I wanted to share my experience with using the thin Integra option with my RFF donor site, since this is a less common choice. I'm currently 7 weeks post op stage 1 with Dr. Llado-Farrulla at OHSU, which was just creating my penis. I am not pursuing UL as part of phalloplasty. The first five photos here show my arm at 7 weeks and the last two show the early healing and the small hematomas that developed. Overall I'm very happy with how my arm has healed up!

For those that are unfamiliar, Integra is a dermal matrix product that some surgeons use on the forearm donor site. It may help aesthetically with evening out the circumference of the donor site, since the split thickness skin graft that covers the area is much thinner than the flap used to created the penis. It may also help protect tendons and nerves. There's no real consensus on the benefits on Integra and some surgeons don't use it at all.

My main reason for opting to go with the thin Integra was to avoid the second surgery that's required when the thicker version is used, which is typically done about 2 weeks after the initial operation. With the thin Integra, it and the split thickness graft are placed in the initial surgery. Having to go back into surgery just as I was settling into a routine at home sounded terrible to me and I also wanted be able to regain independence as soon as possible. I figured this thin version was a nice middle ground, as opposed to forgoing it completely.

When I consulted with Dr. Llado-Farrulla, she told me that the team at OHSU very rarely used this version of Integra, but that the team at the University of Utah had recently published their process with it, so she'd follow their protocol. She seemed generally unconcerned about it.

Surgery itself went great and I spent the first four days in the hospital with my arm in a wound vac and splint. The main complications that developed were some small hematomas. These were apparent once the wound vac was removed and Dr. Llado-Farrulla made some small incisions to help them drain before I was discharged.  Each day during dressing changes my caretaker used a sterile needle to puncture any spots where fluid was collecting and we added extra gauze on top of the Xeroform in those spots to try to help the skin adhere. It largely just required patience to see how those spots would end up taking. It was slow progress, but after about two weeks those spots finally started to heal.

You can see in the photos that there are areas that look a little less healed and more textured where the hematomas were, but I'm thrilled with how well it's healed up given how it started. The hematomas extended the overall healing time of the graft by about two weeks, so I spent about four weeks in Xeroform and gauze dressings.

The good news is that this did not impact my timeline for hand and wrist movement at all. I was able to start using my hand and begin physical therapy about two weeks after surgery. This worked out really well with my care plan and I was able to shower, do wound care, and tend to my basic day to day needs independently once I was cleared to use my hand.

I would say that I'm now back to about 80% mobility in my wrist and have full mobility of my hands and fingers. There's still some swelling in my hand, but I'm hopeful that will continue to decrease and that the transition between the skin graft and my wrist will smooth out over time. I think the forearm tightness is also starting to decrease as I use my arm more. I have not yet started any scar treatments, but I expect to be cleared for that at my final post op appointment now that any scabbing as cleared up. I'm hopeful this will help with the tightness as well.

When I last saw Dr. Llado-Farrulla, she mentioned that visually she saw no difference between my arm and others where the thicker version was used. She said that hematomas were a common complication, but that with the two-staged surgery that's required with the thicker version, they are able to address them surgically before the split thickness graft is placed. So it sounds unlikely that the thinner version was the cause of any complications, but it did require more patience in healing.

Dr. Llado-Farrulla told me that both she and Dr. Peters were following my arm progress and that they may start recommending this approach to other patients who are not choosing urethral lengthening. It seems like the two staged graft would still be beneficial to folks are that pursuing UL because it means they already have OR time booked where they can surgically address any complications that might develop and impact future stages of the UL process. From my perspective, I'm really happy with my decision with the thin Integra and think it's an option worth considering for others as well. 

Though this post is mostly about my arm, I do want to mention that I'm also really happy my penis! I had a couple shallow spots of wound separation around the base that have also required some extra patience and time in the cloud, but it's been smooth sailing otherwise. My general impression of recovery is that it hasn't necessarily been \_hard\_, but it has been very long.

I've also had a great experience with Dr. Llado-Farrulla. She seems like a really talented surgeon and has an up-beat and energetic bedside manner that I found really endearing. I'm looking forward to working with her more for stage two, which should hopefully be this summer. Likewise, pretty much everyone at OHSU has been fantastic. The PA I see for my post op visits is kind and personable, their surgery scheduler was super responsive and great to work with, and the nursing staff on the ward took good care of me. Special shout outs to the resident who told me his entire job during surgery was lining up my tattoos and the other two residents who made my pre-discharge dressing removal more funny than painful.

Experience with thin Integra at OHSU