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Boucher F, Mojallal A. [Vulvoplasty after gender-affirmating genital surgery]. ANN CHIR PLAST ESTH 2023; 68:477-483. [PMID: 37423824 DOI: 10.1016/j.anplas.2023.06.001] [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: 06/01/2023] [Accepted: 06/03/2023] [Indexed: 07/11/2023]
Abstract
Functional and aesthetic results after vaginoplasty in sexual reassignment surgery have improved in recent years. Improved surgical techniques, well-established expert teams and a growing demand for and interest in this type of surgery are some of the reasons for these results. However, there is a growing demand for genital cosmetic surgery, not only among cis women, but also among trans women. The main shortcomings in results are therefore presented and listed. The aesthetic revision surgery techniques specifically indicated are described. Labiaplasty and clitoridoplasty appear to be the two main requests for secondary surgery following trans vaginoplasty.
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Affiliation(s)
- F Boucher
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire, hôpital de la Croix Rousse, hospices civils de Lyon, 103, Grande rue de la Croix Rousse, 69004 Lyon, France.
| | - A Mojallal
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire, hôpital de la Croix Rousse, hospices civils de Lyon, 103, Grande rue de la Croix Rousse, 69004 Lyon, France
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Cosmetic Revision Surgeries after Transfeminine Vaginoplasty. Aesthetic Plast Surg 2023; 47:430-441. [PMID: 36002774 PMCID: PMC9944700 DOI: 10.1007/s00266-022-03029-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 07/16/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Vaginoplasty is the most frequent genital gender-affirming surgery. Although both functional and aesthetic outcomes after transfeminine vaginoplasty have improved over the years, cosmetic revision surgeries demand after transfeminine vaginoplasty appears to be increasing and requires updated knowledge. METHODS All patients who underwent vulvar cosmetic revision surgeries at our institution following transfeminine vaginoplasty from January 2014 to April 2022 were studied. The prevalence, topography and surgical techniques of cosmetic revision surgeries after transfeminine genital gender-affirming surgery were examined using clinical charts review and statistical analysis. RESULTS During the study period, 354 patients underwent gender-affirming vaginoplasty at our single institution (212 penile inversion vaginoplasty, 122 colovaginoplasty and 20 penile inversion vaginoplasty with scrotal skin graft patients). Forty out of these 354 patients (11.29%) required cosmetic revision surgery after transfeminine vaginoplasty; additionally, 44 patients with vaginoplasty performed at other centres also underwent vulvar cosmetic revision surgery at our clinic during the study period. From all performed cosmetic revision surgeries, most of them (31.42%) were labia corrections, followed by clitoris (23.26%) repair surgeries. Mons Venus (10.20%), urethral meatus (9.38%), spongiosus tissue remnants (8.57%) and introitus (6.53%) revisions followed in frequency. Corrections of peri-inguinal scars (5.30%), anterior commissure (2.84%) and inferior fourchette (2.42%) were less prevalent. No differences were found among the different studied vaginoplasty techniques regarding cosmetic revision surgery prevalence or topography following transfeminine vaginoplasty (p < 0.05). CONCLUSIONS Cosmetic revision surgeries after transfeminine vaginoplasty are frequent. In our large and long-term cohort study, labiaplasty followed by clitoroplasty were found as the most required cosmetic revision surgical procedures. Further multicentre, prospective and controlled studies are necessary to improve cosmetic outcomes and scientific evidence after transfeminine vaginoplasty. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Pidgeon TE, Franchi T, Lo ACQ, Mathew G, Shah HV, Iakovou D, Borrelli MR, Sohrabi C, Rashid T. Outcome measures reported following feminizing genital gender affirmation surgery for transgender women and gender diverse individuals: A systematic review. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 24:149-173. [PMID: 37122823 PMCID: PMC10132236 DOI: 10.1080/26895269.2022.2147117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Background Feminizing genital gender affirmation surgery (fgGAS) may be an essential adjunct in the care of some transgender women and gender diverse individuals with gender incongruence. However, the comparison of different techniques of fgGAS may be confounded by variable outcome reporting and the use of inconsistent outcomes in the literature. This systematic review provides the most in-depth examination of fgGAS studies to date, and summarizes all reported outcomes, definitions, and the times when outcomes were assessed following these surgical interventions. Aims/Methods: This work intends to quantify the levels of outcome variability and definition heterogeneity in this expanding field and provides guidance on outcome reporting for future study authors. Candidate studies for this systematic review were sourced via an electronic, multi-database literature search. All primary, clinical research studies of fgGAS were included with no date limits. Paired collaborators screened each study for inclusion and performed data extraction to document the outcomes, definitions, and times of outcome assessment following fgGAS. Results After screening 1225 studies, 93 studies proceeded to data extraction, representing 7681 patients. 2621 separate individual outcomes were reported, 857 (32.7%) were defined, and the time of outcome assessment was given for 1856 outcomes (70.8%) but relied on nonspecific ranges of follow-up dates. "Attainment of orgasm", "Neovaginal stenosis", and "Neovaginal depth/length" were among the most commonly reported outcomes. Profound heterogeneity existed in the definitions used for these and for all outcomes reported in general. Discussion The results demonstrate a need for clear outcomes, agreed definitions, and times of outcome assessment following fgGAS in transgender women and gender diverse individuals. The adoption of a consistent set of outcomes and definitions reported by all future studies of fgGAS (a Core Outcome Set) will aid in improving treatment comparisons in this patient group. This review is the first step in that process.
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Affiliation(s)
| | | | - Andre C. Q. Lo
- University of Cambridge School of Clinical Medicine, Cambridge, UK
| | | | | | - Despoina Iakovou
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Mimi R. Borrelli
- Department of Plastic Surgery, Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Catrin Sohrabi
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Tina Rashid
- Department of Gender Surgery, Parkside Hospital, London, UK
- Department of Urology, St George’s University Hospital NHS Foundation Trust, London, UK
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Özer M, Toulabi SP, Fisher AD, T'Sjoen G, Buncamper ME, Monstrey S, Bizic MR, Djordjevic M, Falcone M, Christopher NA, Simon D, Capitán L, Motmans J. ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery". Sex Med 2022; 10:100471. [PMID: 34971864 PMCID: PMC8847816 DOI: 10.1016/j.esxm.2021.100471] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 10/06/2021] [Accepted: 11/09/2021] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Much has been published on the surgical and functional results following Gender Affirming Surgery ('GAS') in trans individuals. Comprehensive results regarding sexual wellbeing following GAS, however, are generally lacking. AIM To review the impact of various GAS on sexual wellbeing in treatment seeking trans individuals, and provide a comprehensive list of clinical recommendations regarding the various surgical options of GAS on behalf of the European Society for Sexual Medicine. METHODS The Medline, Cochrane Library and Embase databases were reviewed on the results of sexual wellbeing after GAS. MAIN OUTCOMES MEASURE The task force established consensus statements regarding the somatic and general requirements before GAS and of GAS: orchiectomy-only, vaginoplasty, breast augmentation, vocal feminization surgery, facial feminization surgery, mastectomy, removal of the female sexual organs, metaidoioplasty, and phalloplasty. Outcomes pertaining to sexual wellbeing- sexual satisfaction, sexual relationship, sexual response, sexual activity, enacted sexual script, sexuality, sexual function, genital function, quality of sex life and sexual pleasure- are provided for each statement separately. RESULTS The present position paper provides clinicians with statements and recommendations for clinical practice, regarding GAS and their effects on sexual wellbeing in trans individuals. These data, are limited and may not be sufficient to make evidence-based recommendations for every surgical option. Findings regarding sexual wellbeing following GAS were mainly positive. There was no data on sexual wellbeing following orchiectomy-only, vocal feminization surgery, facial feminization surgery or the removal of the female sexual organs. The choice for GAS is dependent on patient preference, anatomy and health status, and the surgeon's skills. Trans individuals may benefit from studies focusing exclusively on the effects of GAS on sexual wellbeing. CONCLUSION The available evidence suggests positive results regarding sexual wellbeing following GAS. We advise more studies that underline the evidence regarding sexual wellbeing following GAS. This position statement may aid both clinicians and patients in decision-making process regarding the choice for GAS. Özer M, Toulabi SP, Fisher AD, et al. ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery". Sex Med 2022;10:100471.
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Affiliation(s)
- Müjde Özer
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Sahaand Poor Toulabi
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Alessandra D Fisher
- Andrology, Women's Endocrinology, Gender Incongruence Unit, Department of Experimental Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - Guy T'Sjoen
- Department of Endocrinology and Center for Sexology and Gender, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Marlon E Buncamper
- Department of Plastic, Reconstructive and Hand Surgery, Ghent University Hospital, Ghent, Belgium
| | - Stan Monstrey
- Department of Plastic, Reconstructive and Hand Surgery, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Marta R Bizic
- Department of Pediatric Urology, University of Belgrade, Belgrade, Serbia
| | | | - Marco Falcone
- Department of Urology, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Nim A Christopher
- Department of Urology, St Peter's Andrology Centre and The Institute of Urology, London, UK
| | - Daniel Simon
- Facialteam Surgical Group, HC Marbella International Hospital, Marbella, Málaga, Spain
| | - Luis Capitán
- Facialteam Surgical Group, HC Marbella International Hospital, Marbella, Málaga, Spain
| | - Joz Motmans
- Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
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Vaginoplasty in Male to Female transgenders: single center experience and a narrative review. Int J Impot Res 2021; 33:726-732. [PMID: 34561673 DOI: 10.1038/s41443-021-00470-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 08/27/2021] [Accepted: 09/10/2021] [Indexed: 11/08/2022]
Abstract
Vaginoplasty in Male to Female (M to F) transgenders is a challenging procedure, often accompanied by numerous complications. Nowadays the most commonly used technique involves inverted penile and scrotal flaps. In this paper the data of 47 M to F patients who have undergone sex affirmation surgery at the Department of Urology of the University of Trieste, Italy since 2014, using our modified vaginoplasty technique with the "Y" shaped urethral flap, have been retrospectively reviewed. Moreover, a non structured review of the literature with regards to short and long-term complications of vaginoplasty has been provided. All patients followed a standardized neo-vaginal dilation protocol. At follow up 2 patients were lost. At 12 months 88.9% of patients (40/45) were able to reach climax, 75.6% (34/45) were having neo-vaginal intercourses and median neo-vaginal depth was 11 cm (IQR 9-13.25): no statistically significant decrease in depth was found at follow up. Only one patient was dissatisfied with aesthetic appearance at 12 months. Our technique provided excellent cosmetic and functional results without severe complications (Clavien-Dindo ≥ 3). The review of the literature has highlighted the need to standardize a postoperative follow up protocol with particular regard to postoperative dilatation regimen. Further, larger randomized clinical trials are pending to draw definitive conclusions.
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Kloer C, Parker A, Blasdel G, Kaplan S, Zhao L, Bluebond-Langner R. Sexual health after vaginoplasty: A systematic review. Andrology 2021; 9:1744-1764. [PMID: 33882193 DOI: 10.1111/andr.13022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/26/2021] [Accepted: 04/12/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Vaginoplasty is a gender-affirming procedure for transgender and gender diverse (TGD) patients who experience gender incongruence. This procedure reduces mental health concerns and enhances patients' quality of life. A systematic review investigating the sexual health outcomes of vaginoplasty has not been performed. OBJECTIVES To investigate sexual health after gender-affirming vaginoplasty for TGD patients. DATA SOURCES MEDLINE/PubMed, Embase, Scopus, and PsycINFO databases were searched, unrestricted by dates or study design. METHODS We included primary literature that incorporated TGD patients, reported sexual health outcomes after vaginoplasty intervention and were available in English. Outcomes included at least one of these sexual health parameters: sexual desire, arousal, sensation, activity, secretions, satisfaction, pleasure, orgasm, interferences, or aids. RESULTS Our search yielded 140 studies with 12 different vaginoplasty surgical techniques and 6,953 patients. The majority of these studies were cross-section or retrospective cohort observational studies (66%). 17.4%-100% (median 79.7%) of patients (n = 2,384) were able to orgasm postoperatively regardless of revision or primary vaginoplasty techniques. Female Sexual Function Index was the most used standardized questionnaire (17 studies, ranging from 16.9 to 28.6). 64%-98% (median 81%) of patients were satisfied with their general sexual satisfaction. The most common interference of sexual activity was dyspareunia. CONCLUSIONS The heterogenous methods of measuring sexual outcomes reflect the difficulty in comparing single-center surgical outcomes, encouraging the need for a standardized and validated metric for reporting sexual health after vaginoplasty for TGD patients. The most common sexual health parameter reported is sexual activity while therapeutic aids and pleasure were the least reported parameters. Future studies are needed to improve and expand methods of measuring sexual health, including prospective studies, validated questionnaires, and inclusive metrics. Systematic review registration number: PROSPERO 01/01/2021: CRD42021224014.
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Affiliation(s)
- Carmen Kloer
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA.,Duke University School of Medicine, Duke Health Systems, Durham, NC, USA
| | - Augustus Parker
- NYU Grossman School of Medicine, New York University Langone Health, New York, NY, USA
| | - Gaines Blasdel
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Samantha Kaplan
- Duke University School of Medicine, Duke Health Systems, Durham, NC, USA
| | - Lee Zhao
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA
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Raigosa M, Avvedimento S, Descarrega J, Yuste M, Cruz-Gimeno J, Fontdevila J. Refinement Procedures for Clitorolabiaplasty in Male-to-Female Gender-Affirmation Surgery: More than an Aesthetic Procedure. J Sex Med 2020; 17:2508-2517. [PMID: 32891560 DOI: 10.1016/j.jsxm.2020.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 06/19/2020] [Accepted: 08/02/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Among the various steps of a penile inversion feminizing genitoplasty, reconstruction of the clitoris and labia minora remains the most challenging procedure. AIM This study aims to evaluate surgical outcomes of neoclitoroplasty performed before and after the introduction of the labia minora's creation in our surgical technique. METHODS A retrospective analysis was carried out comparing 2 groups of patients that underwent penile inversion feminizing surgery: group A (64 patients) who had labia minora and clitoral hood creation and group B (103 patients) who did not. OUTCOMES To describe the surgical technique and outcomes of clitorolabiaplasty in male-to-female gender-affirmation surgery. RESULTS Concerning overall complication rates, there were significant differences in the incidence of hemorrhage and urethral stenosis (P < .01). Hemorrhage surrounding the urethra and labia was identified in 40 patients (group A: n = 8 [12.5%]; group B: n = 32 [31%]) (P = .006). Neomeatal stenosis occurred in 17 patients (group A: n = 1 [1.5%]; group B: n = 16 [15.5%]) (P = .003). Partial necrosis of the clitoris occurred in 2 cases (group A: n = 0; group B: n = 2 [1.9%]) (P = .52). Necrosis of the labia majora occurred in 3 cases (group A: n = 0; group B: n = 3 [2.9%]) (P = .28). 5 patients (group A: n = 2 (3.1%); group B: n = 3 [2.9%]) (P = .93) developed rectovaginal fistula. 6 patients experienced neovaginal canal stricture (group A: n = 3 [4.6%]; group B: n = 3 [2.9%]) (P = .54). 2 patients (group A: n = 0; group B: n = 2 [1.9%]) (P = .52) reported introital stenosis; Persistent granulation tissue inside the neovagina that required in-office treatments occurred in 4 cases (group A: n = 2 [3.1%]; group B: n = 2 [1.9%]) (P = .62). Wound dehiscence occurred in 23 patients (group A: n = 13 [20.3%]; group B: n = 10 [9.7%]) (P = .05). 24 patients (group A: n = 3 [4.6%]; group B: n = 21 [20.3%]) (P = .004) underwent 28 different types of aesthetic refinements. CLINICAL IMPLICATIONS Incorporating the creation of labia minora and clitoral hood in one step is a safe and viable option in patients undergoing male-to-female gender-affirmation surgery. STRENGTHS & LIMITATIONS Strength of the study is the large cohort of patients included and the consistent surgical technique. To our knowledge, this is the first study that compares with a control group, the introduction of labia minora creation in male-to-female gender-affirmation surgery. Limitations include the retrospective nature of the study and the absence of patient-reported outcomes measures. CONCLUSION Technical refinements of our technique led to a significative reduction in urethral stenosis and postoperative hemorrhage without an increased risk of major complications. Raigosa M, Avvedimento S, Descarrega J, et al. Refinement Procedures for Clitorolabiaplasty in Male-to-Female Gender-Affirmation Surgery: More than an Aesthetic Procedure. J Sex Med 2020;17:2508-2517.
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Affiliation(s)
- Mauricio Raigosa
- Plastic and Maxillofacial Dept, Hospital Clinic, Barcelona, Spain.
| | | | - Jordi Descarrega
- Plastic and Maxillofacial Dept, Hospital Clinic, Barcelona, Spain
| | - Marta Yuste
- Plastic and Maxillofacial Dept, Hospital Clinic, Barcelona, Spain
| | - Juan Cruz-Gimeno
- Plastic and Maxillofacial Dept, Hospital Clinic, Barcelona, Spain
| | - Joan Fontdevila
- Plastic and Maxillofacial Dept, Hospital Clinic, Barcelona, Spain
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Boas SR, Ascha M, Morrison SD, Massie JP, Nolan IT, Shen JK, Vyas KS, Satterwhite T. Outcomes and Predictors of Revision Labiaplasty and Clitoroplasty after Gender-Affirming Genital Surgery. Plast Reconstr Surg 2019; 144:1451-1461. [PMID: 31764668 DOI: 10.1097/prs.0000000000006282] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Penile inversion vaginoplasty is the most common gender-affirming procedure for transfeminine patients. Patients undergoing this procedure may require revision labiaplasty and clitoroplasty. This study describes complications and outcomes from the largest reported cohort in the United States to undergo penile inversion vaginoplasty with subsequent revision labiaplasty and/or clitoroplasty. METHODS A retrospective chart review was performed of a single surgeon's experience with penile inversion vaginoplasty with or without revision labiaplasty and/or clitoroplasty between July of 2014 and June of 2016 in a cohort of gender-diverse patients assigned male at birth. Patient demographic data, complications, and quality of life data were collected. Univariate and multivariate comparisons were completed. RESULTS A total of 117 patients underwent penile inversion vaginoplasty. Of these, 28 patients (23.9 percent) underwent revision labiaplasty and/or clitoroplasty, with nine patients (7.7 percent) undergoing both procedures. Patients who underwent penile inversion vaginoplasty necessitating revision were significantly more likely to have granulation tissue (p = 0.006), intravaginal scarring (p < 0.001), and complete vaginal stenosis (p = 0.008). The majority of patients who underwent revision labiaplasty and/or clitoroplasty reported satisfaction with their final surgical outcome (82.4 percent) and resolution of their genital-related dysphoria (76.5 percent). CONCLUSIONS Patients who developed minor postoperative complications following penile inversion vaginoplasty were more likely to require revision surgery to address functional and aesthetic concerns. Patients responded with high levels of satisfaction following revision procedures, with the majority of patients reporting resolution of genital-related dysphoria. Transfeminine patients who undergo penile inversion vaginoplasty should be counseled on the possibility of revisions during their postoperative course. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Samuel R Boas
- From Case Western Reserve University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University; New York University School of Medicine; the University of Sydney School of Medicine; the Department of Plastic Surgery, Mayo Clinic; Brownstein and Crane Surgical Services
| | - Mona Ascha
- From Case Western Reserve University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University; New York University School of Medicine; the University of Sydney School of Medicine; the Department of Plastic Surgery, Mayo Clinic; Brownstein and Crane Surgical Services
| | - Shane D Morrison
- From Case Western Reserve University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University; New York University School of Medicine; the University of Sydney School of Medicine; the Department of Plastic Surgery, Mayo Clinic; Brownstein and Crane Surgical Services
| | - Jonathan P Massie
- From Case Western Reserve University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University; New York University School of Medicine; the University of Sydney School of Medicine; the Department of Plastic Surgery, Mayo Clinic; Brownstein and Crane Surgical Services
| | - Ian T Nolan
- From Case Western Reserve University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University; New York University School of Medicine; the University of Sydney School of Medicine; the Department of Plastic Surgery, Mayo Clinic; Brownstein and Crane Surgical Services
| | - Jacson K Shen
- From Case Western Reserve University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University; New York University School of Medicine; the University of Sydney School of Medicine; the Department of Plastic Surgery, Mayo Clinic; Brownstein and Crane Surgical Services
| | - Krishna S Vyas
- From Case Western Reserve University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University; New York University School of Medicine; the University of Sydney School of Medicine; the Department of Plastic Surgery, Mayo Clinic; Brownstein and Crane Surgical Services
| | - Thomas Satterwhite
- From Case Western Reserve University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University; New York University School of Medicine; the University of Sydney School of Medicine; the Department of Plastic Surgery, Mayo Clinic; Brownstein and Crane Surgical Services
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Cadaver Study of Combined Neurovascular Sensate Flaps to Create Vaginal Erogenous Sensation During Male-to-Female Genital Confirmation Surgery: The Pedicle "O" Flap. Ann Plast Surg 2019; 81:571-575. [PMID: 29994881 DOI: 10.1097/sap.0000000000001558] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The lack of erogenous sensitivity in the neovagina is one of the major shortcomings for patients undergoing male-to-female genital confirmation surgery. Remnant fibers of the dorsal nerve of the penis (DNP) after clitroplasty can potentially be used for a second neurovascular pedicle flap for intravaginal erogenous sensation. METHODS An anatomic dissection of the DNP was performed in 10 male frozen pelvises to identify major trunks and their branches. Lateral branches of DNP were preserved for a sensate "O" pedicle flap for the vagina. The number of main branches in the lateral dorsal aspect of the penis was calculated to ensure sufficient erogenous innervation to the vagina. Cross sections of the penis were used for histological analysis. Optimal width and length of the new sensate flap were described. RESULTS There were 1, 2, and 3 main branches in the lateral compartment in 2 (20%), 6 (30.7%), and 2 (42.8%) cadavers, respectively. A sensate pedicle flap from the lateral aspect of the glans penis with a mean width of 1.14 cm (range, 0.9-1.28 cm) ensured at least one main branch of the DNP for erogenous sensitivity of the vagina. This sensate vaginal flap and its neurovascular pedicle had a mean length of 9.8 cm (range, 8.7-10.3 cm) allowing its inset into the anterior vaginal canal. CONCLUSION Lateral branches of the DNP can be preserved for a pedicle sensate flap to the vagina, which can provide patients with an erogenous vaginal "spot" during male-to-female confirmation surgery.
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Mañero Vazquez I, García-Senosiain O, Labanca T, Gómez Gil E. Aesthetic Refinement in the Creation of the Clitoris, Its Preputial Hood, and Labia Minora in Male-to-Female Transsexual Patients. Ann Plast Surg 2018; 81:393-397. [DOI: 10.1097/sap.0000000000001532] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Claes KE, Pattyn P, D’Arpa S, Robbens C, Monstrey SJ. Male-to-Female Gender Confirmation Surgery. Clin Plast Surg 2018; 45:351-360. [DOI: 10.1016/j.cps.2018.03.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Colebunders B, Brondeel S, D'Arpa S, Hoebeke P, Monstrey S. An Update on the Surgical Treatment for Transgender Patients. Sex Med Rev 2016; 5:103-109. [PMID: 27623991 DOI: 10.1016/j.sxmr.2016.08.001] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 04/27/2016] [Accepted: 08/05/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION As gender dysphoria is becoming increasingly accepted in the general population, the number of patients seeking gender reassignment surgery is increasing. Although not every patient with gender dysphoria requires surgery, medical practitioners taking care of these individuals should be aware of the different surgical options. AIM To review current gender reassignment surgical techniques and update the clinician. METHODS A review of the literature was performed focusing on the most recent techniques of gender reassignment surgery. MAIN OUTCOME MEASURES Main outcomes included a historical review of gender confirmation surgery leading to the techniques of choice in different divisions. For the vaginal lining, penile-scrotal skin flaps remain the technique of choice, and the gold standard for a phalloplasty remains the radial forearm flap. RESULTS Surgical techniques for male-to-female gender reassignment consist of facial feminization surgery, voice surgery, breast augmentation, orchiectomy, and vaginoplasty. Female-to-male gender reassignment surgery includes facial masculinization surgery, subcutaneous mastectomy, and phalloplasty procedures. CONCLUSION Penile-scrotal skin flaps remain the technique of choice for the vaginal lining, although indications for a vaginoplasty with intestinal transfer are becoming more common. The gold standard for a phalloplasty remains the free radial forearm flap.
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Affiliation(s)
- Britt Colebunders
- Department of Plastic Surgery, Ghent University Hospital, Gent, Belgium
| | - Sam Brondeel
- Department of Plastic Surgery, Ghent University Hospital, Gent, Belgium
| | - Salvatore D'Arpa
- Department of Plastic Surgery, Ghent University Hospital, Gent, Belgium
| | - Piet Hoebeke
- Department of Urology, Ghent University Hospital, Gent, Belgium
| | - Stan Monstrey
- Department of Plastic Surgery, Ghent University Hospital, Gent, Belgium.
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Hess J, Hess-Busch Y, Kronier J, Rübben H, Rossi Neto R. Modified Preparation of the Neurovascular Bundle in Male to Female Transgender Patients. Urol Int 2016; 96:354-9. [DOI: 10.1159/000443281] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 12/09/2015] [Indexed: 01/09/2023]
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Hess J, Neto RR, Panic L, Rübben H, Senf W. Satisfaction with male-to-female gender reassignment surgery. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:795-801. [PMID: 25487762 PMCID: PMC4261554 DOI: 10.3238/arztebl.2014.0795] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 08/25/2014] [Accepted: 08/25/2014] [Indexed: 01/28/2023]
Abstract
BACKGROUND The frequency of gender identity disorder is hard to determine; the number of gender reassignment operations and of court proceedings in accordance with the German Law on Transsexuality almost certainly do not fully reflect the underlying reality. There have been only a few studies on patient satisfaction with male-to-female gender reassignment surgery. METHODS 254 consecutive patients who had undergone male-to-female gender reassignment surgery at Essen University Hospital's Department of Urology retrospectively filled out a questionnaire about their subjective postoperative satisfaction. RESULTS 119 (46.9% ) of the patients filled out and returned the questionnaires, at a mean of 5.05 years after surgery (standard deviation 1.61 years, range 1-7 years). 90.2% said their expectations for life as a woman were fulfilled postoperatively. 85.4% saw themselves as women. 61.2% were satisfied, and 26.2% very satisfied, with their outward appearance as a woman; 37.6% were satisfied, and 34.4% very satisfied, with the functional outcome. 65.7% said they were satisfied with their life as it is now. CONCLUSION The very high rates of subjective satisfaction and the surgical outcomes indicate that gender reassignment surgery is beneficial. These findings must be interpreted with caution, however, because fewer than half of the questionnaires were returned.
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Affiliation(s)
- Jochen Hess
- Department of Urology at the University Hospital Essen
| | - Roberto Rossi Neto
- Department of Urology at the University Hospital Essen
- Clinica Urologia, General Hospital Ernesto Simoes Filho, Salvador, Brasilien
| | - Leo Panic
- Department of Urology at the University Hospital Essen
| | | | - Wolfgang Senf
- Department of Psychosomatic Medicine and Psychotherapy, University of Essen
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Plemons ED. It is as it does: genital form and function in sex reassignment surgery. THE JOURNAL OF MEDICAL HUMANITIES 2014; 35:37-55. [PMID: 24322714 DOI: 10.1007/s10912-013-9267-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Surgeons who perform sex reassignment surgeries (SRS) define their goals and evaluate their outcomes in terms of two kinds of results: aesthetic and functional. Since the neogenitals fashioned through sex reassignment surgeries do not enable reproductive function, surgeons must determine what the function of the genitals is or ought to be. A review of surgical literature demonstrates that questions of what constitute genital form and function, while putatively answered in the operating room, are not answerable in the discourses of clinical evaluation used to define them. When the genitals--the word itself derived from the Latin genitas meaning to beget--are not reproductive, the question of their function shifts away from the biological and into other registers: pleasure, intimacy, sociality. As condensed sites of meaning and meaning-making around which selves, affects, resources, anxieties and futures are organized, the genitals signify in excess of the categories of "aesthetic" and "function" that surgeons use to assess them. Not reducible to either aesthetics or function, but constitutive of them both, this excess appears in surgical texts in the form of imagined futures of social and sexual engagement and demonstrates a powerful means by which properly sexed bodies are created.
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Affiliation(s)
- Eric D Plemons
- Department of Anthropology, University of Michigan, 101 West Hall, 1085 South University, Ann Arbor, MI, 48109, USA,
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Esteva de Antonio I, Gómez-Gil E. Coordination of healthcare for transsexual persons: a multidisciplinary approach. Curr Opin Endocrinol Diabetes Obes 2013; 20:585-91. [PMID: 24468763 DOI: 10.1097/01.med.0000436182.42966.31] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To describe the experience in Spain concerning the public healthcare for transsexual persons using a multidisciplinary approach and to review the relevant literature. Treatment includes social and psychological support, cross-hormone treatment, and sex reassignment surgeries. Although the recommendations of The World Professional Association for Transgender Health are used as guidelines, the application of these standards of care varies considerably, probably because of specific clinical and country factors. RECENT FINDINGS The sex reassignment process is complex and requires not only coordination of multiple procedures, but also lifetime follow-up of transsexual individuals. Gender units must provide high-quality services, been essential the principle of accessibility to resources together with a protocolized follow-up and anticipation of secondary effects from the clinical surgical treatment. Two recent challenges are juvenile gender dysphoria and gender variants, which increasingly consult professionals. SUMMARY Transsexualism affects all adaptive physical and psychosocial aspects of a person. As diagnosis is based only on the history and personal perceptions, a broad social debate exists about the need for treatment financed by the public health systems. Some countries restrict the care to transsexuals with private medical policies. Thus, coordination of care also requires participation of the family and associations, with continuous information to the health authorities, the judiciary, and the media of each country.
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Affiliation(s)
- Isabel Esteva de Antonio
- aDepartment of Endocrinology, Andalusian Gender Team (IBIMA), Carlos Haya Hospital, Malaga bDepartment of Psychiatry, Institute Clinic of Neurosciences, Barcelona, Spain *Gender Identity and Sexual Development Disorders Spanish Group
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Surgical Reconstruction for Male-to-Female Sex Reassignment. Eur Urol 2013; 64:141-9. [DOI: 10.1016/j.eururo.2012.12.030] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 12/20/2012] [Indexed: 11/17/2022]
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Guías de práctica clínica para la valoración y tratamiento de la transexualidad. Grupo de Identidad y Diferenciación Sexual de la SEEN (GIDSEEN)*(anexo 1). ACTA ACUST UNITED AC 2012; 59:367-82. [DOI: 10.1016/j.endonu.2012.02.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Revised: 02/02/2012] [Accepted: 02/06/2012] [Indexed: 11/18/2022]
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Demanda de atención sanitaria en las unidades de identidad de género de Andalucía y Cataluña durante la década 2000 a 2009. Rev Clin Esp 2011; 211:233-9. [DOI: 10.1016/j.rce.2011.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Revised: 02/03/2011] [Accepted: 02/06/2011] [Indexed: 11/19/2022]
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Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, Gooren LJ, Meyer WJ, Spack NP, Tangpricha V, Montori VM. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2009; 94:3132-54. [PMID: 19509099 DOI: 10.1210/jc.2009-0345] [Citation(s) in RCA: 610] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim was to formulate practice guidelines for endocrine treatment of transsexual persons. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence, which was low or very low. CONSENSUS PROCESS Committees and members of The Endocrine Society, European Society of Endocrinology, European Society for Paediatric Endocrinology, Lawson Wilkins Pediatric Endocrine Society, and World Professional Association for Transgender Health commented on preliminary drafts of these guidelines. CONCLUSIONS Transsexual persons seeking to develop the physical characteristics of the desired gender require a safe, effective hormone regimen that will 1) suppress endogenous hormone secretion determined by the person's genetic/biologic sex and 2) maintain sex hormone levels within the normal range for the person's desired gender. A mental health professional (MHP) must recommend endocrine treatment and participate in ongoing care throughout the endocrine transition and decision for surgical sex reassignment. The endocrinologist must confirm the diagnostic criteria the MHP used to make these recommendations. Because a diagnosis of transsexualism in a prepubertal child cannot be made with certainty, we do not recommend endocrine treatment of prepubertal children. We recommend treating transsexual adolescents (Tanner stage 2) by suppressing puberty with GnRH analogues until age 16 years old, after which cross-sex hormones may be given. We suggest suppressing endogenous sex hormones, maintaining physiologic levels of gender-appropriate sex hormones and monitoring for known risks in adult transsexual persons.
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Affiliation(s)
- Wylie C Hembree
- The Endocrine Society, 8401 Connecticut Avenue, Suite 900, Chevy Chase, Maryland, USA
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Jarolím L, Šedý J, Schmidt M, Naňka O, Foltán R, Kawaciuk I. ORIGINAL RESEARCH—INTERSEX AND GENDER IDENTITY DISORDERS: Gender Reassignment Surgery in Male-to-Female Transsexualism: A Retrospective 3-Month Follow-up Study with Anatomical Remarks. J Sex Med 2009; 6:1635-1644. [DOI: 10.1111/j.1743-6109.2009.01245.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Sutcliffe P, Dixon S, Akehurst R, Wilkinson A, Shippam A, White S, Richards R, Caddy C. Evaluation of surgical procedures for sex reassignment: a systematic review. J Plast Reconstr Aesthet Surg 2009; 62:294-306; discussion 306-8. [DOI: 10.1016/j.bjps.2007.12.009] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2006] [Revised: 08/06/2007] [Accepted: 12/06/2007] [Indexed: 10/22/2022]
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Soli M, Brunocilla E, Bertaccini A, Palmieri F, Barbieri B, Martorana G. Male to Female Gender Reassignment: Modified Surgical Technique for Creating the Neoclitoris and Mons Veneris. J Sex Med 2008; 5:210-6. [DOI: 10.1111/j.1743-6109.2007.00632.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sohn M, Bosinski HAG. Continuing Medical Education: Gender Identity Disorders: Diagnostic and Surgical Aspects (CME). J Sex Med 2007; 4:1193-207; quiz 1208. [PMID: 17727344 DOI: 10.1111/j.1743-6109.2007.00580.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Transsexualism is defined as a strong and persistent cross-gender identification with the patient's persistent discomfort with his or her sex and a sense of inappropriateness in the gender role of that sex (Diagnostic and Statistical Manual of Mental Disorders, fourth revision, text revision [DSM-IV-TR]). The disturbance is not concurrent with a physical intersex condition and causes clinical distress or impairment in social, occupational, or other important areas of functioning. The trained mental health professional is obliged to find out if the patient fulfills the criteria of an irreversible gender transposition and if he or she will benefit from medical (hormonal and surgical) sex-reassignment treatment. If a patient has absolved 12 months of real-life experience and at least 6 months of continuous hormonal treatment, the indication for surgical sex reassignment may be given. Genital sex-reassignment in male-to-female transsexuals includes vaginoplasty, preferably by inversion of penoscrotal skin flaps, clitoroplasty, and vulvoplasty. The operation may be performed in one or two sessions. In contrast to genital reassignment in male-to-female patients, no operative standards are available in female-to-male subjects. Recently, neophallus creation from sensate free forearm flaps has emerged as the most promising approach for those patients who want to have a neophallus. Other alternatives such as metoidoioplasty or neophallus reconstruction from regional flaps exist, but are also accompanied by multiple possible complications and re-interventions. Best results are to be expected when using multidisciplinary teams of plastic surgeons, urologists, gynecologists, and experts in sexual medicine in large volume centers.
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Affiliation(s)
- Michael Sohn
- Department of Urology, Markus-Hospital, Frankfurt, Germany.
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Dabernig J, Shelley OP, Schaff J. The innervated free toe web flap for clitoris reconstruction. J Plast Reconstr Aesthet Surg 2007; 60:1352-5. [PMID: 17368123 DOI: 10.1016/j.bjps.2007.01.070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Accepted: 01/30/2007] [Indexed: 11/20/2022]
Abstract
Clitoris reconstruction is often used in transgender reassignment. Most techniques now reconstruct the clitoris using glans pedicled on the dorsal phallic neurovascular bundle. Other techniques of clitoris reconstruction re-shape retained elements of the proximal segment of the corpora cavernosa, as well as techniques mobilising local flaps. We are presenting a new technique for clitoris reconstruction using an innervated free web space flap. The operative technique and outcome are illustrated and discussed in this case report.
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Affiliation(s)
- Jörg Dabernig
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Jubilee Building, 84 Castle Street, Glasgow G4 0SF, UK.
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