to the radial forearm free flap
phalloplasty. [Color figure can be viewed at wileyonlineli-
brary.com]
challenges when penile prosthesis implantation in
phalloplasties from any origin is considered because
patients have typically undergone multiple procedures
and the neophallus lacks a tunica albuginea (Neuville
et al. 2016). A retrospective analysis regarding erectile
implants in female-to-male transsexual patients found
that despite the high complication rates prosthesis
implantation is currently the best option for transgender
men to achieve sexual intercourse (Hoebeke et al.
2010). The study evaluated 129 radial forearm flap
phalloplasty patients who had received multiple types
of penile prostheses between 1996 and 2007, and
established a total infection rate of 11.9%, a total dys-
function rate of 13%, and a total malposition rate of
14.6%. Of the patients reviewed, 58.9% still had their
original implant in place (Hoebeke et al. 2010).
Another recent retrospective study by Neuville et al.
(2016) reviewed 95 female-to-male transgender
patients with erectile implants. This study included
patients who had received both radial forearm flap phal-
loplasties and suprapubic phalloplasties. After a median
follow-up of four years, 62.3% of the patients still had
their original prosthesis in place. Early-onset complica-
tions occurred in 4.2% and were related to infection,
while the most common late-onset complications
included malpositioning (12.6%) and dysfunction
(10.5%) (Neuville et al. 2016). However, neither of
these studies specifically assessed the effectiveness of
implantable penile prostheses in patients with the MLD
phalloplasty. To the author’s knowledge, there are no
reviews concerning the success of prosthetic devices in
that subset of patients. Further research is required to
elucidate this matter. It is probable that outcomes will
continue to improve with increasing demand and more
surgical experience.
An alternative technique for MLD phalloplasty was
described by Vesely et al. (2007). In this technique, the
latissimus dorsi muscle is re-innervated as microneur-
rhaphy is performed between the thoracodorsal and
obturator nerves. For the best results, patients must
undergo electrostimulation and electrogymnastics in
the months following surgery to improve muscle move-
ment and control. Eventually the patient is able to con-
tract the adductors and gracilis to induce contraction of
the transplanted muscle. This permits the patient to
experience a “paradox” or “reverse” erection, as
described by the authors, when the neophallus
becomes wider, shorter, and stiffer, thus permitting pen-
etration through muscular contraction. However, this
comes with limitations as the muscle can fade after
repeated contractions (Vesely et al. 2007).
Furthermore, while phalloplasty is rarely performed on
children, MLD phalloplasty has been performed as indi-
cated for pediatric patients with distressing psychological
problems. As with adults, the MLD phalloplasty provides
an acceptable option for children secondary to the size
and length of the neurovascular pedicle (Perovic et al.
2007). Special consideration must be given to the size of
the neophallus in these patients as it will lack androgen
receptors and thus fail to grow as a normal phallus would
during puberty. Djordjevic et al. (2006) examined the
use of MLD phalloplasty in eight children with an average
age of 12 years with indications including congenital
micropenis (3), failed epispadias repair (4), and intersex-
uality (1). The authors reported improved psychological
outcomes for all eight children and their parents. None of
the patients experienced flap loss or necrosis and 50%
experienced moderate donor site scarring. Regarding
urological complications, three of five patients (60%)
who underwent urethroplasty experienced urethral fistu-
lae (Djordjevic et al. 2006). The authors recommend that
the procedure be performed prior to puberty to prevent
worsening psychological sequelae.
CONCLUSION
The MLD flap has favorable results in the area of
phalloplasty for female-to-male transgender patients
who elect to undergo surgical management. Among
its advantages are acceptable donor site appearance,
stiffness sufficient for intercourse, and esthetically
satisfactory genital appearance. The anatomy of the
MLD flap supports the creation of a neophallus for
female-to-male gender affirmation surgery.
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