Refaat B. Karim

The devastating outcome of massive subcutaneous injection of highly viscous fluids in male-to-female transsexuals.

Illicit subcutaneous injections of massive quantities of highly viscous fluids are still performed, often by unqualified persons. Fifteen male‐to‐female transsexuals consulted the authors regarding their devastating long‐term outcomes after the injection of up to 8 liters of alleged silicone or mineral oil to feminize their bodies. After a latency period of up to 17 years, these injections led to complications ranging from scarring and deformity to infections. These patients were treated conservatively for inflammation and infection or surgically by resection of the oil‐infested areas. In view of the potential dangers, feminization by the injection of high‐viscosity fluids should be soundly condemned. (Plast. Reconstr. Surg. 107: 734, 2001.)

Honey-medicated dressing: transformation of an ancient remedy into modern therapy.

Honey has been applied for medicinal purposes since ancient times. Its antibacterial effects have been established during the past few decades. Still, modern medical practitioners hesitate to apply honey for local treatment of wounds. This may be explained by the expected messiness of such local application. Moreover, secondary infectious disease may be caused by contamination of honey with microorganisms. Hence, if honey is to be applied for medicinal purposes, it has to meet certain criteria. The authors evaluated the use and safety of a honey-medicated dressing that was developed to meet these criteria in a feasibility (phase II) study featuring 60 patients with chronic (n = 21), complicated surgical (n = 23), or acute traumatic (n = 16) wounds. In all but 1 patient, it was found easy to apply, helpful in cleaning the wounds, and without side effects. Based on these results, the authors advise to subject this dressing to a randomized, double blind, phase III study.

Abdominoplastic secondary full-thickness skin graft vaginoplasty for male-to-female transsexuals.

&NA; When inversion of combined penile and scrotal skin flaps for vaginoplasty in male‐to‐female transsexuals has become impossible or has not led to functional results, alternative vaginoplasty techniques should be considered. Colocolpopoiesis involves major surgery and often leads to disappointing long‐term results. An Abbé‐McIndoe vaginoplasty applying split‐thickness skin grafts often does not provide favorable results in the scarred area encountered after complications of skin flap inversion surgery. Because thicker skin grafts show less tendency to shrink, the use of a full‐thickness skin graft has been advocated for vaginoplasty in females. In this paper, we present our technique of successful secondary vaginoplasty applying full‐thickness skin grafts in six male‐to‐female transsexuals. In patients with sufficient groin and abdominal skin to spare, a miniabdominoplasty allows for acceptable donor site scarring combined with correction of the abdominal skin surplus. In flat‐tummied patients, the conventional abdominoplasty will allow for sufficient skin to be harvested to ensure successful secondary vaginoplasty. Abdominoplastic vaginoplasty has been proven to provide a good alternative whenever a laparotomy is not favored or is contraindicated in secondary cases. (Plast. Reconstr. Surg. 101: 1512, 1998.)

Evolution of the methods of neovaginoplasty for vaginal aplasia

The aim of vaginoplasty should be the creation without excessive morbidity of a neovagina that will be satisfying in appearance, function and feeling. The multitude of methods described in the literature indicates the fact that an ideal approach has not yet been found. In this paper the various methods are described and discussed. It is concluded that the non-operative impression technique, the peritoneum pull-through technique and the use of skin grafts are methods of choice. In cases where immediate vaginal reconstruction after oncological surgery is indicated, myocutaneous flaps are preferred. Only in cases in which other methods have failed should recto-sigmoid transplantation be considered.

Unfavorable long-term results of rectosigmoid neocolpopoiesis.

We report on unfavorable long-term results after rectosigmoid neocolpopoiesis in 12 patients, as well as on possible prevention and treatment of these results. To prevent neovaginal introitus stenosis, the rectosigmoid mucosa should be sutured to the perineal skin in an exaggerated interdigital fashion. In cases where introitus stenosis has developed, pedicled transposition flaps from perineum or labia or from the gluteal or inguinal plica region have to be used. Similar flaps also may be applied in cases of rectovagina fistulas. Neuromas at the mucosa-perineal junction often are resistant to therapy. So-called diversion colitis may be manifested by mucous discharge, mucosal bleeding, or discomfort. This disorder may be treated successfully by local application of a solution containing short-chain fatty acids. Loperamidehydrochloride (Imodium) administered half an hour before intravaginal penetration may be helpful to weaken or even prevent neovaginal contractions. Because of the possible higher risk of neovaginal adenocarcinoma, long-term follow-up of these patients is indicated.

Ought GIDNOS get nought? Treatment options for nontranssexual gender dysphoria.

Gender identity refers to one’s basic conviction of belonging to one of the sexes. However, rather than conforming to the binary concepts of physical sex (male versus female), psychological gender identity (man versus woman), and social gender role (masculine versus feminine), human gender identity is experienced along a continuum from complete mental agreement between body image and gender to the extreme conflict between physical sex and psychosocial gender identification known as transsexualism. The term gender dysphoric describes a heterogeneous group of individuals who experience some degree of discrepancy between gender identity and physical sex. The pioneer of transsexology, Harry Benjamin,1 divided male gender dysphoric persons into three groups according to the severity of the dysphoria. First, there are those with a low degree of gender dysphoria, who merely want to cross-dress and be socially accepted as women. They are transvestites who accept their anatomic gender but feel constrained and anxious unless they are free to express gender behaviors associated with the other sex. When allowed to cross-dress, transvestites usually demand no therapy for emotional comfort. For patients with a high degree of gender dysphoria, the quest for full hormonal and surgical sex reassignment is vital because they actually feel “trapped” in an anatomically wrong body. These patients are genuinely transsexual, and “cross-dressing is an insufficient help, as aspirin for a brain tumor headache would be.”1 Rather than referring to “transsexuality,” the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders refers to Gender Identity Disorder. For individuals suffering from an intermediate degree of gender dysphoria, mere crossdressing does not suffice to restore or maintain emotional balance. Some physical changes (e.g., breast development), but not all of the anatomic features of the other sex, are requirements for easing the dysphoria.1 Gender Identity Disorder Not Otherwise Specified (GIDNOS) is the classification category included in the Diagnostic and Statistical Manual of Mental Disorders for coding the intermediate degree of gender dysphoria that is not classifiable as transsexuality or transvestitism. GIDNOS is analogous to nontranssexual gender dysphoria or nontranssexual transgender behavior, ‘transgender’ being the umbrella term referring to a diverse group of individuals who cross or transcend culturally defined categories of gender in some way or another.2 Examples of persons with GIDNOS include persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex. Alternatively, a person with GIDNOS may desire some of the anatomy of the other sex (such as breasts or lack of breasts) in addition to its gender behaviors, but not the genitals of the other sex. Giving in to such desires would result in male transgenderists having breasts and a penis, female transgenderists with vaginas but no breasts, or even “intersexed” or “bisexed” individuals with both a penis and a vagina. Even though transsexualism is recognized as a serious and not uncommon gender identity disorder that may be medically treated, the nontranssexual intermediate form of gender identity disorder has not received much medical, let alone surgical, review. A general professional discussion on the possible indications for, and limitations of, treatment for GIDNOS is needed to establish the admissibility and practicability of such treatment.

The importance of near total resection of the corpus spongiosum and total resection of the corpora cavernosa in the surgery of male to female transsexuals.

From 1980 to 1989, 13 male to female transsexuals underwent surgery for resection of the corpus spongiosum, performed at the Department of Plastic and Reconstructive Surgery of the Free University Academic Hospital, Amsterdam, The Netherlands. Except for 1, all patients underwent the primary sex-reassignment procedures in institutions other than this hospital. All had difficulties during sexual activities. After repeat surgery with near complete excision of the corpus spongiosum and also in three instances of the corpus cavernosum, improvement was noticed in all patients. The importance of the total elimination of the erectile tissue is emphasized.

Sensate pedicled neoclitoroplasty for male transsexuals : Amsterdam experience in the first 60 patients

The results of vaginoplasty by inversion of penile and scrotal skin in male-to-female transsexuals, in general, are satisfying. Cosmetic and functional considerations dictate the construction of a neoclitoris ventral to the urethral orifice. Embryologically, the glans penis and clitoris are homologues and mutual substitution seems to be the logical approach. In this paper, the long-term results in the first 60 patients using the pedicled sensate neoclitoroplasty according to Brown are presented and discussed. It has proven to be a safe technique that leads to satisfying cosmetic and functional results in nearly all patients. It should be considered state of the art in primary gender-confirming surgery for male-to-female transsexuals.

Exceptional presenting conditions and outcome of augmentation mammaplasty in male-to-female transsexuals.

Driven by a persistent and unchangeable need to undo the discrepancy between reality of the body and gender of the mind, most male-to-female transsexuals seek physical feminization through hormonal and surgical treatment. The authors report some rare presenting conditions and exceptional results of augmentation mammaplasty in 11 male-to-female transsexuals treated between January 1979 and January 1998, as well as describe how to treat these conditions. In patients in whom gynecomastia was treated previously, the remaining subcutaneous fatty tissue may be insufficient to cover the implants safely, and subpectoral implantation should be considered. Augmentation after unilateral correction of gynecomastia requires different sizes of implants. Although exceptional in male-to-female transsexuals, mastopexy is the treatment of choice to correct any mammary ptosis, but the patient may request augmentation mammaplasty to fill out the breasts. Previous stacking mammaplasty may have been performed subglandularly, subpectorally, or both. Stacking may not have been noticed prior to corrective surgery. Extrusion of the implant may be associated with avascular necrosis or infection, but also with the use of high concentrations of steroid placed within the lumen of fluid-filled implants. The correction involves removal of the implant, with skin graft or flap reconstruction of the affected area. Replacement of the implant may have to be delayed. Symmastia results from overzealous medial dissection coupled with overaugmentation. Combined restoration of the presternal subcutaneous integrity, and medial closure of the pocket by subcutaneous approach only, leads to satisfactory reconstruction of the presternal median cleavage. Galactorrhea may be the result of hyperprolactemia but is more often caused by stimulation of the intercostal nerve by the implants.

Rectosigmoid neocolpopoiesis for male-to-female transsexuals: Amsterdam experience.

Penile skin inversion is the method of choice for vaginoplasty in male-to-female transsexuals. Rectosigmoid neocolpopoiesis should be considered only when penile skin inversion has become impossible or has not led to functional results. In this paper we describe our technique and the results of colocolpopoiesis in 7 male-to-female transsexuals.