Application of embryonic equivalents in male-to-female sex reassignment surgery

ABSTRACT

Introduction: The feeling of incongruence between phenotypic sex and psychological recognition of self-gender is termed gender dysphoria. Transsexualism is the most extreme form of this disorder. Aims and Objectives: The aims and objectives of the study are to evaluate the esthetic and functional outcome of embryonic equivalents-based male-to-female sex reassignment surgery in transwomen using the institutional scoring system. Materials and Methods: Thirty transwomen who had undergone male-to-female embryonic equivalents-based sex reassignment surgery (MFEEbSRS) from October 2012 to March 2016 were retrospectively studied. The outcome was evaluated by two independent plastic surgeons, based on interview with the individuals, visual assessment, and measurements. Surgical Technique: Clitoris was created from reduced glans on dorsal penile pedicle mounted on the crura of the conjoined corpora cavernosa. De-gloved unfurled proximal penile skin formed the introitus, hood for clitoris and labia minora. Neo-external urethral meatus was fashioned from the distal portion of the bulbar urethra. Distal de-gloved inverted penile tube flap was used for the creation of neovagina. Reduced scrotal flaps formed the labia majora. Observation and Results: The maximum length of neovagina in the study was 12 cm, and the average length was 9.8 cm. Based on our institutional scoring system for the assessment of esthetic and functional outcome, we got excellent results in all transwomen. Conclusion: The esthetic and functional outcome in all the patients was good. All patients were relieved of their primordial feminine tension and satisfied with the surgery. Their personality, lifestyle, and self-esteem improved remarkably following surgery.

KEY WORDS

De-gloved penile inversion flap - male to female embryonic equivalents-based sex reassignment surgery - transgenders - transwomen - vaginoplasty

• REFERENCES

• 1 World Professional Association for Transgender Health. The Standards of Care for Health of Transsexual, Transgender, Gender-Nonconforming People 7^th version. New York World Professional Association for Transgender Health; 2012
• 2 Kaufman D, Maasdam JV, Laub DR. Plastic surgery. In: Stephen J. editor Mathes-Surgery for Gender Identity Disorder. 2nd ed.. Ch. 156 Phioladelphia Saunders Elsevier; 2006: p. 1305-16
• 3 Benjamin H. The transsexual phenomenon. Trans N Y Acad Sci New York 1967; 29 (4 seriesII) 428-430 [Doi: 10.1111/j. 2164-0947.1967.tb02273.x].
• 4 Fisk NM. Gender dysphoria syndrome (the how, what and why of a disease). In Laub DR, Gandy PP. editors. Proceedings of the Secondary Interdisciplinary Symposium on Gender Dysphoria Syndrome. Stanford, California: Division of Reconstructive and Rehabilitation Surgery, Stanford University Medical Center; 1973
• 5 Robert L. Spitzer-Diagnostic and Statistical Manual of Mental Disorders. 3rd ed.. Washington, D.C: American Psychiatric Association; 1980
• 6 Meerwijk EL, Sevelius JM. Transgender population size in the United States: A Meta-regression of population-based probability samples. Am J Public Health 2017; 107: e1-8
• 7 Gupta R, Murarka A. Treating transsexuals in India: History, prerequisites for surgery and legal issues. Indian J Plast Surg 2009; 42: 226-33
• 8 Kruijver FP, Zhou JN, Pool CW, Hofman MA, Gooren LJ, Swaab DF. et al. Male-to-female transsexuals have female neuron numbers in a limbic nucleus. J Clin Endocrinol Metab 2000; 85: 2034-41
• 9 Chung WC, De Vries GJ, Swaab DF. Sexual differentiation of the bed nucleus of the stria terminalis in humans may extend into adulthood. J Neurosci 2002; 22: 1027-33
• 10 McMinn RM. Last's Anatomy Regional and Applied. 9th ed.. Edinburgh-Churchill Livingstone; 1994: p. 408-10
• 11 Karim RB, Hage JJ, Mulder JW. Neovaginoplasty in male transsexuals: Review of surgical techniques and recommendations regarding eligibility. Ann Plast Surg 1996; 37: 669-75
• 12 McGregor IA. Fundamental Techniques of Plastic Surgery and Their Surgical Applications. 8th ed.. Edinburgh: Churchill Livingstone; 1989: p. 39-63
• 13 Abraham F. Genitalumwandlung an zwei mnnlichen Transvestiten. Sexwiss Sexpol 1931; 18: 223
• 14 Abbe R. New method of creating a vagina in a case of congenital absence. Med Rec 1898; 54: 836
• 15 McIndoe AH, Banister JB. An operation for the cure of congenital absence of vagina. J Obstet Gynaecol 1938; 45: 490
• 16 Fogh-Andersen P. Transsexualism, an attempt at surgical management. Scand J Plast Reconstr Surg 1969; 3: 61-4
• 17 Gillies H, Millard Jr RD. Genitalia. The Principles of Art of Plastic Surgery. London: Butterworth; 1957: 368-88
• 18 Bouman FG. Sex reassignment surgery in male to female transsexuals. Ann Plast Surg 1988; 21: 526-31
• 19 Jones Jr HW, Schirmer HK, Hoopes JE. A sex conversion operation for males with transsexualism. Am J Obstet Gynecol 1968; 100: 101-9
• 20 Edgerton MT, Bull J. Surgical construction of the vagina and labia in male transsexuals. Plast Reconstr Surg 1970; 46: 529-39
• 21 Cairns TS, de Villiers W. Vaginoplasty. S Afr Med J 1980; 57: 50-5
• 22 Ettner R, Monstrey S, Coleman E. Huang pudendal flap. Principles of Transgender Medicine and Surgery. 2nd ed.. 2016. New York: Routledge; p. 268
• 23 Sneguireff WF. Zwei Falle von Restitutio Vaginiae per Transplantationen. Ani Recti Central Gynakol 1904; 28: 772
• 24 Baldwin JF. XIV. The formation of an artificial vagina by intestinal trransplantation. Ann Surg 1904; 40: 398-403
• 25 Selvaggi G, Ceulemans P, De Cuypere G, VanLanduyt K, Blondeel P, Hamdi M. et al. Gender identity disorder: General overview and surgical treatment for vaginoplasty in male-to-female transsexuals. Plast Reconstr Surg 2005; 116: 135e-145e
• 26 Karim RB. Vaginoplasty in Transsexuals. Amsterdam: VU University Press; 1996
• 27 Edgerton MT, Knorr NJ, Callison JR. The surgical treatment of transexual patients: Limitations and indications. Plast Reconstr Surg 1970; 45: 38-44
• 28 Marten-Perolino R, Cocimano V, Marino G. Male-female transsexualization with glandular preservation. Arch Ital Urol Nefrol Androl 1990; 62: 101-5
• 29 Malloy TR, Noone RB, Morgan AJ. Experience with the 1-stage surgical approach for constructing female genitalia in male transsexuals. J Urol 1976; 116: 335-7
• 30 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: 401-6
• 31 Rubin SO. A method of preserving the glans penis as a clitoris in sex conversion operations in male transsexuals. Scand J Urol Nephrol 1980; 14: 215-7
• 32 von Szalay L. Construction of a neo-clitoris in male-to-female transsexuals. Handchir Mikrochir Plast Chir 1990; 22: 277-8
• 33 Fang RH, Chen CF, Ma S. A new method for clitoroplasty in male-to-female sex reassignment surgery. Plast Reconstr Surg 1992; 89: 679-82
• 34 Eldh J. Construction of a neovagina with preservation of the glans penis as a clitoris in male transsexuals. Plast Reconstr Surg 1993; 91: 895-900
• 35 Hage JJ, Karim RB, Bloem JJ, Suliman HM, van Alphen M. Sculpturing the neoclitoris in vaginoplasty for male-to-female transsexuals. Plast Reconstr Surg 1994; 93: 358-64
• 36 Hinderer UT. Aesthetic plastic correction of incomplete testicular feminization. Aesthetic Plast Surg 1979; 3: 201-17
• 37 Hinderer UT. Reconstruction of the external genitalia in the adrenogenital syndrome by means of a personal one-stage procedure. Plast Reconstr Surg 1989; 84: 325-37
• 38 Brown J. Creation of a functional clitoris and aesthetically pleasing introitus in sex conversion. In: Marchac D, Hueston JT. editors. Transactions of the Sixth International Congress of Plastic and Reconstructive Surgery. Paris: Masson; 1976: p. 654
• 39 Mollard P, Juskiewenski S, Sarkissian J. Clitoroplasty in intersex: A new technique. Br J Urol 1981; 53: 371-3
• 40 Amend B, Seibold J, Toomey P, Stenzl A, Sievert KD. Surgical reconstruction for male-to-female sex reassignment. Eur Urol 2013; 64: 141-9
• 41 Karim RB, Hage JJ, Bouman FG, Dekker JJ. 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. Ann Plast Surg 1991; 26: 554-6
• 42 Neligan PC. Plastic surgery: Lower extremity trunk and burns. In: Loren S, Song DH. editors. Schechter Surgery for Gender Dysphoria. 4th ed.. Vol. 4. London-Elsevier Inc.; 2018: p. 33