Joannes J. A. M. Bloem

Chest wall contouring for female-to-male transsexuals: Amsterdam experience.

Female transsexuals accepted for surgical reassignment usually choose breast removal to achieve a male chest configuration as their first operation, thus facilitating the adjustment to a male lifestyle. At the Academic Hospital of the Free University (Amsterdam, The Netherlands), usually one of three techniques is applied for a subcutaneous mastectomy. We describe and discuss our experience with 70 patients operated on before April 1993. For breasts with minimal to moderate skin redundancy, a concentric periareolar de-epithelialization technique, in combination with a subcutaneous mastectomy by a transareolar approach, is used. For larger breasts, or in cases of severe ptosis resulting from the use of breast-camouflaging devices, this method is extended by skin excision laterally and medially to the nipple-areolar complex. Sometimes, it is believed to be necessary to use a free transplantation of the nipple-areolar complex graft in combination with fusiform skin excisions, resulting in a scar passing under the grafted areola. In case of doubt, the simplest technique should be applied. Secondary corrections are often needed.

Construction of the fixed part of the neourethra in female-to-male transsexuals: experience in 53 patients.

Genital construction in female-to-male transsexuals should ideally involve the creation of a competent neourethra, allowing the patients to void while standing. A short review of the literature on this subject is given. In our hospital, construction of the fixed part of the urethra up to the level of the clitoris has been accomplished using an anterior vaginal flap as described by Thompson and by Bouman in 46 subjects. Initially, serious complications such as vesicovaginal and urethrovaginal fistulas and urinary incontinence were encountered in this series. Subsequently, in experienced hands, this seems to be a technique with few risks. Formation of a urethrocutaneous fistula at the level of the female external urethral orifice can be successfully prevented using this flap. The problem of neourethral urine residue has still to be solved.

Variations of the ulnar nerve and ulnar artery in Guyon's Canal: A cadaveric study

In 23 cadaveric hands the hypothenar region was studied and this report is about the anatomical boundaries and contents of Guyons Canal. It was noted that the contents of Guyons canal exit through two distinct areas termed the deep distal hiatus and superficial distal hiatus. A variation in the course of the deep branch of the ulnar artery, reported to be infrequent, was found to be present in 74% of the specimens. We concluded that the ulnar artery exists distal to the space described by Guyon. When a release of the ulnar nerve is undertaken, surgery should not only open the roof of Guyons space but also the fibrous arcade of the deep distal hiatus.

Obtaining rigidity in the neophallus of female-to-male transsexuals: a review of the literature.

In phalloplasty, the use of transplants and implants to obtain sufficient rigidity allowing for sexual penetration is difficult and often has resulted in complications and failure. Resorption, curving, and fracture of autologous cartilage and bone transplants are reported, and rigid implants have a tendency to erode and extrude. Besides, a constantly rigid phallus may serve as a source of embarrassment to the patient. On the other hand, hydraulic prostheses frequently show mechanical failure compared with nonhydraulic implants. For these reasons, some authorities have their patients use external devices for erection. Others fully rely on edema, scar fibrosis, or congestion to give sufficient rigidity. In this review, the literature on baculum implantation—on the use of external devices as well as on the use of no stiffener at all—is discussed.

Neurofibromatosis in plastic surgery

THE protean manifestations of neurofibromatosis are well documented. Single or multiple, the lesions may involve almost any tissue of the body. Slowly growing, unless sarcomatous change occurs, neurofibromatosis can produce internal symptoms from pressure on vital structures or stenosis of visceral tubes and ducts. Subcutaneous lesions may produce hideous cosmetic deformities. The histological appearances are also well documented but certain features are of special interest to plastic surgeons faced with manifestations of the disease:

The Anatomic Basis of the Anterior Vaginal Flap Used for Neourethra Construction in Female-to-male Transsexuals

For lengthening of the urethra in female-to-male transsexuals, an anterior vaginal wall flap is used. This flap is separated from the posterior urethral wall down to the attachment at the urethral meatus following a glistening cleavage plane. In this paper we present the anatomic and histologic basis of this flap. Prior to this, the relevant vaginal anatomy will be discussed. The anterior vaginal wall and posterior urethral wall are not indissectible structures; this is true even in the caudal two-thirds of the urethra. A long and narrow flap can be raised, thanks to the abundant vascular supply of the vaginal wall and the musculomucosal quality of the flap. A previously performed anatomic and histologic survey of the anterior vaginal wall has shown that the glistening cleavage plane is not composed solely of fascia, but rather consists of longitudinal strands of muscle, fibrous tissue, and elastin.

Constructing a Scrotum in Female-to-male Transsexuals

Genital construction in female-to-male transsexuals also should involve giving the labial region a scrotum-like appearance. A review of the literature on this subject is given. In our hospital, the construction of a scrotum in which testicular prostheses are implanted has been performed usually in combination with lengthening of the pars fixa of the urethra. A bifid scrotum is constructed using a V-Y advancement of the labial skin. Although implant expulsion (in 7 percent) and dislocation of implants (in 11 percent) were encountered in this series of 50 patients, the technique itself is easy to perform and seems to have few major drawbacks. The scars are small and hidden in the scrotal folds and hair. Tissue expansion prior to implantation of the testicular prostheses in the labial skin has proven to be unnecessary with this technique.

Paraffinoma of the face: A diagnostic and therapeutic problem

Abstract The injection of liquid paraffin to improve bodily disharmonies, which is still practiced in some parts of the world, is likely to result in severe chronic inflammatory reactions, followed by ulceration of the skin. The only effective treatment seems to be surgical removal of all affected tissue.

The treatment of muscle hernias by fascial splitting

Abstract Three cases of muscle hernia traumatic in origin were treated by blind fasciotomy, under local anaesthesia, through very small incisions. Movements were not restricted. The Physical and cosmetic complaints were relieved. More extensive reparitive procedures are not justified because they inflict other deformities and carry greater risks. Eight cases in all have now been treated by this technique and all successfully.

Preconstruction of the pars pendulans urethrae for phalloplasty in female-to-male transsexuals.

One of the goals of phallic construction in female-to-male transsexuals should be the creation of a competent neourethra that allows patients to void while standing. Apart from constructing the perineal fixed part of the neourethra, it is therefore necessary to create a phallus with a pendulant part of the neourethra to be connected to the pars fixa urethrae. In patients in whom we apply microsurgical free-flap techniques for phalloplasty, the pars pendulans is usually created the Chinese way (n = 8). If, on the other hand, pedicled abdominal or inguinal skin flaps are used, a skin-lined urethral tube to be incorporated in the phallus should already be extant in the donor area of the flap (n = 25). In the 20-year period 1971-1991, such a preconstruction of the pars pendulans urethrae has been attempted in 25 female-to-male transsexuals employing Snyders technique. This has been successful in all and uneventful in 17 patients. If malelike micturition while standing is the goal and the use of microsurgical free-flap techniques is not indicated, this procedure seems to be the method of choice.