Sensate total clitoris reconstruction via microneurovascular dorsal foot web space flap with pudendal nerve coaptation

Revision surgery after gender-affirming genitoplasty is becoming more and more common as more patients gain access to surgical treatment. The complexity of genitoplasty and extensive dissection of delicate tissues predisposes patients to necrosis of the flap(s) employed, which can leave patients with complications ranging from poor aesthetics to total lack of genital sensation. The purpose of this report is to detail the revision surgery of a 32-year-old transgender woman who underwent vaginoplasty at an outside institution and presented to our clinic for clitoral reconstruction following necrosis and near-total loss of the neoclitoris. Physical exam showed extensive necrosis, and 3-Tesla magnetic resonance (MRI) revealed significant scarring of the pudendal nerve branches at the level of the pubic symphysis. Healthy nerve was identified at the level of the right inferior pubic ramus, and total clitoral reconstruction with an innervated first dorsal web space free flap anastamosed to the deep inferior epigastric vessels was performed. Complications included donor site cellulitis with partial loss of the skin graft and formation of hypertrophic scar tissue. This was treated 6 months postoperatively with excision of scar tissue in the webspace and placement of an additional full-thickness skin graft. At follow-up, the patient reported tactile and erogenous sensation of the neoclitoris itself and subjective satisfaction with the aesthetic outcome. Our results provide evidence that this flap is a feasible option to create an aesthetic and sensate neoclitoris in the setting of previous neoclitoral necrosis. This case report also describes the novel use of 3-Tesla MRI in target selection for nerve coaptation.