Combined vaginoplasty technique for male-to-female sex reassignment surgery: Operative approach and outcomes.

BACKGROUND: Several therapy options exist for male-to-female (MTF) transgenders desiring sex reassignment. Surgery includes numerous different procedures. Of those, vaginoplasty is predominant and aims at providing attractive esthetics and fully functional genitals. This study aimed to present the surgical results of our modified combined vaginoplasty technique in a consecutive patient cohort. METHODS: We included 40 MTF transgender patients who underwent a two-stage sex reassignment surgery (SRS) in an observational prospective study between September 2012 and January 2014. Demographic characteristics, medical and surgical history, operative details, and outcomes after surgery were documented. Postoperatively, 23 patients received a pelvic examination following the standardized protocol. RESULTS: Measured vaginal depth was 11.77-14.99 cm depending on the size of the dilator used (25-40 mm). Vaginal, clitoral, and labial sensitivities were intact and favorable in all examined patients. Nineteen women (47.5%) opted for breast augmentations to achieve a feminine cosmesis, making it the most common nongenital operation. Complications were mostly minor and temporary. Severe adverse events, such as wound infections (n = 3), colon injuries (3), short (1) or narrow (1) vaginas, or partial clitoral necroses (1), were rare and immediately addressed by the surgical team. No vaginal construction was lost, and no secondary reconstructive approaches were required. CONCLUSION: Satisfactory physical results and favorable low rates of complications endorse our combined technique for MTF SRS. These findings, however, need to be confirmed by other research groups as well. Therefore, in our opinion, MTF SRS remains an evolving area of development, whose research is aiming to establish a state-of-the-art surgical technique.

Quality of Life and Patient Satisfaction Following Male-to-Female Sex Reassignment Surgery.

BACKGROUND: Surveys on quality of life (QOL) of male-to-female (MTF) transsexuals have found low QOL scores before and increased satisfaction scores after sex-reassignment surgery (SRS). To our knowledge, many of them lack standardized questionnaires and comparisons with normative data to evaluate different vaginoplasty techniques. AIM: To analyze patient satisfaction and QOL after SRS. METHODS: Forty-seven patients participated in this study. All patients had surgery with our self-developed combined technique on average 19 months before the survey. They completed a self-developed indication-specific questionnaire concerning demographic and socioeconomic issues and postoperative satisfaction. Furthermore, a standardized self-assessment questionnaire on satisfaction and QOL (Fragen zur LebenszufriedenheitModule [FLZM]; Questions on Life SatisfactionModules) was used. The FLZM consists of three modules (general life satisfaction, satisfaction with health, and satisfaction with body image) with scores of weighted satisfaction for each item. Results of the general and health modules were compared with normative data. OUTCOMES: Demographics, QOL, general life satisfaction, satisfaction with health, and satisfaction with body image. RESULTS: The self-developed indication-specific questionnaire showed that 91% experienced an improvement of QOL. All patients stated they would undergo SRS again and did not regret it at all. Patients stated their femininity significantly increased. For the FLZM, the sum score for general life satisfaction (P < .001) was significantly lower than the normative data, whereas the sum score of the satisfaction with health module (P = .038) did not reach statistical significance. The two modules also showed positive trends for different items. Values of the body image module showed a significant increase in satisfaction with breasts (P < .001) and genitals (P = .002). CLINICAL IMPLICATIONS: The findings of this survey emphasize the importance of SRS in the interdisciplinary gender-reassignment process. The detailed description of our combined technique could help to improve the surgical outcome and patient satisfaction of this complex and non-standardized surgery. STRENGTHS AND LIMITATIONS: This is the first description of a new surgical technique (combined technique) for MTF SRS. QOL was assessed by a large number of patients by standardized questionnaires and could be compared with normative data. Because this is a retrospective study, we can draw only careful conclusions for pre- and postoperative changes. CONCLUSION: Our self-developed combined surgical technique seemed to have a positive influence on QOL after SRS. Satisfaction with breasts, genitals, and femininity increased significantly and show the importance of surgical treatment as a key therapeutic option for MTF transsexuals. Papadopulos NA, Lellé J-D, Zavlin D, et al. Quality of Life and Patient Satisfaction Following Male-to-Female Sex Reassignment Surgery. J Sex Med 2017;14:721-730.

The free osteofasciocutaneous fibula flap: clinical applications and surgical considerations.

INTRODUCTION: The aim of this study was to investigate the intraoperative findings, postoperative complications, donor site morbidity and patients' Quality of Life in order to evaluate the usefulness of the free osteofasciocutaneous fibula flap in the reconstruction or construction of a mandibula, neophallus, lower leg or forearm. MATERIALS AND METHODS: 104 patients were treated with free osteofasciocutaneous fibula flaps in our clinic. 23 for mandible reconstruction, 66 for neophallus reconstruction, 9 for lower leg reconstruction and 6 for forearm reconstruction. These patients were asked to answer a questionnaire and to be present for a clinical and a radiological examination in our department. In addition, their previous records were evaluated retrospectively. RESULTS: The dimension of the surface of the skin island was 178.6 cm(2) (72-352 cm(2)) in average and the average length of the fibular bony part was 15.4 cm (10-23 cm). The most frequent and severe complication was skin island edge necrosis (n=7); no total flap necrosis was found. Donor-site morbidity was low, since no joint instability could be reported. Quality of Life was improved according to the standardised FLZ(M) questionnaire. CONCLUSION: Advantages of free osteofasciocutaneous fibula flaps were the wide cortical bone and the relative constant anatomy, the long pedicle, flat, uniform and sufficient large and pliable skin island, as well as the good blood circulation also by massive modelling of the skin and bone part. The skin island could be harvested large enough in order to reconstruct extended soft-tissue defects in the face and the extremities as well as to construct neophallus in its normal size without any restrictions. The lower leg donor-site morbidity was moderate and can be readily covered with a sock in patients' everyday life common activities. Finally, in our hands, the utilisation of the free osteofasciocutaneous fibula flap is the best possible therapy for these difficult composite reconstructions.

A new protocol for complete phalloplasty with free sensate and prelaminated osteofasciocutaneous flaps: experience in 37 patients.

BACKGROUND: Herein, we present our latest protocol of following three operative stages for complete phalloplasty, applied in 37 female-to-male transsexuals: first, mastectomy, ovariohysterectomy, urethral lengthening, vaginectomy, colpocleisis, and neourethra prelamination; second, neophallus creation with free sensate osteofasciocutaneous fibula (n = 31) or radial forearm (n = 6) flap; and third, urethral connection, neoscrotum formation, and testicle prosthesis implantation. RESULTS: Occasionally, wound healing disturbance and slight asymmetry of the breasts was observed, as well as colpocleisis revision needed. Partial flap necrosis took place in 6 patients, while 12 presented urethral stricture and 6 a fistula. Despite inferior neophallus sensibility, patients whose neophallus was created using fibula flap experienced better sexual intercourse. However, overall patients' satisfaction was superior. CONCLUSIONS: The applied protocol demonstrates the effectiveness of such a multistage and interdisciplinary approach for female-to-male transsexuals, offering an essential improvement of their quality of life, concerning their successful integration into the reassigned gender position in the society.

Mandibular reconstruction with free osteofasciocutaneous fibula flap: a 10 years experience.

SUMMARY: The aim of this study was to evaluate the usefulness of the free osteofasciocutaneous fibular flap in mandible reconstruction in 23 patients. We reviewed their clinical records and asked the subjects to answer a questionnaire, as well as to attend our hospital for a clinical and radiological examination. The mean follow up was 1.3 years. In 15 patients, the flap was used for contemporaneous intraoral mucosal and extraoral cutaneous reconstruction. In seven cases, bilateral mandibular reconstruction was performed. Skin paddle edge necrosis was observed in seven flaps postoperatively, however, no total flap loss resulted. No additional soft-tissue flap was needed since the fibular flap harvested held an extended skin paddle reaching up to 352 cm(2). The donor-site morbidity was moderate and furthermore most of the patients were satisfied with their functional and aesthetic result. The free osteofasciocutaneous fibular flap is the best possible therapy for the demanding reconstruction of the mandible. The fibular bony part is a safe foundation for the placement of osseointegrated implants which further improves the patient's quality of life.

The use of free prelaminated and sensate osteofasciocutaneous fibular flap in phalloplasty.

SUMMARY: The aim of this study was to present our latest modified protocol on neophallus construction that we have applied in 32 female-to-male transsexuals. The applied protocol consisted of neourethra prelamination with split skin thickness grafting at the lateral donor lower leg, and neophallus construction after 6 months with the free, prelaminated, and sensate osteofasciocutaneous fibular flap, followed by urethro-urethral anastomosis. Because of initial difficulties on harvesting and positioning the fibular flap, we had 2 total and 4 partial necrosis. Ten patients had a urethral stricture, and 7 a fistula. In 6 patients a stricture expansion was required and in 5 closure of the fistula was needed. The donor-site morbidity was moderate. In conclusion, in our series this protocol proved to be the method of choice in this very demanding field of genitalia reconstructive surgery, offering an essential improvement of the quality of life of transsexual patients.

Donor site morbidity after harvest of free osteofasciocutaneous fibular flaps with an extended skin island.

Since 1993, a total of 41 free osteofasciocutaneous fibular flaps with an extended skin island (average dimensions, 16.9 cm long [range, 12-22 cm] x 10.7 cm wide [range, -16 cm], or 180.8 cm [range, 112-352 cm ]) have been used in by the authors in various clinical applications. To evaluate donor site morbidity, the 41 patients involved were asked to answer a questionnaire and to present themselves for clinical and radiological examination. The subjective findings reported by these patients, and the examinations, showed that donor site morbidity was moderate. Apart from some occurrence of mild edema and pain, as well as modest motor weakness of the great toe, and deficiency of distal nervous segments, only 7 patients were found to have a slightly positive anterior drawer of the talus (anterior subluxation of the talus), but no instability. In conclusion, donor site morbidity after harvest of osteofasciocutaneous fibular flaps for different clinical indications, where extended skin islands were needed, is moderate.

Long-term fate of the bony component in neophallus construction with free osteofasciocutaneous forearm or fibula flap in 18 female-to-male transsexuals.

Female-to-male transsexuals have been operated on in the authors' department since 1975. Between 1981 and 1995, 46 patients underwent neophallus construction with a free osteofasciocutaneous forearm or fibula flap. The bony part of these flaps is embedded in tissue with excellent blood circulation, has no contact with the skeleton, and is free of mechanical stress. To evaluate the long-term fate of the bony component of these flaps, the authors examined 18 of the 46 patients (39.1 percent) who had received a neophallus by means of one of these methods (12 with forearm and six with fibula flap) and who were willing to participate in the updating of the results of the previous two decades; this represented a follow-up of 5 to 112 months postoperatively (average, 27.4 months). The following investigations were undertaken: clinical and radiologic examination, bone scintigraphy, magnetic resonance imaging, and histologic examination of the neophallus bony component. In all patients, the clinical examination showed no significant variations in the shape and rigidity of the neophallus bone. The radiologic examination showed a compact bone structure, and the magnetic resonance imaging proved the vitality of the neophallus in all patients, with no significant changes over time. Bone scintigraphy did not prove to be useful in determining the long-term fate of the neophallic bony component. Histologically, subperiosteal neoformation of fibrous bone was shown, whereas the lamellar cortical bone was predominantly avital. The results of this study reveal the vitality of the bony component in neophallus construction with free osteofasciocutaneous flaps. Even 112 months after the procedure, it provided sufficient stiffness for sexual intercourse. This continuing adequate rigidity of the bony component, in addition to the well-known advantages of the free osteofasciocutaneous flap, is further evidence of its usefulness in neophallus construction.