Gender-affirming Phalloplasty: A Postoperative Protocol for Success.

Increased access to care and insurance coverage has led to an increase in gender-affirming surgeries performed in the United States. Gender-affirming phalloplasty has a variety of donor sites and surgical techniques including both pedicled and free flaps. Although surgical techniques and patient outcomes are well-described, no reports in the literature specifically discuss postoperative management, which plays a crucial role in the success of these operations. Here, we present a postoperative protocol based on our institution's experience with gender-affirming phalloplasty with the hope it will serve as a standardized, reproducible reference for centers looking to offer these procedures. Methods: Patients undergoing gender-affirming phalloplasty at our institution followed a standardized protocol from the preoperative stage through phases of postoperative recovery. Medication, laboratory, physical and occupational therapy, flap monitoring, and dressing change guidelines were extracted and compiled into a single resource detailing the postoperative protocol in full. Results: Our institution's standardized postoperative protocol for gender-affirming phalloplasty is detailed, focusing on flap monitoring, mobilization and activity, medications, and postoperative dressing care. One hundred thirty first-stage phalloplasty procedures were performed between May 2017 and December 2021, with two patients (1.5%) experiencing partial necrosis and one incidence (0.8%) of total flap loss. Conclusions: For optimal and safe surgical outcomes, the surgical and extended care teams need to understand flap monitoring as well as specific postoperative protocols. A systematic approach focusing on flap monitoring, mobilization and activity, medications, and postoperative dressing care decreases errors, accelerates recovery, shortens length of stay, and instills confidence in the patient.

Technique to Improve Tracheostomy Speaking Valve Tolerance after Head and Neck Free Flap Reconstruction.

Increased upper airway resistance from postoperative changes after major head and neck surgery may cause elevated transtracheal pressures and result in tracheostomy speaking valve intolerance. This may be particularly true among patients with baseline pulmonary disease. We describe a patient recovering from oral cancer resection and flap reconstruction who demonstrated prolonged ventilator dependence and tracheostomy speaking valve intolerance with abnormal tracheal manometry. We attempted to improve speaking valve tolerance through the adaptation of a valve modification intended to reduce transtracheal pressures. Drilling holes into the 1-way speaking valve allowed for excess air egress and resulted in normalization of transtracheal pressures with improved speaking valve tolerance. This 1-way speaking valve modification may serve as a simple method to allow for earlier restoration of voicing and potentially reduce the number of ventilator- dependent days in this patient population.