In performing a phalloplasty for a FTM transsexual, the surgeon should reconstruct an aesthetically appealing neophallus, with erogenous and tactile sensation, which enables the patient to void while standing and have sexual intercourse like a natural male, in a one-stage procedure.17,18 The reconstructive procedure should also provide a normal scrotum, be predictably reproducible without functional loss in the donor area, and leave the patient with minimal scarring or disfigurement.
Despite the multitude of flaps that have been employed and described (often as Case Reports), the radial forearm is universally considered the gold standard in penile reconstruction.17,19,20,21,22,23,24,25,26,27,28
In the largest series to date (almost 300 patients), Monstrey et al29 recently described the technical aspects of radial forearm phalloplasty and the extent to which this technique, in their hands approximates the criteria for ideal penile reconstruction.
For the genitoperineal transformation (vaginectomy, urethral reconstruction, scrotoplasty, phalloplasty), two surgical teams operate at the same time with the patient first placed in a gynecological (lithotomy) position. In the perineal area, a urologist may perform a vaginectomy, and lengthen the urethra with mucosa between the minor labiae. The vaginectomy is a mucosal colpectomy in which the mucosal lining of the vaginal cavity is removed. After excision, a pelvic floor reconstruction is always performed to prevent possible diseases such as cystocele and rectocele. This reconstruction of the fixed part of the urethra is combined with a scrotal reconstruction by means of two transposition flaps of the greater labia resulting in a very natural looking bifid scrotum.
Simultaneously, the plastic surgeon dissects the free vascularized flap of the forearm. The creation of a phallus with a tube-in-a-tube technique is performed with the flap still attached to the forearm by its vascular pedicle (Fig. 8A). This is commonly performed on the ulnar aspect of the skin island. A small skin flap and a skin graft are used to create a corona and simulate the glans of the penis (Fig. 8B).
(A–D) Phallic reconstruction with the radial forearm flap: creation of a tube (urethra) within a tube (penis).
Once the urethra is lengthened and the acceptor (recipient) vessels are dissected in the groin area, the patient is put into a supine position. The free flap can be transferred to the pubic area after the urethral anastomosis: the radial artery is microsurgically connected to the common femoral artery in an end-to-side fashion and the venous anastomosis is performed between the cephalic vein and the greater saphenous vein (Fig. 8C). One forearm nerve is connected to the ilioinguinal nerve for protective sensation and the other nerve of the arm is anastomosed to one of the dorsal clitoral nerves for erogenous sensation. The clitoris is usually denuded and buried underneath the penis, thus keeping the possibility to be stimulated during sexual intercourse with the neophallus.
In the first 50 patients of this series, the defect on the forearm was covered with full-thickness skin grafts taken from the groin area. In subsequent patients, the defect was covered with split-thickness skin grafts harvested from the medial and anterior thigh (Fig. 8D).
All patients received a suprapubic urinary diversion postoperatively.
The patients remain in bed during a one-week postoperative period, after which the transurethral catheter is removed. At that time, the suprapubic catheter was clamped, and voiding was begun. Effective voiding might not be observed for several days. Before removal of the suprapubic catheter, a cystography with voiding urethrography was performed.
The average hospital stay for the phalloplasty procedure was 2½ weeks.
Tattooing of the glans should be performed after a 2- to 3-month period, before sensation returns to the penis.
Implantation of the testicular prostheses should be performed after 6 months, but it is typically done in combination with the implantation of a penile erection prosthesis. Before these procedures are undertaken, sensation must be returned to the tip of the penis. This usually does not occur for at least a year.
The Ideal Goals of Penile Reconstruction in FTM Surgery
What can be achieved with this radial forearm flap technique as to the ideal requisites for penile reconstruction?
A ONE-STAGE PROCEDURE
In 1993, Hage20 stated that a complete penile reconstruction with erection prosthesis never can be performed in one single operation. Monstrey et al,29 early in their series and to reduce the number of surgeries, performed a (sort of) all-in-one procedure that included a SCM and a complete genitoperineal transformation. However, later in their series they performed the SCM first most often in combination with a total hysterectomy and ovariectomy.
The reason for this change in protocol was that lengthy operations (>8 hours) resulted in considerable blood loss and increased operative risk.30 Moreover, an aesthetic SCM is not to be considered as an easy operation and should not be performed “quickly” before the major phalloplasty operation.
AN AESTHETIC PHALLUS
Phallic construction has become predictable enough to refine its aesthetic goals, which includes the use of a technique that can be replicated with minimal complications. In this respect, the radial forearm flap has several advantages: the flap is thin and pliable allowing the construction of a normal sized, tube-within-a-tube penis; the flap is easy to dissect and is predictably well vascularized making it safe to perform an (aesthetic) glansplasty at the distal end of the flap. The final cosmetic outcome of a radial forearm phalloplasty is a subjective determination, but the ability of most patients to shower with other men or to go to the sauna is the usual cosmetic barometer (Fig. 9A-C).
(A–C) Late postoperative results of radial forearm phalloplasties.
The potential aesthetic drawbacks of the radial forearm flap are the need for a rigidity prosthesis and possibly some volume loss over time.
TACTILE AND EROGENOUS SENSATION
Of the various flaps used for penile reconstruction, the radial forearm flap has the greatest sensitivity.1 Selvaggi and Monstrey et al. always connect one antebrachial nerve to the ilioinguinal nerve for protective sensation and the other forearm nerve with one dorsal clitoral nerve. The denuded clitoris was always placed directly below the phallic shaft. Later manipulation of the neophallus allows for stimulation of the still-innervated clitoris. After one year, all patients had regained tactile sensitivity in their penis, which is an absolute requirement for safe insertion of an erection prosthesis.31
In a long-term follow-up study on postoperative sexual and physical health, more than 80% of the patients reported improvement in sexual satisfaction and greater ease in reaching orgasm (100% in practicing postoperative FTM transsexuals).32
VOIDING WHILE STANDING
For biological males as well as for FTM transsexuals undergoing a phalloplasty, the ability to void while standing is a high priority.33 Unfortunately, the reported incidences of urological complications, such as urethrocutaneous fistulas, stenoses, strictures, and hairy urethras are extremely high in all series of phalloplasties, as high as 80%.34 For this reason, certain (well-intentioned) surgeons have even stopped reconstructing a complete neo-urethra.35,36
In their series of radial forearm phalloplasties, Hoebeke and Monstrey still reported a urological complication rate of 41% (119/287), but the majority of these early fistulas closed spontaneously and ultimately all patients were able to void through the newly reconstructed penis.37 Because it is unknown how the new urethra—a 16-cm skin tube—will affect bladder function in the long term, lifelong urologic follow-up was strongly recommended for all these patients.
Complications following phalloplasty include the general complications attendant to any surgical intervention such as minor wound healing problems in the groin area or a few patients with a (minor) pulmonary embolism despite adequate prevention (interrupting hormonal therapy, fractioned heparin subcutaneously, elastic stockings). A vaginectomy is usually considered a particularly difficult operation with a high risk of postoperative bleeding, but in their series no major bleedings were seen.30 Two early patients displayed symptoms of nerve compression in the lower leg, but after reducing the length of the gynecological positioning to under 2 hours, this complication never occurred again. Apart from the urinary fistulas and/or stenoses, most complications of the radial forearm phalloplasty are related to the free tissue transfer. The total flap failure in their series was very low (<1%, 2/287) despite a somewhat higher anastomotic revision rate (12% or 34/287). About 7 (3%) of the patients demonstrated some degree of skin slough or partial flap necrosis. This was more often the case in smokers, in those who insisted on a large-sized penis requiring a larger flap, and also in patients having undergone anastomotic revision.
With smoking being a significant risk factor, under our current policy, we no longer operate on patients who fail to quit smoking one year prior to their surgery.
NO FUNCTIONAL LOSS AND MINIMAL SCARRING IN THE DONOR AREA
The major drawback of the radial forearm flap has always been the unattractive donor site scar on the forearm (Fig. 10). Selvaggi et al conducted a long-term follow-up study38 of 125 radial forearm phalloplasties to assess the degree of functional loss and aesthetic impairment after harvesting such a large forearm flap. An increased donor site morbidity was expected, but the early and late complications did not differ from the rates reported in the literature for the smaller flaps as used in head and neck reconstruction.38 No major or long-term problems (such as functional limitation, nerve injury, chronic pain/edema, or cold intolerance) were identified. Finally, with regard to the aesthetic outcome of the donor site, they found that the patients were very accepting of the donor site scar, viewing it as a worthwhile trade-off for the creation of a phallus (Fig. 10).38 Suprafascial flap dissection, full thickness skin grafts, and the use of dermal substitutes may contribute to a better forearm scar.
(A,B) Aspect of the donor site after a phalloplasty with a radial forearm flap.
For the FTM patient, the goal of creating natural-appearing genitals also applies to the scrotum. As the labia majora are the embryological counterpart of the scrotum, many previous scrotoplasty techniques left the hair-bearing labia majora in situ, with midline closure and prosthetic implant filling, or brought the scrotum in front of the legs using a V-Y plasty. These techniques were aesthetically unappealing and reminiscent of the female genitalia. Selvaggi in 2009 reported on a novel scrotoplasty technique, which combines a V-Y plasty with a 90-degree turning of the labial flaps resulting in an anterior transposition of labial skin (Fig. 11). The excellent aesthetic outcome of this male-looking (anteriorly located) scrotum, the functional advantage of fewer urological complications and the easier implantation of testicular prostheses make this the technique of choice.39
Reconstruction of a lateral looking scrotum with two transposition flaps: (A) before and (B) after implantation of testicular prostheses.
In a radial forearm phalloplasty, the insertion of erection prosthesis is required to engage in sexual intercourse. In the past, attempts have been made to use bone or cartilage, but no good long-term results are described. The rigid and semirigid prostheses seem to have a high perforation rate and therefore were never used in our patients. Hoebeke, in the largest series to date on erection prostheses after penile reconstruction, only used the hydraulic systems available for impotent men. A recent long-term follow-up study showed an explantation rate of 44% in 130 patients, mainly due to malpositioning, technical failure, or infection. Still, more than 80% of the patients were able to have normal sexual intercourse with penetration.37 In another study, it was demonstrated that patients with an erection prosthesis were more able to attain their sexual expectations than those without prosthesis (Fig. 12).32
(A,B) Phalloplasty after implantation of an erection prosthesis.
A major concern regarding erectile prostheses is long-term follow-up. These devices were developed for impotent (older) men who have a shorter life expectancy and who are sexually less active than the mostly younger FTM patients.
Alternative Phalloplasty Techniques
A metoidioplasty uses the (hypertrophied) clitoris to reconstruct the microphallus in a way comparable to the correction of chordee and lengthening of a urethra in cases of severe hypospadias. Eichner40 prefers to call this intervention “the clitoris penoid.” In metoidioplasty, the clitoral hood is lifted and the suspensory ligament of the clitoris is detached from the pubic bone, allowing the clitoris to extend out further. An embryonic urethral plate is divided from the underside of the clitoris to permit outward extension and a visible erection. Then the urethra is advanced to the tip of the new penis. The technique is very similar to the reconstruction of the horizontal part of the urethra in a normal phalloplasty procedure. During the same procedure, a scrotal reconstruction, with a transposition flap of the labia majora (as previously described) is performed combined with a vaginectomy.
FTM patients interested in this procedure should be informed preoperatively that voiding while standing cannot be guaranteed, and that sexual intercourse will not be possible (Fig. 13).
Results of a metoidioplasty procedure.
The major advantage of metoidioplasty is the complete lack of scarring outside the genital area. Another advantage is that its cost is substantially lower than that of phalloplasty. Complications of this procedure also include urethral obstruction and/or urethral fistula.
It is always possible to perform a regular phalloplasty (e.g., with a radial forearm flap) at a later stage, and with substantially less risk of complications and operation time.
There have been several reports on penile reconstruction with the fibular flap based on the peroneal artery and the peroneal vein.27,41,42 It consists of a piece of fibula that is vascularized by its periosteal blood supply and connected through perforating (septal) vessels to an overlying skin island at the lateral site of the lower leg. The advantage of the fibular flap is that it makes sexual intercourse possible without a penile prosthesis. The disadvantages are a pointed deformity to the distal part of the penis when the extra skin can glide around the end of fibular bone, and that a permanently erected phallus is impractical.
Many authors seem to agree that the fibular osteocutaneous flap is an optimal solution for penile reconstruction in a natal male.42
NEW SURGICAL DEVELOPMENTS: THE PERFORATOR FLAPS
Perforator flaps are considered the ultimate form of tissue transfer. Donor site morbidity is reduced to an absolute minimum, and the usually large vascular pedicles provide an additional range of motion or an easier vascular anastomosis. At present, the most promising perforator flap for penile reconstruction is the anterolateral thigh (ALT) flap. This flap is a skin flap based on a perforator from the descending branch of the lateral circumflex femoral artery, which is a branch from the femoral artery. It can be used both as a free flap43 and as a pedicled flap44 then avoiding the problems related to microsurgical free flap transfer. The problem related to this flap is the (usually) thick layer of subcutaneous fat making it difficult to reconstruct the urethra as a vascularized tube within a tube. This flap might be more indicated for phallic reconstruction in the so-called boys without a penis, like in cases of vesical exstrophy (Fig. 14). However, in the future, this flap may become an interesting alternative to the radial forearm flap, particularly as a pedicled flap. If a solution could be found for a well-vascularized urethra, use of the ALT flap could be an attractive alternative to the radial forearm phalloplasty. The donor site is less conspicuous, and secondary corrections at that site are easier to make. Other perforator flaps include the thoracodorsal perforator artery flap (TAP) and the deep inferior epigastric perforator artery flap (DIEP). The latter might be an especially good solution for FTM patients who have been pregnant in the past. Using the perforator flap as a pedicled flap can be very attractive, both financially and technically.
Penile reconstruction with a pedicled anterolateral thigh flap. (A) Preoperative and (B) postoperative results.
A transgender woman who underwent a vaginoplasty to have her penis turned into a vagina has described in graphic detail what the process was really like.
Jessica, who identifies as a queer woman, had already started hormone replacement therapy and gone all the way to South Korea to have vocal chord surgery to transform her baritone voice when she decided to have a breast augmentation surgery and a vaginoplasty in one operation.
After her vaginoplasty, which she had near her home in East Bay Area, California, she warned 'there are going to be parts of you that are going to melt off' in an interview with Truth Speak Project.
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Melting: A transgender woman has described what it is like to undergo gender reassignment surgery; a video reenactment by the European Association of Urology shows what genitals might look like after the procedure
Jessica, whose partner was also born male and had already had the surgery, said there were elements of her recovery that she was not warned about by doctors, adding that it was 'really scary'.
She said: 'There are going to be parts of you that are going to melt off...It is really scary. But it’s also perfectly normal and most people recover from that completely as if nothing has happened.
'Basically the furniture down there gets rearranged during the surgery. One of the many things I learned along this journey is that male genitalia and female genitalia aren’t that different. They’re arranged differently, but the individual parts are really similar.
'So vaginoplasty consists of a re-positioning and folding of all these tissues using the existing tissues.
'When that’s done, some of the tissues might not get as much blood flow as they did before, so they get starved of nutrients and oxygen.
'That’s when the surface tissue tends to die off — which is as gross as it sounds. It is really really awful.'
Warning: Jessica, who was born male, said: 'There are going to be parts of you that melt off' after surgery (medical diagram shown)
Although Jessica said she was expecting her vagina to 'look like Frankenp***y' after surgery, it was much worse that she could have imagined.
At one point she claims she thought she was 'dying'.
'It’s red, there’s stitches and it’s swollen, you can see the stitch lines. You expect that,' she said.
'What you don’t expect is this yellow-y, clumpy, almost mucus-y, looks-like-someone-sneezed-on-your-p***y kind of residue.
'So you might have a chunk of your inner labia just die off, just fall off, and it’ll just grow right back. It’s hard to believe because when you lose a limb or a toe it doesn’t grow back. But it turns out that your p***y does. It’s strange.
'And it’s gross and it’s funky and it’s awful and you think, "Oh my god, What is happening? My p***y is melting. I’m dying." But it turns out that it is perfectly normal.'
She said doctors should better prepare patients for what will happen following the surgery.
'It’s something doctors should tell patients beforehand. Because you’re already dealing with so many changes, working with so many geographic changes on your body.
Healing: She said she had anticipated her vagina looking 'like Frankenp***y' after surgery, pictured in diagram, but said it was much worse than she expected (medical diagram shown)
'Your clitoris, which used to be the head of your penis, is positioned in a completely different way,' she said.
In the early days after the operation, Jessica said there were occasions when she thought she still had male genitalia.
She said: 'There were times early on when I felt like I could feel my penis. I figured out what was going on though.
'Basically, my clit was telling me that it was still the head of my penis, that the most sensitive part of it was still there. It took a lot of adjusting and it was pretty weird at first.'
She said she has shown her new sexual organs to cisgender females who have told her the surgeon 'did a great job'.
Jessica said she has a G-spot and that she has had orgasms - but they are 'very different' to what she experienced before surgery.
She said: 'I do have a G-spot. In fact, I still have a prostate, even though it’s much smaller than it was because of hormone replacement therapy. But it’s still there and it can still be stimulated. It’s still very enjoyable...
'Orgasms are very different. Oh my goodness. They were different even before my surgery after I started hormone replacement therapy. That’s when I started having more full-body orgasms.
Icon: Transgender actress Laverne Cox, 31, left, has previously said she was pleased she could undergo gender reassignment in private; transgender model Andreja Pejic, right, also underwent the procedure in 2014
'The sensation wasn’t just concentrated immediately around my genitals anymore. It was more like waves of pleasure throughout my body.
'So that started happening with just hormones. But then, of course, the surgery changes everything.'
She added: 'I didn’t think that I would get such good results from my surgery but there they are.
'I definitely experience internal stimulation orgasms and they are different from the orgasms I get from clitoral stimulation.
'They’re deeper and they’re more intense — always gush from internal orgasms.'
She said the development of surgery has made experiences for people undergoing the procedure 'a lot better' in the last decade.
She added: 'Some things are different for trans feminine people who had their surgery ten years ago.
'Doctors have gotten to a point now where they can make a vagina that allows you to come and really gush from internal vaginal stimulation just like a cis-gendered woman does, if that’s something that you’re capable of doing.'
Jessica paid for her breast augmentation herself but the vaginoplasty was covered by her insurance as required by California law after a doctor said it was medically needed.
Despite having done so herself, Jessica warned against having both surgeries in one operation.
'I woke up in the recovery room in a world of pain, unable to move,' she said. 'I really underestimated how much the recovery from breast augmentation takes out of you.'
She said she opted for a full vaginal canal because she wanted to experience penetrative sex and to 'relate to cis-gendered women'.
Content: Jessica said she is pleased with the surgery, pictured above, and said since then she has found she has a G-spot and has had orgasms
Progress: Jessica said vaginoplasty surgery, pictured in diagram, has developed considerably over last decade
She added: 'I had to wear a pad every day and I get it. The struggle is real...I have this newfound respect and empathy for my fellow sisters. I get it now...
'I just had my first p-in-v sex as a vagina-haver and it was different from what I expected. It was more intense than I expected.
'I had gotten used to the process of dilating my vagina, which I do with a medical phallus one to two times a day, to keep the new vagina from closing up.
'I’ve been doing that for 9.5 months since my surgery. So having something in my vagina is a normal sensation for me because I experience it every day.
'There are going to be parts of you that are going to melt off... It is really scary. But it’s also perfectly normal
Jessica, transgender woman
'But having a person inside my vagina was a relatively new experience for me. I’ve had fingers but I’ve never had a penis.
'It was a little overwhelming, but it was pleasant and fun and I would totally do it again. The person I had sex with was a preoperative trans woman.'
Transgender model Andreja Pejic underwent gender-reassignment surgery, also known as gender-reconfirmation surgery, in 2014.
Talking about the decision last year the Bosnian model told Vogue: 'Society doesn't tell you that you can be trans. I thought about being gay, but it didn't fit…
'I thought, well, maybe this is just something you like to imagine sometimes'.
Orange Is The New Black star Laverne Cox said she does not like the focus on gender reassignment surgery - saying she is 'grateful' she could have gender reassignment surgery in 'private' unlike Caitlyn Jenner.
The transgender actress told Entertainment Weekly last year: 'I’m so grateful that I had the luxury of transitioning in private because when you transition in the public eye, the transition becomes the story.
'I’m always disturbed when I see conversations about trans people that focus on surgery. But I believe Caitlyn will transcend this moment.'
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