Novel surgical techniques in female to male gender confirming surgery

Abstract

The current management of female to male (FTM) gender confirmation surgery is based on the advances in neo phalloplasty, perioperative care and the knowledge of the female genital anatomy, as well as the changes that occur to this anatomy with preoperative hormonal changes in transgender population. Reconstruction of the neophallus is one of the most difficult elements in surgical treatment of female transsexuals. While there is a variety of available surgical techniques, their results are not equally acceptable to all patients. The preference for a particular surgical technique mostly depends on the patient’s desires and expectations. Nevertheless, the surgeon’s duty is to fully inform the patient about all the advantages and disadvantages, as well as all complications that might occur after surgical procedure—and even to talk them out of a desired surgical technique if there are contraindications. Metoidioplasty is a technically demanding surgical procedure used in FTM transsexuals who desire a gender reassignment surgery (GRS) without undergoing a complex, multi-staged surgical creation of an adult-sized phallus. Metoidioplasty is viable in cases where the clitoris seems large enough after androgen hormonal treatment. Since the clitoris plays the main role in female sexual satisfaction, its impact on the outcome of FTM transgender surgery is predictable. Various free flaps have been reported for total phalloplasty, such as radial forearm flap, latissimus dorsi flap, anterolateral tight flap, different abdominal wall flaps, free deltoid flap, scapular free flap, sensate osteocutaneous free fibula flap, tensor fasciae latae, deep epigastric artery perforator flap and dorsalis pedis flap. The fact that there are so many techniques for penile reconstruction in cases of penis absence, proves that none of the above mentioned techniques succeeded in achieving the ideal goals of penis reconstruction. We will emphasize the most commonly used surgical techniques in genital confirmation in FTM transsexuals with reference to respective eligibility criteria for each procedure.

Phalloplasty: understanding the chaos

“…At present, the most commonly employed flap for phallic construction in transmasculine patients is the RFFF, first reported by Chang and Hwang [28] in 1984 [ Figure 2]. Advantages of the RFFF are: (1) extremely reliable vascular and peripheral neural anatomy [39] ; (2) the forearm is thin and pliable in most individuals, allowing for simultaneous creation of the pars pendulans urethra via the "tube-in-a-tube" technique [28,40] ; and (3) the RFFF having the highest innervation density of all the available flaps, providing the best potential for cutaneous reinnervation, and the ulnar, volar surface of the forearm being hair-free in many individuals, lessening or sometimes even obviating the need for hair removal prior to phalloplasty. In addition, the RFFF donor site results in no significant functional disturbance of the arm and hand for the large majority of patients [41] .…”

Conventional surgical techniques and emerging transplantation in complex penile reconstruction

“…As described by Perovic, reconstruction with LDMF takes place in several stages including flap harvest and creation of the neophallus, two stages of urethroplasty using a buccal mucosa inlay, and finally the insertion of a penile prosthesis. Muscle sparing thoracodorsal artery perforator flaps have also been described in phalloplasty [41] , as well as other perforator flaps based on the subscapular vessel system including the scapular and parascapular flaps [3,42,43] .…”

Metoidioplasty as a one-stage phallic reconstruction in transmen

“…The latest modification of the original technique involves simultaneous removal of internal female organs, vaginectomy (colpocleisis), complete clitoral lengthening and straightening with the urethroplasty to the tip of the glans, and scrotoplasty with bilateral testicular implants insertion as a one-stage procedure. The current technique relies on the embryological and anatomical homology between the clitoris and penis, confirming the clitoris as a smaller version of the penis with impaired urethral development [2,14] [ Figure 1]. The procedure involves laparoscopically-assisted hysterectomy with bilateral salpingo-oophorectomy, if not performed prior to metoidioplasty, and complete vaginal mucosa removal by colpocleisis, with male-like perineoplasty, except for one small portion close to the native urethral meatus.…”

“…Minor complications are usually managed conservatively (hematoma, skin infection, urinary tract infection, partial skin necrosis, and dribbling and spraying during voiding). Major complications are usually related to urethroplasty and include either urethral fistulae or stricture, problems with testicular implants (displacement and rejection), and persistent vaginal cavity; these require surgical repair [2,5,26,33,34] . In our latest study, we reported overall complications in 46.8% of our 793 patients.…”

“…Genital reconstructive surgeries, known as "bottom surgeries", are performed according to Standards of Care (SOC) of the World Professional Association for Transgender Health (WPATH): they require two letters of recommendation by two board certified mental health professionals and must come after at least 12 months of substitution hormonal therapy [1] . Preoperative consultation with the selected surgeon performing gender affirmation surgery (GAS) is welcome in order to reconcile the patients' expectations of surgery outcomes and the possibilities of modern medicine, to prevent any postoperative disappointmen [2] . Even though under testosterone therapy transmen's body encounters a lot of changes, some individuals still require facial and body masculinization procedures or frontline hair procedures.…”