Summary:
Gender dysphoria, the incongruence between anatomical sex and gender identity, is estimated to affect 1 percent of the population. Creation of a feminine vulva with labia minora remains a technical challenge for surgeons, especially in circumcised patients. The authors present the technique developed by the senior author (S.M.) that uses prepuce skin in uncircumcised patients or distal shaft skin in circumcised patients for creation of both clitoral hood and labia minora. A retrospective case review was conducted of all penile inversion vaginoplasties performed by the senior author between 2014 and 2016. Patient characteristics, history of circumcision, and revision surgery were recorded. Surgical technique to create and inset the neoclitoris and labia minora in a single-stage penile inversion vaginoplasty is described in detail. A total of 161 penile inversion vaginoplasty operations were performed. Creation of labia minora and clitoral hood was achieved in all patients, with 4.3 percent undergoing an early intervention for bleeding or dehiscence and 5.6 percent requiring late revision surgery for diverted urinary stream. Average length of follow-up was 29 months. Age, hormonal therapy time, body mass index, smoking, and diabetes were the investigated risk factors for postoperative complications, but no significant correlations were found. All patients met the standards of care set forth by the World Professional Association for Transgender Health. Creation of the clitoral hood and labia minora during penile inversion vaginoplasty is achievable in both circumcised and uncircumcised patients, with good aesthetic results and a low revision surgery rate.
CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
Introduction
The free radial forearm (FRFA) flap is universally still considered as the gold standard technique in penile reconstruction. Typically, a considerably large flap is required, often involving almost the entire circumference of the forearm. Partial necrosis may occur at the distal-most (dorsoradial) part of the flap as a result of insufficient perfusion.
Aim
To describe a new technique using the posterior interosseous artery (PIOA) to supercharge FRFA phalloplasty.
Methods
In a 12-month period, all patients having FRFA flap phalloplasty were enrolled. Perioperative, after complete flap dissection, an indocyanine green perfusion scan was performed. In case of insufficient perfusion at the distalmost part of the flap, a supramicrosurgical anastomosis was performed between the FRFA pedicle and the PIOA (artery only).
Main Outcome Measures
Studied outcomes included the rate of marginal necrosis, surgical time, postoperative posterior interosseous nerve damage and urethral complications (fistula, stenosis or necrosis).
Results
A total of 27 FRFA flap phalloplasties was performed. Anastomosis of the PIOA was needed in 15 cases. No marginal necrosis was observed in these cases. There were no cases of postoperative posterior interosseous nerve damage. There were no significant differences in urethral complications (fistula, stenosis or necrosis) between the 2 groups.
Clinical Implications
In selected cases where insufficient perfusion of the dorsoradial part of the flap is present, patients may benefit from arterial supercharging to prevent postoperative marginal necrosis.
Strength & Limitations
Strengths include a single surgeon, thus lending continuity of skill and technique, a consecutive series, and 100% short-term follow-up. Limitations include single institution series and a limited number of patients.
Conclusion
Arterial supercharging is effective in improving perfusion of large FRFA flaps used in phalloplasty when dorsoradial hypoperfusion is detected on an indocyanine green perfusion scan. It is a technically challenging addition to the standard technique because of the small size of the vessels, the close relationship between the PIOA and the posterior interosseous nerve, and the vulnerability of the newly constructed intra-flap anastomosis.
This study concludes a rather constant position of the dominant perforator. Therefore, preoperative-computed tomographic angiography is not always essential to find this perforator and Doppler ultrasound could be considered as an alternative, thereby carefully assessing all advantages and disadvantages inherent to either of these imaging methods.
Background
The coronaplasty is an important step of the phalloplasty procedure as it creates a prominent coronal ridge and a constricted coronal sulcus, resulting in the transformation of a regular skin flap into a flap resembling a circumcised penis.
Aim
The aim of this article is to describe our new coronaplasty technique that exploits opposing contracting forces of 2 different skin grafts to hold the shape of a thick, distally based skin flap, resulting in a natural looking neo-phallus.
Methods
A distally based flap is raised at the junction of the middle and distal thirds of the neo-phallus. The dissection continues until adequate mobilization is obtained, so the flap can stand almost perpendicular to the axis of the shaft. 2 separate full-thickness skin grafts are harvested and placed: the first at the raw undersurface of the flap, the second at the flap's donor site. To make the sulcus deeper and to define the ridge, the lower part of the graft placed on the undersurface of the distal flap is sutured with tacking sutures. Depending on the type of flap used this procedure can be done during the phalloplasty procedure itself (axial flaps) or at least 1 week later (perforator flaps).
Outcomes
The new technique that we developed shows a more distinct coronal sulcus and coronal ridge, long-lasting results, and a more aesthetically pleasing and natural-appearing glans penis.
Results
The harvested distal flap is progressively thicker and not folded, resulting in a more naturally looking ridge. The donor site is deeper than other techniques, creating a well-defined sulcus. By using 2 skin grafts the opposing force vectors increase the projection of the ridge and the deepness of the sulcus.
Clinical Translation
This technique results in a more prominent glans penis and is an important step in creating an almost naturally looking neo-phallus.
Conclusions
This procedure can be applied to all different kind of flaps used for phalloplasty, both in an immediate or delayed fashion. As grafts are used, partial or complete graft lost can appear. Furthermore, attention must be paid not to incise the distal flap too deep so vascularity to the distal part of the flap will not be impaired. A continuous search to optimize the aesthetic outcome of the phalloplasty procedure is necessary and with this new coronaplasty technique we hope to raise attention and take another step toward creating “the real thing.”
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