[Choice of flaps for phalloplasty: what is the contemporary standard? Consensus Statement of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels]. / "Wahl der Lappenplastik zur Phalloplastik ­ was ist zeitgemäßer Standard" ­ Konsensus-Bericht der deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße.

The ever-expanding number of transmen as well as their surgeons share an increasing interest in the construction of a neophallus. While the indication for surgery and the positive effect of a phalloplasty on the quality of life, mental health and sexual function has already been thoroughly analysed, there is a lack of data comparing and evaluating the surgical steps. During the consensus conference on the "choice of flaps for phalloplasty" at the annual meeting of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels, the current literature was discussed and a consensus on the surgical technique of a phalloplasty was reached. This manuscript publishes jointly developed recommendations on the following topics: choice of flaps for phalloplasty, preoperative diagnostic tests before phalloplasty, urethral construction in the radial forearm flap and anterior lateral thigh flap, preformation of the urethra at the forearm or thigh, venous drainage of the radial forearm flap, innervation of the phallus, staged phalloplasty, coronaplasty and managing the donor site of a radial forearm flap.

Quality of Life and Satisfaction in Transgender Men After Phalloplasty in a Retrospective Study.

BACKGROUND: Partly as a result of the increasing attention directed toward transgender individuals and despite much research work on the topic of quality of life (QOL) of transgender, there is still a lack of studies using standardized questionnaires in their evaluation. AIMS: We designed a survey to evaluate the influence of surgery after phalloplasty (osteofasciocutaneous fibula free flap or osteofasciocutaneous radial free forearm flap) on QOL, emotional stability, self-esteem, and psyche of postoperated transgender men. METHODS: The present study included 32 transgender men who had undergone gender-affirming surgery (GAS) exclusively in our department between 2000 and 2012. Apart from our self-developed, indication-specific questionnaire with questions on socioeconomic and demographic data as well as postoperative satisfaction, the testing instrument included 4 frequently used, standardized testing instruments, which we compared with normative data. These included (a) a self-assessment test Fragebogen zur Lebenszufriedenheit with questions on QOL consisting of 3 modules (general satisfaction, satisfaction with health, and satisfaction with body image/outer appearance), (b) the Freiburg Personality Inventory, (c) the Rosenberg Self-Esteem Questionnaire, and (d) the Patient Health Questionnaire 4. FINDINGS: Our self-developed, indication-specific questionnaire showed that 88% of our patients were very satisfied with the aesthetic result, 75% have had sex after surgery, and 72% were very satisfied with sexual function after GAS. Eighty-one percent had a strong improvement of QOL, and 91% would undergo the same treatment again. Eighty-four percent would recommend GAS to others. All patients lived as men fulltime. DISCUSSION: Our study reveals that GAS plays an important part in the interdisciplinary treatment of transgender individuals as it improves the QOL in transgender men in most aspects of everyday life and has a positive influence on the patients' psyche and self-esteem in a retrospective study.

Psychological Pathologies and Sexual Orientation in Transgender Women Undergoing Gender Confirming Treatment.

BACKGROUND: There are few studies evaluating depression, self-esteem, and mental health after gender confirming treatment of transgender women. Most of these studies include different surgical techniques and nonvalidated questionnaires. With our survey, we are aiming to assess psychopathologies and mental health as well as sexuality among a group of patients treated by the same surgeon performing our self-developed combined surgical technique. This vaginoplasty approach is characterized by constructing the vaginal cavity with parts of the penile and scrotal skin as well as the longitudinally incised urethra. MATERIALS AND METHODS: Forty-seven transgender women who underwent gender confirming treatment between 2007 and 2013 were included in a retrospective study. The assessment of our study group was performed by means of self-developed indication-specific questionnaires and 3 standardized questionnaires that can be compared with norm data. RESULTS: Preoperative psychotherapy was mostly considered as helpful by the patients, yet postoperatively, only a third of our study participants were still under therapeutic treatment. Furthermore, we could show a change in sexual preference toward a more bisexual orientation. Gender confirming treatment satisfied the expectations for most of the patients and, in their opinion, should have been performed earlier. Results of the standardized Patient Health Questionnaire 4, a short depression screening questionnaire, did not significantly differ from healthy norm data. The Freiburg Personality Inventory, Revised, revealed normal emotionality and sane self-assessment within our study group. High self-esteem and significantly higher scores than norm data were found for the Rosenberg Self-esteem Scale. CONCLUSIONS: Gender confirming treatment with the combined technique is an important part of a multi-structured treatment of transgenders and does have effects on psychological well-being. It seems to decrease psychopathologies and implicates several ameliorations for transgender women. Findings need to be verified in prospective studies including preoperative evaluations.

Age-Related Differences for Male-to-Female Transgender Patients Undergoing Gender-Affirming Surgery.

INTRODUCTION: It has been theorized that there are 2 subgroups within the male-to-female (MtF) transgender population: individuals who are predominantly androphilic and those who are predominantly gynephylic or interested in both male and female partners. AIM: To explore the role of a dichotomous distribution of age at dysphoria onset in individuals diagnosed with MtF gender dysphoria. METHODS: 40 patients who presented to a surgical clinic in Germany for gender-affirming surgery (GAS) were included in this study. Their age distribution was plotted as a histogram and the population was then divided at the median self-reported age of onset of gender dysphoria-that is, those 17 years and younger and those 18 years and older. The 2 groups were then compared with regard to demographic data, partnership history, various quality of life parameters, as well as sexual orientation and sexual history. MAIN OUTCOME MEASURE: Self-designed questionnaires for demographics and sexuality, Questions on Life Satisfaction and Body Image (FLZM), Freiburg Personality Inventory, Rosenberg Self-Esteem Scale, and Patient Health Questionnaire were used. RESULTS: Early-onset, gender-dysphoric MtF patients underwent GAS at a much younger age (mean 32.7 vs 43.8 years, P = .004), but had similar characteristics regarding weight, height, body mass index, marital status, and living situation to individuals who reported later onset of gender dysphoria. Preoperatively, they showed greater depressive symptoms (4.6 vs 3.3 points, P = .045), which disappeared after GAS. Following surgery, the younger MtFs were predominantly attracted to men (52.6%), whereas individuals who were diagnosed with late-onset of gender dysphoria preferred women or both men and women (85.7%) as sexual partners (P = .010). Younger trans individuals were more frequently sexually active (73.7% vs 42.9%, P = .049). CONCLUSION: Our findings suggest that there are 2 MtF populations that differ in age of dysphoria onset, sexual history, and multiple personal details including sexual orientation. These data may be used to improve care to transgender individuals by providing treatment reflecting their sexual interests. Zavlin D, Wassersug RJ, Chegireddy V, et al. Age-Related Differences for Male-to-Female Transgender Patients Undergoing Gender-Affirming Surgery. Sex Med 2019;7:86-93.

Male-to-Female Sex Reassignment Surgery using the Combined Vaginoplasty Technique: Satisfaction of Transgender Patients with Aesthetic, Functional, and Sexual Outcomes.

BACKGROUND: Currently available patient-reported outcome measures are limited in the field of sex reassignment surgery (SRS). Standardized questionnaires deliver high evidence data on satisfaction of male-to-female (MTF) transgender patients but do not allow any modification in their clinical application. We therefore designed a prospective study using self-developed indication-specific questionnaires to evaluate the aesthetic, functional, and sexual outcomes of MTF patients undergoing SRS. METHODS: Forty-nine adult MTF transgender patients who underwent two-stage SRS were eligible for study inclusion between September 2012 and January 2014. Forty patients (= N) ultimately filled out both parts of the questionnaire sets: 1 day before the first stage (T0) and 6 months after the second stage of SRS (T1). These questionnaires focused on demographic characteristics, the satisfaction with aesthetic and functional results, and sexuality. RESULTS: Patients rated their surgical satisfaction of most items with mean scores above 7 on a 0-10-point scale. Many items evaluating everyday life activities improved significantly after SRS compared to T0 (p < 0.01). All but one patient (97.5%) reported no regrets about having undergone surgery, and the majority recommended it to other patients with gender dysphoria. Femininity and sexual activity increased significantly postoperatively (p < 0.01). Satisfaction with intercourse and orgasm was high: 6.70 and 8.21, respectively, on a 0-10 scale. CONCLUSION: Satisfaction with the cosmetic outcome, as well as the functional and sexual outcomes, reveal positive effects of SRS using the combined technique on transgender patient lives. Nevertheless, standardized and validated SRS-specific questionnaires are lacking. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Male-to-Female Sex Reassignment Surgery Using the Combined Technique Leads to Increased Quality of Life in a Prospective Study.

BACKGROUND: The authors' previous research showed that various plastic surgical procedures can increase a patient's quality of life in its different aspects. In a prospective setting, they evaluated whether sex reassignment surgery has similar effects for male-to-female transgender patients compared to baseline data before sex reassignment surgery. METHODS: All 39 patients who underwent their first-stage male-to-female sex reassignment surgery between October of 2012 and January of 2014 received one set of questionnaires preoperatively (time 0) and approximately 6 months after their final operation (time 1). Each set contained self-developed, indication-specific questions combined with the standardized validated Questions on Life Satisfaction, Modules (German version) questionnaire, the Freiburg Personality Inventory, the Rosenberg Self-Esteem Scale, and the Patient Health Questionnaire, which were compared to available norm data. RESULTS: The mean patient age was 38.6 years. The majority of the patients were highly educated, childless, and single. Significant improvements were found in the Questions on Life Satisfaction, Modules (German version), especially for the items "partnership," "ability to relax," "energy," "freedom from anxiety," "hair," "breast," and "penis/vagina" (p < 0.01). Furthermore, the patients appeared more emotionally stable (p = 0.03), showed higher self-esteem (p = 0.01), and showed much lower depression/anxiety (p < 0.01). CONCLUSIONS: The positive study findings were confirmed with the results from prior retrospective studies. However, medical literature focuses largely on surgical and functional satisfaction and not overall quality of life. In addition, standardized questionnaires are used rarely and solely retrospectively, with the risk of recall bias. The increased quality of life of transgender women postoperatively endorses sex reassignment surgery as a valuable option for these patients. CLINICAL QUESTON/LEVEL OF EVIDENCE: Therapeutic, IV.

The innervated free toe web flap for clitoris reconstruction.

Clitoris reconstruction is often used in transgender reassignment. Most techniques now reconstruct the clitoris using glans pedicled on the dorsal phallic neurovascular bundle. Other techniques of clitoris reconstruction re-shape retained elements of the proximal segment of the corpora cavernosa, as well as techniques mobilising local flaps. We are presenting a new technique for clitoris reconstruction using an innervated free web space flap. The operative technique and outcome are illustrated and discussed in this case report.

Urethral reconstruction using the radial forearm free flap: experience in oncologic cases and gender reassignment.

OBJECTIVES: Urethra reconstruction in men remains a complex problem, particularly in patients who have had previous amputation for penile tumour or who have undergone gender reassignment. Many reconstructive techniques currently in use recreate the urethra but are prone to recurrent stricture formation and fail to achieve micturition with a good stream when standing. The authors propose using the radial forearm fasciocutaneous free flap as a single-stage technique of male urethral reconstruction. METHODS: During 1999-2004, nine patients underwent microsurgical reconstruction of the male urethra using the radial forearm fasciocutaneous free flap. Three patients underwent urethral reconstruction following previous subcutaneous penectomy for penile cancer. Another six patients had urethral reconstruction performed after failure of primary urethra construction as part of their gender reassignment surgery. RESULTS: The average age at the time of surgery was 35.1 yr (range: 22-55 yr) and average follow-up time was 41.8 mo (range: 13-55 mo). Flap reconstruction was successful in all cases, with no instances of free flap failure; however, two patients developed significant stenosis requiring revision, and no patients had postoperative fistula formation. Therefore, the success rate for urethral reconstruction after the first operation was seven of nine. Two patients with stenosis were treated operatively to release strictures with local flaps. Uroflowmetry demonstrated that these patients had satisfactory flow rates. CONCLUSION: Patient satisfaction and objective studies have demonstrated that urethral reconstruction with the use of radial forearm free flap is a good reconstructive procedure particularly when the patients need an extensive and long urethral reconstruction.

Urethra reconstruction following resection of penile leiomyosarcoma.

Leiomyosarcoma is a rare tumor, particularly in genital area. We present a case of penile lyomyosarcoma. Surgical treatment involved subcutaneous penectomy, preserving a sensate skin envelope, bilateral groin dissection and perineal urethrostomy. Reconstruction of the urethra and soft tissue was carried out using a free radial forearm flap. We believe that subcutaneous penectomy should be considered as a treatment option in selected cases of penile tumor as this facilitates urethral reconstruction.