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CC BY-NC-ND 4.0 · Indian J Plast Surg 2022; 55(02): 188-195
DOI: 10.1055/s-0041-1740530
Original Article

Achieving Correct Axis and Good Depth in Gender Affirming Vaginoplasties by Penile-Perineoscrotal Flap Vaginoplasty

Richie Gupta 
1   Department of Plastic, Aesthetic and Reconstructive Surgery, and Gender Identity Clinic, Fortis Hospital Shalimar Bagh, Delhi, India
,
Rajat Gupta
1   Department of Plastic, Aesthetic and Reconstructive Surgery, and Gender Identity Clinic, Fortis Hospital Shalimar Bagh, Delhi, India
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Abstract

Objectives Vaginoplasty as a part of feminizing genitoplasty (FG) in transwomen helps alleviate gender dysphoria and improves mental health, sexual and psychosocial functioning, and quality of life in these individuals. Penile inversion technique (PSFV) remains the gold standard procedure for FG with least morbidity but has inherent limitations often resulting in inadequate depth and incorrect (posteroinferior) vaginal axis, precluding sexual intercourse.

Material and Methods Over the past 27 years, the senior author has refined his technique considerably incorporating several modifications penile perineo-scrotal flap vaginoplasty (PPSFV) to overcome the limitations in PSFV. Most of these modifications were in place by March 2015. Out of 630 primary FGs, retrospective review of all PPSFV with minimum 6 months follow-up operated during the period March 2015 to July 2020 was done for intra and postoperative complications.

Results There were 183 patients who underwent PPSFV during the study period. Average follow-up was 31 (6–62) months. There were no cases of injury to bladder, rectum, urethral stenosis, or neovaginal prolapse. Average operative time was 4 hours and eight (4.37%) patients required blood transfusion. The vaginal depth was 13 to 14 cm or more in 159 (86.88%), 10 to 12 cm in 17 (9.29%), and 7.5 to 9 cm in seven (3.82%) patients. Ten (5.46%) patients complained of intravaginal hair growth. Touch up procedures in the form of anterior commissure and labia plasty were required in 13 (7.10%) patients. All (100%) patients had good clitoral sensitivity and preserved posterosuperior vaginal axis. One-hundred thirty nine (75.96%) patients were able to have satisfactory penetrative sexual intercourse, while 39 (21.31%) had not attempted intercourse and five (2.73%) complained of poor sexual experience on account of inadequate vaginal dimensions.

Conclusion PPSFV addresses the limitations in PSFV and results in good vaginal depth and posterosuperior axis, which facilitates penetrative sexual intercourse, at the same time, avoiding potential complications of procedures such as intestinal vaginoplasties.

Keywords

vaginoplasty - penile inversion vaginoplasty - feminizing genitoplasty - gender affirmation surgery - gender incongruence - gender dysphoria

Financial Disclosure

None.




Publication History

Article published online:
18 July 2022

© 2022. Association of Plastic Surgeons of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Berli JU, Knudson G, Fraser L. et al. What surgeons need to know about gender confirmation surgery when providing care for transgender individuals: a review. JAMA Surg 2017; 152 (04) 394-400
    CrossrefPubMedGoogle Scholar
  • 2 Arcelus J, Bouman WP, Van Den Noortgate W, Claes L, Witcomb G, Fernandez-Aranda F. Systematic review and meta-analysis of prevalence studies in transsexualism. Eur Psychiatry 2015; 30 (06) 807-815
    CrossrefPubMedGoogle Scholar
  • 3 Conron KJ, Scott G, Stowell GS, Landers SJ. Transgender health in Massachusetts: results from a household probability sample of adults. Am J Public Health 2012; 102 (01) 118-122
    CrossrefPubMedGoogle Scholar
  • 4 Winter S, Diamond M, Green J. et al. Transgender people: health at the margins of society. Lancet 2016; 388 (10042): 390-400
    CrossrefPubMedGoogle Scholar
  • 5 Dora Richter from Wikipedia. Accessed March 15, 2021 at: https://en.wikipedia.org/wiki/Dora_Richter
    Google Scholar
  • 6 Lile Elbe from Wikipedia. Accessed March 15, 2021 at: https://en.wikipedia.org/wiki/Lili_Elbe
    Google Scholar
  • 7 Gillies H, Millard Jr RD. Genitalia. In: The Principles and Art of Plastic Surgery. London: Butterworth; 1957: 368-388
    Google Scholar
  • 8 Jones Jr HW, Schirmer HKA, Hoopes JE. A sex conversion operation for males with transsexualism. Am J Obstet Gynecol 1968; 100 (01) 101-109
    CrossrefPubMedGoogle Scholar
  • 9 Pandya NJ, Stuteville OH. A one-stage technique for constructing female external genitalia in male transsexuals. Br J Plast Surg 1973; 26 (03) 277-282
    CrossrefPubMedGoogle Scholar
  • 10 Foerster DW, Reynolds CL. Construction of natural appearing female genitalia in the male transsexual. Plast Reconstr Surg 1979; 64 (03) 306-312
    CrossrefPubMedGoogle Scholar
  • 11 Meyer R, Kesselring UK. One-stage reconstruction of the vagina with penile skin as an island flap in male transsexuals. Plast Reconstr Surg 1980; 66 (03) 401-406
    CrossrefPubMedGoogle Scholar
  • 12 Eldh J. Construction of a neovagina with preservation of the glans penis as a clitoris in male transsexuals. Plast Reconstr Surg 1993; 91 (05) 895-900 , discussion 901–903
    CrossrefPubMedGoogle Scholar
  • 13 Perović S. Male to female surgery: a new contribution to operative technique. Plast Reconstr Surg 1993; 91 (04) 703-711 , discussion 712
    CrossrefPubMedGoogle Scholar
  • 14 Perovic SV, Stanojevic DS, Djordjevic ML. Vaginoplasty in male transsexuals using penile skin and a urethral flap. BJU Int 2000; 86 (07) 843-850
    CrossrefPubMedGoogle Scholar
  • 15 Reed HM. Aesthetic and functional male to female genital and perineal surgery: feminizing vaginoplasty. Semin Plast Surg 2011; 25 (02) 163-174
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Fang RH, Chen TJ, Chen TH. Anatomic study of vaginal width in male-to-female transsexual surgery. Plast Reconstr Surg 2003; 112 (02) 511-514
    CrossrefPubMedGoogle Scholar
  • 17 Gupta R, Gupta R, Mehta R, Aggarwal A, Mathur A. Gender Dysphoria. In: Agrawal K, Mahajan RK. eds. Textbook of Plastic, Reconstructive and Aesthetic Surgery Volume IV. Noida, Uttar Pradesh: Thieme Publishers; 2019: 259-293
    Google Scholar
  • 18 Coleman E, Bockting W, Botzer M, Cohen-Kettenis P. et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, 7th version. 2012; 13 (04) 165-232
    PubMedGoogle Scholar
  • 19 Gupta R, Kaushik N, Asokan A. et al. Surgical Care: Surgical Management of Gender Incongruence. In: Indian Standards of Care for Persons with Gender Incongruence and People with Differences in Sexual Development/Orientation Version 1. Delhi: Wisdom Publishers; 2020: 66-165
    Google Scholar
  • 20 Bizic M, Kojovic V, Duisin D. et al. An overview of neovaginal reconstruction options in male to female transsexuals. ScientificWorldJournal 2014; 2014: 638919
    CrossrefPubMedGoogle Scholar
  • 21 Selvaggi G, Ceulemans P, De Cuypere G. et al. Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals. Plast Reconstr Surg 2005; 116 (06) 135e-145e
    CrossrefPubMedGoogle Scholar
  • 22 Parsons JK, Gearhart SL, Gearhart JP. Vaginal reconstruction utilizing sigmoid colon: complications and long-term results. J Pediatr Surg 2002; 37 (04) 629-633
    CrossrefPubMedGoogle Scholar
  • 23 Gaither TW, Awad MA, Osterberg EC. et al. Postoperative complications following primary penile inversion vaginoplasty among 330 male to female transgender patients. J Urol 2018; 199 (03) 760-765
    CrossrefPubMedGoogle Scholar
  • 24 Goddard JC, Vickery RM, Qureshi A, Summerton DJ, Khoosal D, Terry TR. Feminizing genitoplasty in adult transsexuals: early and long-term surgical results. BJU Int 2007; 100 (03) 607-613
    CrossrefPubMedGoogle Scholar
  • 25 Krege S, Bex A, Lümmen G, Rübben H. Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients. BJU Int 2001; 88 (04) 396-402
    CrossrefPubMedGoogle Scholar
  • 26 Wagner S, Greco F, Hoda MR. et al. Male-to-female transsexualism: technique, results and 3-year follow-up in 50 patients. Urol Int 2010; 84 (03) 330-333
    CrossrefPubMedGoogle Scholar
  • 27 Rossi Neto R, Hintz F, Krege S, Rubben H, Vom Dorp F. Gender reassignment surgery—a 13 year review of surgical outcomes. Int Braz J Urol 2012; 38 (01) 97-107
    CrossrefPubMedGoogle Scholar
  • 28 Raigosa M, Avvedimento S, Yoon TS, Cruz-Gimeno J, Rodriguez G, Fontdevila J. Male-to-female genital reassignment surgery: a retrospective review of surgical technique and complications in 60 patients. J Sex Med 2015; 12 (08) 1837-1845
    CrossrefPubMedGoogle Scholar
  • 29 Wangjiraniran B, Selvaggi G, Chokrungvaranont P, Jindarak S, Khobunsongserm S, Tiewtranon P. Male-to-female vaginoplasty: Preecha's surgical technique. J Plast Surg Hand Surg 2015; 49 (03) 153-159
    CrossrefPubMedGoogle Scholar
  • 30 Buncamper ME, van der Sluis WB, van der Pas RSD. et al. Surgical outcome after penile inversion vaginoplasty: a retrospective study of 475 transgender women. Plast Reconstr Surg 2016; 138 (05) 999-1007
    CrossrefPubMedGoogle Scholar
  • 31 Pariser JJ, Kim N. Transgender vaginoplasty: techniques and outcomes. Transl Androl Urol 2019; 8 (03) 241-247
    CrossrefPubMedGoogle Scholar
  • 32 Salibian AA, Schechter LS, Kuzon WM. et al. Vaginal canal reconstruction in penile inversion vaginoplasty with flaps, peritoneum or skin grafts: where is the evidence?. Plast Reconstr Surg 2021; 147 (04) 634e-643e
    CrossrefPubMedGoogle Scholar
  • 33 Massie JP, Morrison SD, Van Maasdam J, Satterwhite T. Predictors of patient satisfaction and postoperative complications in penile inversion vaginoplasty. Plast Reconstr Surg 2018; 141 (06) 911e-921e
    CrossrefPubMedGoogle Scholar