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Berger LE, Lava CX, Spoer DL, Huffman SS, Martin T, Bekeny JC, Fan KL, Lisle DM, Del Corral GA. The Effect of Obesity on Vaginoplasty Outcomes. Ann Plast Surg 2024; 92:447-456. [PMID: 38319959 DOI: 10.1097/sap.0000000000003808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND Some surgeons use body mass index criteria within the patient selection processes before vaginoplasty, thereby limiting access to select obese patients. We sought to better characterize the effect of obesity on postoperative outcomes across multiple vaginoplasty techniques. METHODS A single-center retrospective review of all transfeminine patients undergoing primary vaginoplasty procedures from December 2018 to July 2022 was conducted. Patients were stratified into cohorts according to the World Health Organization Obesity Class criteria. Data regarding demographics, comorbidities, operative details, postoperative complications, and all-cause revision were collected. RESULTS A total of 237 patients met the inclusion criteria. Average follow-up duration was 9.1 ± 4.7 months. Multivariate regression revealed that patients with class I and class II/III obesity were associated with higher odds of developing vaginal stenosis (class I: odds ratio [OR], 7.1 [ P = 0.003]; class II/III: OR, 3.4 [ P = 0.018]) and all-cause revision (class I: OR, 3.7 [ P = 0.021]; class II/III: OR, 4.8 [ P = 0.027]). Undergoing either robotic peritoneal or robotic intestinal vaginoplasty was associated with lower odds of delayed wound healing (peritoneal: OR, 0.2 [ P < 0.001]; intestinal: OR, 0.2 [ P = 0.011]). Lastly, adherence to dilation regimen was negatively associated with development of vaginal stenosis (OR, 0.04; P < 0.001). CONCLUSIONS Patients with obesity may be at a higher risk of developing vaginal stenosis after vaginoplasty, which may ultimately necessitate operative revision. Although patients with obesity may remain surgical candidates, proper preoperative counseling and adherence to postoperative vaginal dilation regimens are critical to optimizing outcomes.
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Affiliation(s)
| | | | | | | | - Taylor Martin
- Georgetown University School of Medicine, Washington, DC
| | - Jenna C Bekeny
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Kenneth L Fan
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - David M Lisle
- Division of Colorectal Surgery, Department of General Surgery, MedStar Franklin Square Medical Center, Baltimore, MD
| | - Gabriel A Del Corral
- Department of Plastic and Reconstructive Surgery, MedStar Washington Hospital Center, Washington, DC
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Sanchez Figueroa N, Zheng E, Kuruoglu D, Martinez-Jorge J. The use of Integra Dermal Regeneration Template in the surgical management of revision penile inversion vaginoplasty: A case series. J Plast Reconstr Aesthet Surg 2023; 87:91-97. [PMID: 37826968 DOI: 10.1016/j.bjps.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/04/2023] [Accepted: 08/12/2023] [Indexed: 10/14/2023]
Abstract
Since its initial design and use for the temporary coverage of severe full-thickness burn defects, Integra® (Integra LifeSciences) Dermal Regeneration Template has been increasingly used all over the body, yielding successful results in coverage of wound beds with insufficient vascularity and suboptimal conditions for proper healing. In this study, we report an institutional case series and outcomes of gender-affirming vaginoplasty revision for vaginal lengthening or reopening of the canal via placement of Integra® to assist in optimizing the wound bed for subsequent skin grafting when wound conditions were deemed to be suboptimal. A retrospective chart review was conducted in patients who underwent this technique by a single surgeon (JM) at the authors' institution. Demographics, vaginal depth, and complications were recorded and compared. Our patient population thus far includes 178 primary vaginoplasties, of which 9 of those needing revision were treated with this approach. The age at revision mean was 47 ± 13.5 years, and the body mass index mean was 31 ± 4.1. All patients had comorbidities and five were former smokers. Eight patients had prior revision conducted without Integra®, with a mean of 1.89 ± 1.76 and the time to first revision mean was 15.89 ± 14.2 months. No long-term complications after Integra® reported and most of the patients did not require further revision. The follow-up mean was 8.48 ± 8.66 months. A mean of 6.77 ± 5.35 cm was gained after the Integra® revision (4.92 ± 4.1 cm before versus 12.54 ± 3.07 cm after). The final depth after Integra® + full-thickness skin graft mean was 13.34 ± 4.65 cm. Overall, the depth gain mean was 7.48 ± 5.77 cm; in total, seven patients gained depth after revision with an average of 78% skin graft take. Overall, Integra® presents an alternative option for revision vaginoplasty with complicated wound beds potentially aiding in the healing process before grafting.
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Affiliation(s)
| | - Eugene Zheng
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Doga Kuruoglu
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jorys Martinez-Jorge
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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3
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Maisner RS, Keenan E, Mansukhani PA, Berlin R, Weisberger JS, Mulloy CD, Lee ES. A multimetric health literacy analysis of online gender affirmation surgery materials: From facial to genital surgery. J Plast Reconstr Aesthet Surg 2023; 87:449-460. [PMID: 37944456 DOI: 10.1016/j.bjps.2023.10.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 09/20/2023] [Accepted: 10/07/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The transgender patient population is expanding, and gender affirming surgery (GAS) volume is increasing. Accurate, comprehensive, and easily navigable resources on GAS are lacking. We aim to evaluate the readability of online materials for specific gender affirming surgical procedures to identify mechanisms of improving information access for transgender patients. MATERIALS AND METHODS "Facial feminization", "facial masculinization", "MTF breast augmentation", "FTM chest masculinization", "MTF vaginoplasty", "metoidioplasty", and "FTM phalloplasty" were searched on Google. Per keyword, the first 75 text-containing results were included. Text was analyzed for reading difficulty using the Flesch-Kincaid Reading-Ease (FKRE) test and grade level using the Flesch-Kincaid Grade Level (FKGL) formula, Gunning Fog Index (GFI), Simple Measure of Gobbledygook (SMOG), and Coleman-Liau Index (CLI). Scores were compared using independent t-and ANOVA tests (α = 0.05). RESULTS Mean readability scores (FKRE 37.44) and grade-levels (FKGL 12.87, GFI 15.61, SMOG 11.91, CLI 15.00) correlated with college-level difficulty. Masculinizing surgical materials were more difficult to read than feminizing ones (p ≤ 0.023). Top surgery materials were easier to read than facial and genital surgery materials (p ≤ 0.013). Specifically, chest masculinization resources were more difficult to read than those for breast augmentation (p ≤ 0.006). No differences were found between facial feminization and masculinization surgery resources, nor between resources for different gender affirming genital surgeries. CONCLUSION Online GAS materials are written above the recommended 6th grade reading-level, with resources for transgender men being significantly more challenging to understand. Improving readability of online resources can help overcome barriers to care for the transgender patient population.
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Affiliation(s)
- Rose S Maisner
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, USA.
| | - Emily Keenan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Newark, NJ 07103, USA
| | - Priya A Mansukhani
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Newark, NJ 07103, USA
| | - Ryan Berlin
- Department of Surgery, New York-Presbyterian Queens, 56-45 Main Street, Flushing, NY 11355, USA
| | - Joseph S Weisberger
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Newark, NJ 07103, USA
| | - Clairissa D Mulloy
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Newark, NJ 07103, USA
| | - Edward S Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Newark, NJ 07103, USA
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Madec FX, Sabbagh P, Schirmann A, Morel-Journel N, Neuville P. [Genital gender affirming surgery in trans women: Vulvo-vaginoplasty review]. ANN CHIR PLAST ESTH 2023; 68:468-476. [PMID: 37648588 DOI: 10.1016/j.anplas.2023.08.002] [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: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION A trans woman is a woman who was assigned male at birth, and who has a female gender identity. The majority are requesting a gender affirming genital surgery by vulvo-vaginoplasty. The objective is to review this surgery based on its history, then by presenting the different surgical techniques and their success and complication rates. MATERIAL AND METHODS A narrative review was performed, based on a bibliography search with keywords from 2000 to 2022 on Pubmed. RESULTS Vulvo-vaginoplasty for trans women began in 1931, and the first case series date from 1969. The procedure includes excision of scrotal skin, orchiectomy, clitoroplasty, urethroplasty, labioplasty, recto-vesico-prostatic dissection and creation of a vaginal cavity (performed by penile skin inversion and graft, intestine, or peritoneum). Vulvo-vaginoplasty by penile skin inversion (VPPI) is today the reference surgical technique. It represents the vast majority of surgeries performed with the longest follow-up. The majority of trans women are satisfied with the procedure aesthetically (90%) and functionally (80%), with an active sexuality. Major complications are rare (< 5%), they correspond to fistulas or vaginal stenosis. CONCLUSION VPPI is the gold standard technique with satisfactory overall results, but long-term follow-up is requested.
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Affiliation(s)
- F-X Madec
- Service d'urologie, hôpital Foch, Suresnes, France.
| | - P Sabbagh
- Service d'urologie, hôpital Foch, Suresnes, France
| | - A Schirmann
- Service d'urologie, hôpital Foch, Suresnes, France
| | | | - P Neuville
- Service d'urologie, CHU de Lyon Sud, Pierre-Bénite, France
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Principles and outcomes of gender-affirming vaginoplasty. Nat Rev Urol 2023; 20:308-322. [PMID: 36726039 DOI: 10.1038/s41585-022-00705-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 02/03/2023]
Abstract
Vaginoplasty is the most frequently performed gender-affirming genital surgery for gender-diverse people with genital gender incongruence. The procedure is performed to create an aesthetic and functional vulva and vaginal canal that enables receptive intercourse, erogenous clitoral sensation and a downward-directed urine stream. Penile inversion vaginoplasty (PIV) is a single surgical procedure involving anatomical component rearrangement of the penis and scrotum that enables many patients to meet these anatomical goals. Other options include minimal-depth, peritoneal and intestinal vaginoplasty. Patient quality of life has been shown to improve drastically after vaginoplasty, but complication rates have been documented to be as high as 70%. Fortunately, most complications do not alter long-term postoperative clinical outcomes and can be managed without surgical intervention in the acute perioperative phase. However, major complications, such as rectal injury, rectovaginal fistula, and urethral or introital stenosis can substantially affect the patient experience. Innovations in surgical approaches and techniques have demonstrated promising early results for reducing complications and augmenting vaginal depth, but long-term data are scarce.
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Huang JB, Lai A, Morgantini LA, Smith JB, Millman AL, Cedeno JD, Crivellaro S, Acar O, Kocjancic E. Gender‐affirming vaginoplasty: Technical considerations in patients with genital skin deficiency. Neurourol Urodyn 2022. [DOI: 10.1002/nau.25091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 10/22/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Jason B. Huang
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
| | - Andrew Lai
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
| | - Luca A. Morgantini
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
| | - John B. Smith
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
| | - Alexandra L. Millman
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
- Department of Surgery Women's College Hospital Toronto Ontario Canada
| | - Juan D. Cedeno
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
| | - Simone Crivellaro
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
| | - Omer Acar
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
| | - Ervin Kocjancic
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
- Department of Surgery The University of Chicago Medicine Chicago Illinois USA
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Smith SM, Yuan N, Stelmar J, Zaliznyak M, Lee G, Bresee C, Garcia MM. Penile and Scrotal Skin Measurements to Predict Final Vaginal Depth With Penile Inversion Vaginoplasty. Sex Med 2022; 10:100569. [PMID: 36152492 PMCID: PMC9780772 DOI: 10.1016/j.esxm.2022.100569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/13/2022] [Accepted: 08/18/2022] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION No nomogram exists to predict maximum achievable neovaginal depth before penile inversion vaginoplasty (PIV) based on available penile & scrotal skin (SS). Maximal depth is important to patients and is determined by available skin and available anatomic space within the pelvis and varies with surgical technique. AIM We endeavored to create a nomogram to predict expected postoperative vaginal depth. METHODS Retrospective review of all patients undergoing primary PIV at a single institution from June 2017 to February 2020 (n = 60). Pre-op: Dorsal penile and midline scrotal skin length were measured. Intra-op: Tubularized scrotal skin length measured on a dilator. Immediate post-op: Final vaginal depth measured with a dilator. OUTCOMES The amount of available penile and scrotal skin was not associated with vaginal depth. The only variable that did significantly increase depth was the use of penile + scrotal skin, as compared to penile skin alone. (P < .001) RESULTS: In patients who underwent PIV-SS, the final vaginal depth (13.3 ± 1.9 cm) was 87% of pre-op measured penile skin length (15.3 ±- 3.0 cm). In patients who underwent PIV+SS, pre-op penile skin length was 11.1 ± 4.7±cm and pre-op midline scrotal length was 22.8 ± 2.6 cm. with a final post-op vaginal canal depth of 15.2 ± 1.3 cm. In 45/46 (98%) surgeries utilizing SS grafts, SS tube length exceeded the length necessary to achieve maximal vaginal depth, and required trimming and discard. Given that in most cases there was an excess of SS, final post-op depth equaled the maximal vaginal depth that could be surgically dissected, and was not limited by the amount of available skin. CLINICAL IMPLICATIONS Our findings suggest that for most patients it should not be necessary to include additional tissue sources (eg, peritoneum) to create a vaginal canal during primary vaginoplasty. STRENGTHS AND LIMITATIONS Any penile skin that was discarded due to poor quality (eg, tight phimosis, poor viability) was not measured and accounted for. This likely resulted in a slight overestimation of the contribution of the penile skin to the final vaginal depth, but did not change the overall finding that final depth was not limited by available skin. CONCLUSION SS grafts, when harvested and tubularized using optimized technique, supplied an excess of skin necessary to line a vaginal canal space of maximal achievable depth. We found that additional tissue sources can, instead, be reserved for future salvage surgery if it becomes necessary to augment depth. Smith SM, Yuan N, Stelmar J, et al. Penile and Scrotal Skin Measurements to Predict Final Vaginal Depth With Penile Inversion Vaginoplasty. Sex Med 2022;10:100569.
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Affiliation(s)
- Shannon M. Smith
- Cedars-Sinai Medical Center, Los Angeles, Division of Urology; Los Angeles, CA, USA,Cedars-Sinai Transgender Surgery and Health Program; Los Angeles, CA, USA
| | - Nance Yuan
- Huntington Plastic Surgery Institute; Pasadena, CA, USA
| | - Jenna Stelmar
- Cedars-Sinai Transgender Surgery and Health Program; Los Angeles, CA, USA
| | | | - Grace Lee
- Cedars-Sinai Transgender Surgery and Health Program; Los Angeles, CA, USA
| | - Catherine Bresee
- Biostatistics and Bioinformatics Core, Cedars-Sinai Samuel Oschin Comprehensive Cancer Center Biostatistics Core; Los Angeles, CA, USA
| | - Maurice M. Garcia
- Cedars-Sinai Medical Center, Los Angeles, Division of Urology; Los Angeles, CA, USA,Cedars-Sinai Transgender Surgery and Health Program; Los Angeles, CA, USA,University of California San Francisco; Department of Urology and Department of Anatomy; San Francisco, CA, USA,Corresponding Author: Maurice M. Garcia, MD, MAS, Cedars-Sinai Medical Center, Los Angeles, Division of Urology, 8635 W. Third Street, Suite 1070W, Los Angeles, CA 90048, USA. Tel: +1 310-423-4700
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Abstract
Genital gender affirming surgery is an effective treatment for gender dysphoria in transgender individuals. Optimization of medical and mental health conditions, including coordination with a patient's entire care team, is essential. Feminizing procedures include vaginoplasty (creation of female genitalia with a vaginal canal) and vulvoplasty (creation of female genitalia with a short or absent vaginal canal). Masculinizing procedures include metoidioplasty (construction of male genitals via local tissue rearrangement) and phalloplasty (creation of a phallus from extra-genital tissue). We aim to provide an overview of genital gender affirming surgery for providers who are interested in learning more about genital gender affirming surgery.
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Affiliation(s)
- Virginia Y Li
- Department of Urology, 82579Kaiser Permanente Los Angeles, Los Angeles, CA, USA
| | - Alysen Demzik
- Department of Urology, 2331UNC School of Medicine, Chapel Hill, NC, USA
| | - Liem Snyder
- Department of Urology, 2331UNC School of Medicine, Chapel Hill, NC, USA
| | - Adeyemi A Ogunleye
- Department of Surgery, Division of Plastic Surgery, 2331UNC School of Medicine, Chapel Hill, NC, USA
| | - Annmarie Wang
- Department of Urology, 2331UNC School of Medicine, Chapel Hill, NC, USA
| | - Bradley D Figler
- Department of Urology, 2331UNC School of Medicine, Chapel Hill, NC, USA
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A Systematic Approach to Incision Planning and Graft Excision in Gender-affirming Vaginoplasty. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4103. [PMID: 35186642 PMCID: PMC8846344 DOI: 10.1097/gox.0000000000004103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/03/2021] [Indexed: 11/25/2022]
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