Marlon E. Buncamper

Aesthetic and Functional Outcomes of Neovaginoplasty Using Penile Skin in Male-to-Female Transsexuals

INTRODUCTIONnIn the treatment of transgender women, the surgical construction of a neo-vagina, or vaginoplasty, is the final stage in the transition to the desired gender. Surgeons aim to create a neovagina that is in function and appearance as close to a biological vagina as possible. However, to date, it is insufficiently clear whether transgender women are satisfied with the functional and cosmetic outcomes of vaginoplasty.nnnAIMSnOur aim was to assess if penile skin inversion neovaginoplasty performed in transgender women meet the objectives strived for, by determining functional and aesthetic outcomes, as well as the physical and sexual well-being and satisfaction.nnnMETHODSnWe performed a retrospective survey study on 49 transgender women who underwent vaginoplasty using the penile skin inversion technique. Participants were asked to fill out the Female Sexual Function Index (FSFI), a combination of the Amsterdam Hyperactive Pelvic Floor Scale--Women (AHPFS-W) and the Female Genital Self-Imaging Scale, and a short questionnaire for self-evaluation of vaginoplasty. Photographs of the genitalia were taken for objective assessment by an independent panel.nnnMAIN OUTCOME MEASURESnPrimary outcomes were the functional and aesthetic evaluation as perceived by the trangender women themselves. Secondary outcomes were the aesthetic evaluation of the vaginoplasty by an independent panel.nnnRESULTSnFunctionality and appearance were both given an average score of 8 out of 10. Despite this high score, 56% is sexually dysfunctional according to the FSFI, mainly because of not being sexually active, or due to problems with lubrication and discomfort. In 75%, the result met the expectation and 70% thinks their genital is feminine enough.nnnCONCLUSIONnThis study demonstrates that, despite relatively low FSFI scores, this group of transgender women is very satisfied with both the functional and aesthetic results of neovaginoplasty using penile skin inversion.

Subcutaneous mastectomy in female-to-male transsexuals: a retrospective cohort-analysis of 202 patients.

INTRODUCTIONnSubcutaneous mastectomy is the first surgical procedure to be completed by female to male transsexuals after appropriate mental health and endocrine therapy. Objectives of subcutaneous mastectomy in this group are to masculinize the chest by the removal of breast tissue and skin excess, reduction and proper positioning of the nipple-areola complex, obliteration of the infra-mammary fold, and ideally with a minimal of chest wall scars. In this study, the largest series of subcutaneous mastectomies in female-to-male transsexuals to date is presented.nnnAIMSnOur aim was to determine relations between surgical technique, risk factors, complications, reoperations and secondary corrections in female-to-male transsexuals.nnnMETHODSnWe performed a retrospective survey study on 404 mastectomies in 202 female-to-male transsexuals during the period of 2000-2011.nnnMAIN OUTCOME MEASURESnPrimary outcomes for this study were complication rate, acute reoperations, secondary corrections, surgical time, and length of hospital stay in relation to the surgical technique used.nnnRESULTSnThe average age of these patients at time of the intervention was 31 years (±10) with an average BMI of 25 kg/m(2) (±4). The chosen technique depended strongly on breast volume, which, in turn, was strongly related to BMI and age. The number of acute reoperations and secondary corrections depended on the surgical technique. The total rate of acute complications was 5.0%. This percentage was highest in surgeries without skin resection (10.5%). To improve overall aesthetic results, the following secondary corrections were performed: nipple and/or areola corrections (8.9%), scar revisions (12.6%), and chest contouring (17.8%).nnnCONCLUSIONnThis study shows a correlation between the surgical technique, complication rate, and length of hospital stay. In general, the larger the breast, the larger the scars that remain after the operation. On the other hand, the smaller the scars resulting from the operation, the higher the risk of hematoma.

Patient-Reported Esthetic and Functional Outcomes of Primary Total Laparoscopic Intestinal Vaginoplasty in Transgender Women With Penoscrotal Hypoplasia

INTRODUCTIONnPuberty-suppressing hormonal treatment may result in penoscrotal hypoplasia in transgender women, making standard penile inversion vaginoplasty not feasible. For these patients, intestinal vaginoplasty is a surgical alternative, but knowledge on patient-reported postoperative outcomes and quality of life is lacking.nnnAIMSnTo assess patient-reported functional and esthetic outcomes, quality of life, satisfaction, and sexual well-being after primary total laparoscopic intestinal vaginoplasty in transgender women.nnnMETHODSnA survey study was performed on transgender women who underwent primary total laparoscopic intestinal vaginoplasty with at least 1 year of clinical follow-up. Thirty-one transgender women completed the questionnaires (median age at time of surgeryxa0= 19.1 years, rangexa0= 18.3-45.0) after a median clinical follow-up of 2.2 years (rangexa0= 0.8-7.5). Consenting women were asked to complete a combined questionnaire of the Subjective Happiness Scale, the Satisfaction With Life Scale, Cantrils Ladder of Life Scale, the Female Sexualxa0Function Index, the Female Genital Self-Imaging Scale, the Amsterdam Hyperactive Pelvic Floor Scale-Women, and a questionnaire addressing postoperative satisfaction.nnnMAIN OUTCOME MEASURESnPatient-reported functional and esthetic outcomes and postoperative quality of life.nnnRESULTSnPatients graded their life satisfaction a median of 8.0 (rangexa0= 4.0-10.0) on Cantrils Ladder of Life Scale. Patients scored a mean total score of 27.7 ± 5.8 on the Satisfaction With Life Scale, which indicated high satisfaction with life, and a mean total score of 5.6 ± 1.4 on the Subjective Happiness Scale. Functionality was graded a median score of 8.0 of 10 (rangexa0= 1.0-10.0) and esthetics a score of 8.0 out of 10 (rangexa0= 3.0-10.0). The mean Female Sexual Function Index total score of sexually active transgender women was 26.0 ± 6.8.nnnCONCLUSIONnThis group of relatively young transgender women reported satisfactory functional and esthetic results of the neovagina and a good quality of life, despite low Female Sexual Function Index scores.

Cosmetic Outcome Assessment following Breast-Conserving Therapy: A Comparison between BCCT.core Software and Panel Evaluation

Purpose. Over recent decades, no consensus has yet been reached on the optimal approach to cosmetic evaluation following breast-conserving therapy (BCT). The present study compared the strengths and weaknesses of the BCCT.core software with a 10-member panel from various backgrounds. Methods. Digital photographs of 109 consecutive patients after BCT were evaluated for 7 items by a panel consisting of 2 breast surgeons, 2 residents, 2 laypersons, and 4 plastic surgeons. All photographs were objectively evaluated using the BCCT.core software (version 20), and an overall cosmetic outcome score was reached using a four-point Likert scale. Results. Based on the mean BCCT.core software score, 41% of all patients had fair or poor overall cosmetic results (10% poor), compared with 51% (14% poor) obtained with panel evaluation. Mean overall BCCT.core score and mean overall panel score substantially agreed (weighted kappa: 0.68). By contrast, analysis of the evaluation of scar tissue revealed large discrepancies between the BCCT.core software and the panel. The analysis of subgroups formed from different combinations of the panel members still showed substantial agreement with the BCCT.core software (range 0.64–0.69), independent of personal background. Conclusions. Although the analysis of scar tissue by the software shows room for improvement, the BCCT.core represents a valid and efficient alternative to panel evaluation.

Total laparoscopic sigmoid vaginoplasty

OBJECTIVEnTo demonstrate step by step our technique for total laparoscopic sigmoid vaginoplasty.nnnDESIGNnSurgical video tutorial.nnnSETTINGnAcademic medical center.nnnPATIENT(S)nTransgender women with penile hypoplasia or with a failed primary vaginoplasty and biological women with either acquired or congenital absence of a functional vagina.nnnINTERVENTION(S)nAn original technique for total laparoscopic sigmoid vaginoplasty is shown on video. Surgery is performed via a simultaneous abdomino-perineal approach. The genital surgeon dissects the neovaginal cavity and performs a bilateral orchiectomy and shortening of the urethra. Out of penile and scrotal skin, a clitoro-vulvaplasty is created. Meanwhile, the laparoscopic surgeon mobilizes the sigmoid segment and transects it down to the base of the sigmoid arteries. The segment is guided in an iso-peristaltic way through the neovaginal tunnel on to the perineum. The distal staple line is opened and sutured in an exaggerated interdigitating fashion to the perineum and inverted penile skin. Length of the segment is measured with a transilluminated perspex dildo, after which the segment is stapled at the proper level. A neovaginopexy is performed on the promontory. Bowel continuity is restored with an intra-abdominal side-to-side oversewn stapled anastomosis. The patient provided written informed consent for the use of this video in this article.nnnMAIN OUTCOME MEASURE(S)nNone.nnnRESULT(S)nGiven current literature, intestinal vaginoplasty is associated with low complication rates. Since 2008 our group performed 42 primary and 21 secondary procedures, mainly in transgender women, with at least 1xa0year of clinical follow-up. Complications comprised three rectal perforations and two anastomotic leakages. These were addressed laparoscopically without long-term fistula formation. There were no conversions to laparotomy.nnnCONCLUSION(S)nTotal laparoscopic sigmoid vaginoplasty is a feasible and safe procedure in the hands of an experienced team with the right infrastructure. It provides good surgical and functional results. In selected cases it is indicated for primary vaginoplasty, as well as for revision vaginoplasty.

Penile Inversion Vaginoplasty with or without Additional Full-thickness Skin Graft: To Graft or Not to Graft?

Background: Penile inversion vaginoplasty is considered to be the gold standard for gender reassignment surgery in transgender women. The use of additional full-thickness skin graft as neovaginal lining is controversial. Some believe that having extra penile skin for the vulva gives better aesthetic results. Others believe that it gives inferior functional results because of insensitivity and skin graft contraction. Methods: Transgender women undergoing penile inversion vaginoplasty were studied prospectively. The option to add full-thickness skin graft is offered in patients where the penile skin length lies between 7 and 12 cm. Neovaginal depth was measured at surgery and during follow-up (3, 13, 26, and 52 weeks postoperatively). Satisfaction with the aesthetic result, neovaginal depth, and dilation regimen during follow-up were recorded. Satisfaction, sexual function, and genital self-image were assessed using questionnaires. Results: A total of 100 patients were included (32 with and 68 without additional full-thickness skin graft). Patient-reported aesthetic outcome, overall satisfaction with the neovagina, sexual function, and genital self-image were not significantly associated with surgical technique. The mean intraoperative neovaginal depth was 13.8 ± 1.4 cm. After 1 year, this was 11.5 ± 2.5 cm. The largest decline (−15 percent) in depth is observed in the first 3 postoperative weeks (p < 0.01). Conclusions: The authors can confirm neither of the suggested arguments, for or against full-thickness skin graft use, in penile inversion vaginoplasty. The additional use of full-thickness skin graft does not influence neovaginal shrinkage, nor does it affect the patient- and physician-reported aesthetic or functional outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Double flap phalloplasty in transgender men: Surgical technique and outcome of pedicled anterolateral thigh flap phalloplasty combined with radial forearm free flap urethral reconstruction

Radial forearm free flap (RFFF) tube‐in‐tube phalloplasty is the most performed phalloplasty technique worldwide. The conspicuous donor‐site scar is a drawback for some transgender men. In search for techniques with less conspicuous donor‐sites, we performed a series of one‐stage pedicled anterolateral thigh flap (ALT) phalloplasties combined with RFFF urethral reconstruction. In this study, we aim to describe this technique and assess its surgical outcome in a series of transgender men.

Symptomatic HPV-related neovaginal lesions in transgender women: case series and review of literature

Objective Worldwide, transgender women are an at-risk population for contracting sexually transmitted infections. Little information exists on symptoms and characteristics of neovaginal human papillomavirus (HPV) infections and associated diseases. We describe a case series of transgender women with symptomatic HPV-related neovaginal lesions and a review of current literature. Methods Transgender women with symptomatic HPV-related neovaginal lesions were identified from a departmental database comprising clinical and outpatient data on transgender women who underwent vaginoplasty between 1990 and 2015. HPV status was determined on excision and biopsy specimens by HPV DNA testing using GP5+6+-PCR and p16INK4A immunohistochemistry. Current literature was reviewed using the MEDLINE and EMBASE databases. Results This case series includes four transgender women with symptomatic, HPV-related neovaginal lesions. Two women presented with neovaginal and neovulvar pain and condylomata/leukoplakia, which were excised. These lesions showed moderate-to-severe dysplasia at histopathological examination, and were positive for high-risk HPV (hrHPV) and p16INK4A. Recurrence occurred in one patient and was treated with laser evaporation. Two women presented with neovaginal coital pain, neovaginal bleeding and condylomata. Neovulvar lesions were treated with podophyllotoxin. Neovaginal lesions were excised or evaporated. These lesions were low-risk HPV (lrHPV) positive. The literature search shows treatment options varying from conservative, topical podophyllotoxin to excision or laser evaporation under general anaesthesia. Conclusions Neovaginal HPV infection can lead to benign condylomata (lrHPV) and various grades of dysplasia (hrHPV). We advise physicians to consider HPV infection and associated lesions in transgender women with otherwise unexplainable neovaginal pain or bleeding after vaginoplasty.

The tunnelled lower leg fillet flap, a reconstructive salvage option in patients with severe pressure ulcers.

Pressure sores remain a common problem in paraplegic or bedridden patients with an incidence of 25%e85%. For stage IV ulcers, surgical treatment is often indicated. The goal is to reconstruct the debrided defect with well vascularised, durable tissue. Most pressure ulcers in the pelvic region are treated using locoregional flaps harvested from the buttock and thigh region. In very complicated caseswhere all locoregional solutions are exhausted, surgeons might find themselves in a ‘back against the wall’ situation. For these extreme cases we present a fillet flap technique, using soft tissue of the lower leg, pedicled on the superficial femoral artery and vein. Surgery starts in supine position. An incision is made along the musculus Sartorius. The channel of Hunter is opened. The superficial femoral vessels are freed along their entire length. A midline incision over the tibia is made and a circumferential incision around the knee joint. The soft tissue and fibula (by splitting the interosseous membrane) is freed from the tibia. The tendons around the knee are cut. The foot can be amputated at different levels depending on the amount of tissue needed (Figure 1). After exarticulation of the knee, the tibia and foot are removed. The fibula is removed while taking care to preserve the anterior tibial vessels. A subcutaneous tunnel is made from the groin to the defect in the gluteal region. The flap is pulled through and temporarily bandaged against the upper leg. To close the

Reply: Surgical Outcome after Penile Inversion Vaginoplasty

237e Reply: Surgical Outcome after Penile Inversion Vaginoplasty: A Retrospective Study of 475 Transgender Women Sir: We sincerely thank Massie et al. for their interest in our article1 and valuable recommendations. This letter emphasizes the importance of more research in this field. The main aim of gender-confirming surgery is to relieve the distress caused by a discrepancy between the biological gender identity and the gender identity perceived by the transgender person. In transgender women, vaginoplasty is one of the surgical procedures in the comprehensive treatment to alleviate this distress. Worldwide, the method of choice for vaginoplasty in trans women is the penile inversion vaginoplasty. However, few articles report on the outcomes of this procedure.2 Jonathan Massie and colleagues connect with the worldwide awareness that the outcome of a treatment as experienced by the patient is central for evaluating its success. Development of patient-reported outcome measures has really taken off. We agree that patient-reported outcomes are central for evaluation of treatment, especially if the treatment is aimed at alleviation of distress. In fact, we were one of the first to measure patientreported outcomes after vaginoplasty in trans women.3–5 We also established that there is a need for transgenderspecific questionnaires, because existing questionnaires are not very appropriate for this population.3 Massie and colleagues argue that knowledge about surgical outcomes is most important for providers, whereas patient-reported outcomes are more important for the patients and that a study reporting on just one of these outcomes would be incomplete. We propose that both surgical outcomes and patient-reported outcomes are important to evaluate. Of course it is great if you can assess both at the same time; nevertheless, information about either of these outcomes remains valuable. Knowledge about surgical outcomes is important for optimizing the technique and for adequately informing the patient. We suggest that a well-informed patient will be more satisfied with the outcome of treatment. The need for transgender-specific questionnaires has been recognized in recent years. Because of 3. De Cuypere G, T’Sjoen G, Beerten R, et al. Sexual and physical health after sex reassignment surgery. Arch Sex Behav. 2005;34:679–690. 4. Vyas KS, Johnson K, Mardini S. The role of patient-centered outcomes research in plastic surgery. Ann Plast Surg. 2016;77:585–586. 5. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient-reported outcome measure for breast surgery: The BREAST-Q. Plast Reconstr Surg. 2009;124:345–353. 6. Bouman MB, van der Sluis WB, van Woudenberg Hamstra LE, et al. Patient-reported esthetic and functional outcomes of primary total laparoscopic intestinal vaginoplasty in transgender women with penoscrotal hypoplasia. J Sex Med. 2016;13:1438–1444. increasing cooperation between gender health care providers, development of validated patient-reported measures for this growing population has now become feasible. DOI: 10.1097/PRS.0000000000003487