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Allepot K, Morel-Journel N, Boucher F. Microsurgical phalloplasty: Anatomical study evaluating the use of the external pudendal vessels as recipients. Clin Anat 2023; 36:393-399. [PMID: 36193814 DOI: 10.1002/ca.23958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/18/2022] [Accepted: 09/25/2022] [Indexed: 11/06/2022]
Abstract
The inferior epigastric artery (IEA) is commonly used as a recipient vessel in microsurgical phalloplasty but its use can be associated with abdominal parietal complications (hernia, bulging). To preclude such complications and avoid involvement of the femoral artery, we assessed an external pudendal artery (EPA) as a recipient vessel. We studied the disposition of the external pudendal system and its general anatomy. Then we compared the external diameter of the EPA to that of the first branches of the femoral artery. The most important point was to determine the location of the EPA through a reference line to facilitate a surgical approach. We then illustrated this preliminary study with a clinical case to check the reliability of the identified landmarks. Ten adult cadavers were dissected. The arteries of interest were part of a system consisting of either a common trunk or a duplicated system. The branches of the pudendal system arose from either the femoral artery or the deep femoral artery. On a horizontal reference line passing through the two pubic tubercles, we observed that 83% of EPAs arose between the reference line and 3 cm below it, at the level of a vertical axis centered on the femoral artery. The EPA could be suitable as recipient vessel in phalloplasty owing to its location, size, and ease of dissection. Using it instead of the IEA precludes abdominal parietal complications and reduces scarring in the recipient area.
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Affiliation(s)
- Killian Allepot
- Department of Plastic Surgery, Hospices Civils de Lyon, Lyon, France
| | | | - Fabien Boucher
- Department of Plastic Surgery, Hospices Civils de Lyon, Lyon, France
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Cripps C. Thinking outside the box: Alternative techniques for gender affirming phalloplasty. Neurourol Urodyn 2022. [DOI: 10.1002/nau.25104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/10/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Courtney Cripps
- Division of Plastic Surgery The University of Chicago Medicine & Biological Sciences Chicago Illinois USA
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Purohit RS, Kent M, Djordjevic ML. Penile Prosthesis in Transgender Men after Phalloplasty. Indian J Plast Surg 2022; 55:168-173. [PMID: 36017401 PMCID: PMC9398527 DOI: 10.1055/s-0041-1740523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A penile prosthesis can be successfully implanted after phalloplasty in transgender men to permit sexual intercourse. A prosthesis can be categorized as malleable or inflatable. The most common penile prosthesis implanted after masculinizing genital surgery is the inflatable prosthesis but this can be a challenging operation with high complication rates. Penile prosthesis in transgender patients differs from cis-patients in many respects but one critical difference is the absence of the tough, protective tunica of the corporal body to contain the prosthesis. This causes greater mobility of the prosthesis under the skin and increases the risk of migration and erosion of the device through the skin. In addition, to overcome the absence of a corpora cavernosa, the proximal portion of the prosthesis must be anchored to bone. Complications include injury to the urethra, vascular injury, skin breakdown, infection, device migration, device failure, extrusion, and erosion. There is no robust data on the use of penile prosthesis in transgender men with only multiple reports of small numbers of patients. While successful implantation can improve patients' quality of life, surgeons should counsel patients about the relatively high risk of the need for revision surgery.
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Affiliation(s)
- Rajveer S. Purohit
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Marissa Kent
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Miroslav L. Djordjevic
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
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Primary Use of the Deep Inferior Epigastric Pedicle for Free-flap Phalloplasty: Rationale, Technique, and Outcomes. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4307. [PMID: 35702357 PMCID: PMC9187185 DOI: 10.1097/gox.0000000000004307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/07/2022] [Indexed: 11/25/2022]
Abstract
Most free-flap phalloplasty reports describe the femoral artery and great saphenous vein as recipient vessels, with the deep inferior epigastric artery and venae comitantes (DIEA/V) only rarely reported. We review our experience with preferentially using the DIEA/V as recipient vessels in gender-affirming free-flap phalloplasty, with DIEV as primary venous outflow.
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Allepot K, Cristofari S, Boucher F. [Scapular flap, an alternative to the radial forearm flap in phalloplasty: Advantages and limitations]. ANN CHIR PLAST ESTH 2021; 67:49-56. [PMID: 34949490 DOI: 10.1016/j.anplas.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/22/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Antebrachial phalloplasty is considered as the standard technique in total penile reconstruction. This technique allows the creation of a phallus and a neourethra in one step at the cost of significant sequelae of the donor site. Thus, this technique has been replaced in some centers by other techniques such as the MSLD flap or the ALT flap. However, in Western populations, these techniques require the addition of a technique dedicated to the urethroplasty. The scapular flap is a technique that is not widely described in the literature and, like the antebrachial flap, allows the creation of a phallus and a urethra in one step according to the "tube within tube" technique. AIM The aim of the study was to detail this technique, to study its vascularization and to adapt the measurements of the flap to a western population. PATIENTS AND METHODS Six cadaveric dissections were performed in the laboratory. Intravascular injection of colored latex allowed easier identification of the vessels of interest and study of the subcutaneous vascular tree. Scapular flaps of variable size were raised to adapt the size to a Western population. RESULTS Six dissections were performed in Caucasian subjects. The scapular circumflex artery was constant and had a mean diameter of 3.5mm (3.3mm-3.8mm). The mean pedicle length was 7.3cm (6.8cm-8.1cm). The size of the flaps was adapted to the subcutaneous tissue and flaps of at least 14×16cm allowed the "tube within tube" technique to be performed. CONCLUSION The scapular flap has the advantage of allowing phalloplasty with urethroplasty to be performed at the same time. The pedicle is constant and of good diameter. In addition, the sequelae of the donor site are minimal. On the other hand, the pedicle used is short and the flap cannot be surgically reinnervated. Nevertheless, the restoration of a protective sensitivity allows the implantation of a penile prosthesis.
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Affiliation(s)
- K Allepot
- Hospices civils de Lyon, Lyon, France.
| | - S Cristofari
- Assistance Publique des Hôpitaux de Paris, Paris, France
| | - F Boucher
- Hospices civils de Lyon, Lyon, France
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Phalloplasty – Sensate radial forearm free flap for creation of neourethra and neophallus in gender affirmation surgery: A case report. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.947606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Surgical Options for Patients Seeking Gender-Affirming Surgery. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020. [DOI: 10.1007/s13669-020-00300-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Stowell JT, Horowitz JM, Thomas S. Gender-affirming surgical techniques, complications, and imaging considerations for the abdominal radiologist. Abdom Radiol (NY) 2020; 45:2036-2048. [PMID: 31915851 DOI: 10.1007/s00261-019-02398-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Gender-affirming surgery is a group of surgical procedures that alters the physical appearance of a transgender person to resemble that socially associated with their identified gender. Masculinization and feminization surgeries include chest and breast surgery as well as genital reconstruction. The genital reconstruction surgeries have unique anatomic imaging features and are associated with complications that may require radiologic evaluation. This review provides a review of the imaging anatomy, expected findings, and complications associated with gender-affirming surgeries.
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Affiliation(s)
- Justin T Stowell
- Department and Institution Department of Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Jeanne M Horowitz
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Stephen Thomas
- Department of Radiology, Sharp Rees-Stealy Medical Group, San Diego, CA, USA.
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Gender Affirmation Surgery: A Primer on Imaging Correlates for the Radiologist. AJR Am J Roentgenol 2019; 213:1194-1203. [PMID: 31414889 DOI: 10.2214/ajr.19.21686] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Jun MS, Crane CN, Santucci RA. What urologists need to know about female-to-male genital confirmation surgery (phalloplasty and metoidioplasty): techniques, complications, and how to deal with them. MINERVA UROL NEFROL 2019; 72:38-48. [PMID: 31692307 DOI: 10.23736/s0393-2249.19.03611-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Transmasculine gender-affirming surgery (GAS) is technically challenging, and in the past associated with a high but improving complication rate. Few surgical centers are performing this surgery, which can include metoidioplasty and phalloplasty, and patients often travel great distances for their surgery. While many will continue care with their original surgeons, others cannot due to social/geographic factors, or because emergencies arise. Thus, patients may seek care with their local urologist for relief of delayed complications, the most common of which include urethral stricture, penile prosthesis issues and urethrocutaneous fistula. This review will discuss the surgical elements behind metoidioplasty and phalloplasty, and the diagnosis and treatment for the most common postoperative issues.
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Affiliation(s)
- Min S Jun
- Department of Reconstructive Urology and Trauma, NYU Langone Health, New York, NY, USA -
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Ganor O, Taghinia AH, Diamond DA, Boskey ER. Piloting a Genital Affirmation Surgical Priorities Scale for Trans Masculine Patients. Transgend Health 2019; 4:270-276. [PMID: 31656855 PMCID: PMC6814078 DOI: 10.1089/trgh.2019.0038] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Many transgender men seek surgical interventions to create male genitalia. Currently, there is no standardized tool to assess individual goals and expectations for such reconstructive genital surgery. The purpose of this study was to develop and pilot a genital affirmation surgical priorities scale (GASPS) in transgender men seeking metoidioplasty and/or phalloplasty. Methods: The research team developed the GASPS and piloted it with 63 patients seeking reconstructive genital surgery. The scale was constructed after a comprehensive literature review identified key areas of importance, including size, erogenous and tactile sensation, interest in penetrative sex, ability to urinate standing up, and maintenance of orgasmic function. Results were then tabulated and analyzed to look for trends. Results: Sixty three consecutive patients, mean age 24.98 years (standard deviation [SD]=5.87), were administered the assessment. On the 5 point Likert scale, patients were most concerned about being able to stand to urinate (mean=4.38, SD=1.06) and erotic sensation (mean=4.21, SD=0.8). The ability to engage in penetrative intercourse (mean=3.98, SD=1.34), tactile sensation (mean=3.93, SD=1.01), and penis length (mean=3.37, SD=1.18), and girth (mean=3.09, SD=1.20) were not universally considered to be important and responses varied widely. Most patients (86%) stated they had a history of being able to orgasm, and 8% did not know. Feedback suggested that scale use helped patients clarify goals for surgery. Conclusion: GASPS use confirmed the diversity of patient priorities and the importance of individualized goal assessment. It also confirmed previous reports that standing to urinate is a major genital affirmation motivation for many transgender men.
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Affiliation(s)
- Oren Ganor
- Center for Gender Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Amir H Taghinia
- Center for Gender Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - David A Diamond
- Center for Gender Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Elizabeth R Boskey
- Center for Gender Surgery, Boston Children's Hospital, Boston, Massachusetts
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Sullivan P, Trinidad J, Hamann D. Issues in transgender dermatology: A systematic review of the literature. J Am Acad Dermatol 2019; 81:438-447. [DOI: 10.1016/j.jaad.2019.03.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 03/06/2019] [Accepted: 03/09/2019] [Indexed: 10/27/2022]
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Zurada A, Salandy S, Roberts W, Gielecki J, Schober J, Loukas M. The evolution of transgender surgery. Clin Anat 2018; 31:878-886. [DOI: 10.1002/ca.23206] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 04/25/2018] [Accepted: 04/30/2018] [Indexed: 01/16/2023]
Affiliation(s)
- Anna Zurada
- Department of Radiology, Collegium Medicum, School of Medicine; University of Warmia and Mazury; Olsztyn Poland
- Department of Anatomy; University of Warmia and Mazury; Olsztyn Poland
| | - Sonja Salandy
- Department of Anatomical Sciences, School of Medicine; St. George's University; Grenada West Indies
| | - Wallisa Roberts
- Department of Anatomical Sciences, School of Medicine; St. George's University; Grenada West Indies
| | - Jerzy Gielecki
- Department of Radiology, Collegium Medicum, School of Medicine; University of Warmia and Mazury; Olsztyn Poland
- Department of Anatomy; University of Warmia and Mazury; Olsztyn Poland
| | - Justine Schober
- Department of Pediatric Urology; UPMC Hamot; Erie Pennsylvania
| | - Marios Loukas
- Department of Anatomical Sciences, School of Medicine; St. George's University; Grenada West Indies
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