INTRODUCTION
Transsexuality is a dynamic and biopsychosocial condition in which a person has
the subjective feeling of belonging to a different gender than the anatomical
gender (corresponding phenotype and genotype)1. These individuals have significantly lower quality of life
indices compared to the general population, which is probably related to
problems of personal self-esteem and a social character2.
The World Professional Association for Transgender Health
(WPATH) standardized principles based on evidence for the
care of transgender individuals, both for the diagnosis and treatment, taking
into account that gender correction surgeries are needed to alleviate gender
dysphoria in these individuals3.
Accordingly, genital surgery is a safe and reliable option, which drastically
reduces dysphoria and improves the quality of life4,5 in relation to
psychological aspects and social relations, with an improved ability to develop
relationships, greater professional acceptance, and greater feeling of
integration into society6.
Transgender women who undergo genital surgery seek reconstruction of the external
genitalia with appropriate esthetic appearance and functionality. Different
techniques can accomplish this, including penile inversion techniques, scrotal
flaps, scrotal grafts, non-scrotal grafts/flaps, and techniques that use the
large intestine or peritoneum4.
The most studied and currently used technique is penile inversion4,7,8, which is
recommended initially before recommending intra-abdominal techniques8. This technique involves dissection of the
penile skin, formation of a neovaginal cavity between the rectum and bladder,
and inversion of the skin in this cavity, and may use a full-thickness graft of
the scrotal skin for the vaginal covering. Despite the differences in surgical
details, the criteria for patient selection, and the evaluation of results8,9, this technique presents good results10, with an overall satisfaction index of 88%4.
From the functional point of view, satisfaction with the result is seen in more
than 86% of the patients4,11,12, with more than 70% reaching an orgasm1,4,8,10,13.
Even so, additional procedures are often necessary to achieve the best possible
result14,15. Additional corrections of the labia
after surgery are needed in 43% of cases10 and other procedures in general in up to 66% of patients6, given that 28% to 38% of patients
reported being only partially satisfied7
and 9% to 15% reported being dissatisfied with the results obtained1,7,9,11.
These indices can be even higher due to low rates of responses to quality of life
questionnaires in several studies1. The
esthetic and functional outcome of surgery seems to be the most important factor
in the satisfaction or the repentance of the patients after the surgery5, determining the need for additional
procedures.
However, the surgical technique or preoperative care16 have not been standardized, due to the lack of long-term
follow-up of patients and few publications reporting refinements and technical
advances17.
OBJECTIVE
This study proposes to suggest esthetic refinements to the appearance of the
vulva, describing some parallels and limitations of some of the reported
techniques, seeking to increase the postoperative esthetic and functional
satisfaction. The author describes a series of 7 cases and the results of these
technical modifications.
METHODS
A retrospective study with 7 patients operated with the technique described in
this article, between August 2017 and February 2018, was held. The patients
fulfilled the requirements of the Federal Council of Medicine for surgery in
Brazil (older than 21 years of age, at least 2 years since gender transition,
and follow-up with a multidisciplinary team consisting of a psychologist,
psychiatrist, endocrinologist, social worker, and surgeon). Informed consent was
obtained from all patients.
Preoperative care
On the day before surgery, the patients are advised to have a residue-free
diet during the day (without red meat, vegetables, fruits, carbonated
drinks, or alcohol) and liquid diet at dinner. The intestinal preparation is
done with two tablets of bisacodyl at lunch and two tablets at the end of
the afternoon. At night, patients ingest 120 mL of lactulone diluted in 500
mL of filtered orange or lemon juice, which is ingested within 30 minutes,
followed by oral hydration up to 8 hours before the scheduled time of
surgery to prevent dehydration.
Surgical technique
With the patient in the lithotomy position, a perineal and scrotal skin graft
is withdrawn, preserving a 2 cm extension triangular perineal flap, at the
level of the central tendon of the perineum (Figures 1A and 1B).
Orchiectomy is performed with ligation of the inguinal cord at the level of
the superficial inguinal ring. The urethra is separated from the corpus
cavernosum using a catheter to guide its dissection and thebulbospongiosus
muscle and excess corpus spongiosum are removed.
Figure 1 - A: Schematic showing the marking of the skin
graft and the perineal flap; B: Marking of the skin
graft and the perineal flap.
Figure 1 - A: Schematic showing the marking of the skin
graft and the perineal flap; B: Marking of the skin
graft and the perineal flap.
The glans is incised to prepare the clitoris in the form of a trident (Figure 2), including 1.5 cm of its dorsal
portion in a rounded shape, extending laterally to the corona and the cervix
of the glans up to the prepuce, preserving a range of proximal preputial
skin of 1.5 cm. The tube of penile skin is separated from the penile shaft,
preserving its pedicle.
Figure 2 - Illustration showing the flap marking to prepare the
clitoris.
Figure 2 - Illustration showing the flap marking to prepare the
clitoris.
The tunica albuginea is incised laterally and included together with the
neurovascular pedicle, being separated from the corpora cavernosa, which are
ligated at its base and removed. The suture of the trident lateral regions
near the central flap in its most proximal portion is performed with vicryl
3.0, which simulates the corpora cavernosa of the clitoris and defines the
clitoral glans in the central region. The entire flap is folded over and
fixed in the pubic symphysis. The urethra is spatulated, with its distal
portion resected in a triangular shape, which is attached anteriorly to the
clitoris with vicryl 3.0, between the distal portions of the lateral flaps
of the trident (Figure 3).
Figure 3 - Schematic showing all flaps in position. The sutures to
prepare the prepuce and the anterior commissure and definition
of the labia minora are also shown.
Figure 3 - Schematic showing all flaps in position. The sutures to
prepare the prepuce and the anterior commissure and definition
of the labia minora are also shown.
The construction of the vaginal canal is performed using a combination of
blunt dissection with electrocautery, through the central tendon of the
perineum and the Denonvilliers’ fascia. The rectal wall is protected
posteriorly by one of the hands of the surgeon, while the other hand
performs the dissection and the assistant uses an enlightened valve to move
anteriorly the urethra and the penile tissue. The vaginal cavity is
dissected by about 15 cm deep.
The removed scrotal skin is prepared as a total skin graft and sutured in a
pouch to the penile flap. The hair follicles are individually cauterized
and, after hemostatic review, the penile flap is invaginated and inserted
into the cavity. The posterior skin of this flap is opened to accommodate
the perineal flap. Suction drainage is used to prevent fluid accumulation
between the flap/graft and the canal, which is held in place by a vaginal
tamponade of gauze soaked in metronidazole and bacitracin cream.
The exteriorization of the clitoris and the labia minora is performed by
incising the penile flap at the midline at the height of the clitoris until
immediately below the urethral ostium. The lower region of the urethral
stump and the preputial skin of the clitoris are sutured to the penile skin
with vicryl 3.0. In order to define the anterior commissure of the lábia and
the clitoral prepuce, 3 transdermal running sutures are made cranially to
the clitoris with vicryl 3.0, with an inlet and an outlet opening 1 cm from
the midline (Figure 3). A Greek bar
suture is performed to define the labia minora from the height of the
clitoris to the vaginal ostium with vicryl 3.0 (Figure 3). The excess scrotal skin is resected and the
skin closed in 3 planes (Figures 4A
and 4B), followed by compressive
dressing.
Figure 4 - A: Immediate postoperative aspect;
B: Immediate postoperative aspect.
Figure 4 - A: Immediate postoperative aspect;
B: Immediate postoperative aspect.
Postoperative care
The patient is kept at absolute rest for 24 hours. The dressing is removed on
the second day and walking is encouraged. On the third day, the drain is
removed and the patient is discharged from the hospital with a urinary probe
and a vaginal plug. The patient returns between the 7th and 10th day, when
the vesical catheter and the vaginal tampon are removed and postoperative
dilatations are initiated.
RESULTS
The mean age of the 7 patients was 28.3 ± 6.8 years. The only relevant medical
history was hypothyroidism (n = 1) and HIV infection1, both of which were adequately clinically controlled. None
of the patients were smokers. Surgical history included augmentation mammoplasty
(n = 4) and facial feminization (3), with 1 patient without any previous
surgeries. All patients had undergone previous hormonal treatment. The mean
depth reached in the dissection of the vaginal canal was 15.14 ± 0.73 cm. The
hospital stay was 3 days in all cases.
Among the complications, 1 case needed additional surgery for correction due to
the loss of definition of the anterior commissure and higher clitoral exposure
than desired (Figure 5). The more serious
complications were postoperative bleeding (n=1), which required blood
transfusion and cauterization of the bleeding vessel, and a rectal lesion (1),
which was intraoperatively repaired. There was no fistula or stenosis in this
group of patients, nor was there a partial or total necrosis of the
clitoris.
Figure 5 - Eight months postoperative aspect showing loss of the anterior
commissure and exposure of the neoclitoris.
Figure 5 - Eight months postoperative aspect showing loss of the anterior
commissure and exposure of the neoclitoris.
No patient presented with complaints related to vulvar sensitivity and all
reported being satisfied with the surgery and being able to reach orgasm after 3
months of the procedure.
DISCUSSION
Georges Burou and Harold Gillies are known for their description of the penile
inversion technique in transgender women in 1950s7,18, with the
inclusion of a scrotal flap by Howard Jones18. The classic procedure of choice for clitoral reconstruction is
to use the glans (total or partially) as a neurovascular pedicle flap in island,
described by Hinderer19 and modified by
Brown20. The inclusion of the tunica
albuginea21 is technically simple and
decreases the risk of nerve injury.
The basic steps of the penile inversion technique involve: orchiectomy, penile
disassembly, creation of the vaginal cavity between the rectum and bladder,
reconstruction of the clitoris and orthotopic female urethral meatus, and
creation of the labia majora16. Adequate
urogenital function and an attractive esthetic result should be sought from the
genitals, which are key factors for a high rate of satisfaction of patients
submitted to surgery14.
This includes adequate urethral positioning to foster a straight jet of urine,
with an appropriately wide and deep vagina for sexual intercourse and with
adequate sensitivity to experience orgasm, and the use of the whole tissue
available for this is recommended14.
Modern techniques with the preservation of tissues showed best indices of sexual
function compared to the simple penile inversion in standardized
questionnaires22, which reinforces
this recommendation. Thus, in patients with a small penis and without the use of
additional coverage of the vaginal cavity, the esthetic result will depend on
the chosen neovaginal depth, which is resolved with the use of skin grafts7.
The main objectives of an optimal clitoridoplasty are as follows: reproducible,
reliable, and safe single stage technique; appropriate clitoris size under
normal functional conditions; reconstruction of the anatomical structure with
erectile tissue preserving its erogenous innervation; presence of mucous or
epithelial tissue in the vestibular region and around the clitoris; absence of
painful or withdrawn scars; and presence of frenulum and preputial covering23.
The sensitivity of the clitoris is important as a pre-requisite likely to achieve
the sexual orgasm13. When the dorsal
region of the glans is used for the clitoris, a greater stimulus intensity is
required for light touch and pressure stimuli than in cisgender women with
comparable vibration sensitivity12.
Similar results were obtained in another study13, which emphasized the common occurrence of hypersensitivity of
the clitoris and the need for a clitoral hood to protect it from the
hyperstimulation caused by clothes and movement. The technique of the author
addresses both of these needs, increasing the area of erogenous sensation to
include the region of the corona of the glans and prepuce to the dorsal flap,
and at the same time the clitoris also being surrounded by the foreskin and
cranially approximated skin.
The anatomical basis for the creation of the dorsal neurovascular flap using the
author’s technique has already been described. Small branches parallel to the
dorsal nerve of the penis run along the dorsolateral surface of the penis and
penetrate posteriorly in the whole area of the penile corona24. Immediately below the lateroventral
corona of the penis, the dorsal nerve is divided in four branches: a proximal
branch heading dorsally in the direction of the coronal tissue, a branch
diverging (laterally to medially) to the central parenchyma of the glans, and
two other branches diverging laterally and ventrally toward the ventral
region23.
To increase the sensitivity of the clitoris, it is suggested that the Buck fascia
be incised laterally, starting at the base of the penis and the elevation of the
neurovascular pedicle be made deeply to the tunica albuginea of the corpus
cavernosum24. This preserves more
nerve fibers, which run dorsolateral 1.5 to 2 cm from the midline in the erect
penis23.
Techniques using the region of the corona of the glans to increase the surface
area and the erogenous sensory potential of the clitoris have already been
described. Clitoridoplasty using the ventral region of the glans25 would lead to a more complete erogenous
sensation compared to that using the dorsal region by following the anatomical
direction of the nerves in the glans, including the two lateroventral branches
of the dorsal nerve23.
Another technique described uses a bifid and symmetrical flap of the corona of
the glans in the shape of a lotus flower23, preserving the preputial skin in the flap and positioning the
urethra in a manner similar to that described here. The author’s criticism of
this technique is the excessive anteroposterior elongation of the clitoris,
which does not present the ideal clitoral shape from the esthetic point of view
and which decreases the vestibular area above the urethral meatus. In addition,
this technique involves the removal of oval-shaped skin (5.0 x 4.0 cm) from the
dorsal region of the penile flap to externalize the clitoris and urethra, which
decreases the amount of tissue available to define the labia minora and may
increase clitoral exposure.
A very similar technique to that of the author is used for years in Thailand26, with the preparation of a flap in M
preserving preputial skin, which is folded over itself to make the labia minora.
An appraisal of the author to this technique is that the small labia minora are
made only to the height of the urethral meatus, which would be the maximum
length of the lateral M flaps and the adjacent prepuce, and not to the
lateroposterior region of the vaginal introitus as is expected in the vulvar
anatomy.
Accordingly, the definition of the labia minora subsequently depends exclusively
on the excess skin of the penile flap. The author also prefers the rounded shape
of the central region of the trident, as bringing it from the lateral flaps
forms a discreet anterior projection, building the clitoris more reliably (a
technique demonstrated by Marci Bowers to the author, in the 1st half of 2014).
In the author’s view, the approach to expose in block the clitoris/urethra
decreases the risk of urethral stenosis and preserves a greater quantity of skin
for preparation of the labia minora.
Preputial skin can be used to define the labia minora, as described in the
previous paragraph, but the most common approach is to use the lateral and
proximal part of the penile flap. Some authors perform this procedure in a
second stage, some months after the vaginoplasty14. Thus, zetaplasty can be used in the pubic region for the
advancement of the labia minora18 or for
clitoral coverage and labial convergence13,27. The use of
sutures to define the labia minora has been described28.
As held by the author, the preputial skin is sutured to the longitudinal opening
of the penile flap, forming the inner wall of the labia minora. The Greek bar
suture from the clitoris to the posterior region of the vaginal meatus helps
better define the labia minora (a technique demonstrated by Marci Bowers to the
author, in the 1st half of 2014). Similarly, the approximation of the cranial
skin toward the clitoris in the direction of the midline defines the anterior
commissure and the clitoral prepuce, protecting it from tactile
hyperstimulation.
Some of the techniques use a long scrotal flap to prepare the posterior vaginal
wall7,23,26,27,29. The author
has experience with this type of longer flaps and believes (as the authors of
these techniques) that the posterior commissure suture line should be interposed
with a flap to avoid stenosis, but currently prefers a short flap to avoid
growth of hair in the vagina.
There is a progressive improvement in the timing of the perception of the
esthetic result by patients and medical staff due to the improvement in
postoperative edema and the healing of surgical wounds29, which was also verified by the author (Figures 6 and 7).
Figure 6 - Two months postoperative aspect (patient in the lithotomy
position).
Figure 6 - Two months postoperative aspect (patient in the lithotomy
position).
Figure 7 - Two months postoperative aspect (patient standing).
Figure 7 - Two months postoperative aspect (patient standing).
The satisfaction with surgery reported by patients was excellent and higher than
that reported earlier1,4,10,11, although
the small number of patients makes it impossible to perform a statistical
comparison and some studies do not specify the technique used. The same is the
case with the sensitivity and the ability of patients to achieve orgasms.
Some reports indicate that more than half of the patients operated on show a
greater intensity of orgasms compared to the preoperative period1. Other factors may be associated with
sexual satisfaction and may contribute to the overall well-being, such as
stability and satisfaction with relationships, acceptance of body image, mood
disorders, and physical health6,7.
CONCLUSION
The esthetic refinements defended in this article by the author and proposed by
the surgeons who preceded him seek the closest possible results of sex
reassignment surgery to the female anatomy and proper vaginal function,
presenting high levels of satisfaction and sensitivity. This area is constantly
evolving, but obviously has its limitations. Patients must always be aware that
additional procedures are often necessary to achieve the best possible
result15, and their expectations,
often unrealistic and unattainable, must be adjusted.
Due to the significant dissemination of information on and awareness of
transgenderism, studies on sex reassignment surgeries are advancing at a higher
pace14, but more prospective studies
are needed, as well as standardization of surgical procedures and long-term
follow-up with larger numbers of patients to identify the most effective
techniques for better aesthetic and functional results and greater satisfaction
of patients, among the various technical variations and preferences of the
surgeons.
COLLABORATIONS
|
MZM
|
Analysis and/or interpretation of data; statistical analyses;
conception and design of the study; conception and design of the
study; writing the manuscript or critical review of its
contents.
|
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1. Faculdade de Medicina do ABC, Santo André, SP,
Brazil.
Corresponding author: Matheus Zamignan
Manica Rua Tenente Gomes Ribeiro, nº 78, cj 114 - Vila Clementino,
São Paulo, SP, Brazil Zip Code 04038-040 E-mail:
contato@drmatheusmanica.com.br
Article received: June 12, 2018.
Article accepted: August 7, 2018.
Conflicts of interest: none.
