Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Trochanter
These defects are common in patients positioned laterally for prolonged periods.
Flap reconstruction most commonly TFL, but pedicled ALT flap is also an option.
TFL blood supply consistent from underlying TFL muscle, but distal part of flap is random blood
supply that may need to be delayed.
If there is a SCI below L3, the TFL can be sensate via L1–L3 by way of the lateral femoral cutaneous
nerve (Figure 99.5).
FIGURE 99.5 Flap options for pressure injury reconstruction. A. Local advancement of fasciocutaneous flap. B. V-Y
advancement/hamstring flap. C. Tensor fascia lata flap. D. Gluteal rotation flap for sacral pressure injury can be elevated as
myocutaneous or fasciocutaneous flap. E. Single- or double-opposing V-Y advancement flaps can be elevated as
myocutaneous or fasciocutaneous flaps.
(Reprinted with permission of Cleveland Clinic Center for Medical Art & Photography ©2018. All rights reserved.)
mebooksfree.net

Ears, Scapula, Heels
Ears and scapula may be amenable to primary closure or local tissue rearrangement.
Heels may require lifelong wound care, free flap coverage, or amputation depending on patient
functional status and comorbid state.
Lower-extremity pressure injuries require careful assessment of vascular status and treatment of
underlying ischemia.
mebooksfree.net

Massive or Multifocal Pressure Injuries
It may not be logistically feasible to cover with local or distant flap(s) because of overwhelming size,
medical comorbidities, and ability to tolerate and comply with postoperative management.
Local wound care indefinitely, with consideration of radical procedures such as Girdlestone resection
and multiple flap reconstruction, or amputation with total thigh flap closure (Figure 99.6).
FIGURE 99.6 Tensor fascia lata with vastus lateralis for coverage of a resected femoral head (Girdlestone procedure).
(Reprinted with permission of Cleveland Clinic Center for Medical Art & Photography ©2018. All rights reserved.)
mebooksfree.net

Postoperative Considerations
Acute Management
Continue behavioral modifications and multidisciplinary, team-based management of patient
comorbidities and postoperative care to optimize wound healing.
Place the patient on a pressure-relieving surface such as an air-
 fluidized bed or low-air loss
mattress. A period of bedrest is beneficial to allow surgical incisions to heal without disruption;
however, this must be considered in the context of the risks of bedrest such as pneumonia, VTE, and
deconditioning. Recommendations vary from 2 weeks to approximately 6 weeks depending on
surgeon preference, extent of the reconstruction, and location of the injury.
Avoid sitting upright in bed. Resume sitting on a limited basis with gradual increase over several
days. Ensure patient is seated on an appropriate pressure-reducing surface.
DVT risk assessment: Patients with SCI are particularly susceptible to venous thromboembolism
(VTE). Risk stratification such as the Caprini Risk Assessment Model may be useful to guide
perioperative VTE prophylaxis. Although there is no evidence to suggest that there is higher risk of
postoperative VTE in the plastic surgery population with chronic SCI, physicians are encouraged to
exercise vigilance in monitoring for venous thromboembolic events, as the incidence of VTE has been
reported as high as 11% in the acute SCI population, despite receiving VTE prophylaxis. 50
Awareness of potential AD in SCI patients: Caused by disordered response to stimuli below the level
of the lesion, such as bladder and bowel distension. Clinical manifestations may include severe
hypertension, increased intracranial pressure leading to seizures or hemorrhage, and cardiac
complications including myocardial ischemic, arrhythmias, and pulmonary edema. Patients should
be monitored for increase in blood pressure of >20%, headache, flushing, sweating, chills, nasal
congestion, piloerection, and pallor. Patients with lesions above T6 are particularly susceptible.
mebooksfree.net

Postoperative Complications
Complication rates are high, with recurrence and wound dehiscence as the most common complications.
Recurrence rates as high as 80% are reported in some studies. 43,47 However, the literature examining
complications and outcomes remains varied and is often limited to single-center retrospective analyses.
Unfortunately, postoperative complications further raise the already substantial cost of surgery and care
for these pressure-related injuries 51 (Table 99.2).
TABLE 99.2
Risk Factors for Postoperative Complications
Recurrence/Reoperation
Young age (<45 yr)
Low albumin <3.5 g/dL
African American
Ischial location
Flap choice: V-Y thigh flap a
Smoking
Premature sitting
Anemia requiring perioperative blood transfusion
Infection
Diabetes
American Society of Anesthesiologists class >3
Perioperative blood transfusion
Longer operative times
Wound Dehiscence/Flap Failure
Ischial location
Low albumin <3.5 g/dL
Anemia requiring perioperative blood transfusion
Longer operative time
Acute osteomyelitis
HgbA1c >6%
aControversial because of tension on closure.
mebooksfree.net

Mortality Risk
The association between pressure injuries and increased risk of mortality is well documented, especially
among elderly patients. 52 Patients who develop a pressure injury in an ICU setting have in-hospital
mortality rates as high as 48%. 53 Further, an Agency for Health Research and Quality report
demonstrated a 4.2% in-hospital 
 mortality rate for patients with a primary diagnosis of pressure injury,
with an 11.6% in-hospital mortality rate in patients with secondary diagnosis of pressure injury,
compared to only 2.6% mortality rate for all other diagnoses. 4 In a recent study examining the US-based
National Surgical Quality Improvement Program, Kwok et al found that over 3% of all patients
undergoing pressure injury surgery for closure die within 30 days of the operation. 25 Age above 65 years,
diabetes, and total functional dependency were associated with increased mortality risk; however, given
the data reporting style of the National Surgical Quality Improvement Program, exact cause of mortality
could not be defined. Pressure injuries are a marker of other underlying disease processes, and the overall
risks of surgery must be carefully discussed with patients and family members.
mebooksfree.net

Rehabilitation and Prevention
Recovery after surgical debridement and/or flap reconstruction may be best completed at a skilled
nursing or rehabilitation facility to secure adequate assistance. Psychiatry and social services may need to
be involved to assist with home environment, safety, 
 compliance, and provide resources for access to
services and supplies.
Prior to resuming sitting and returning to the home environment, the factors contributing to injury
development must be addressed:
Pressure injuries—depending on how much time is spent in bed versus chair, whether the patient
has help at home, access to offloading devices or a special bed, and the age of their wheelchair, may
need referral to rehabilitation medicine and/or a homecare nurse for care.
Extremity injuries—depending on whether the wound resulted from pressure from a brace or
footwear, and what they plan to use moving forward, in addition to their weight-bearing 
 status,
may need referral to podiatry or orthotics for proper fitting.
mebooksfree.net

Long-Term Management
Some patients may never be surgical candidates, in which case long-term nonoperative management is
indicated. However, quality local wound care is labor-intensive, and social and financial considerations
may limit long-term follow-up and compliance with regimen, ultimately leading to poor outcomes.
Chronic nonhealing injuries must be monitored for carcinoma (Marjolin ulcer). It is highly likely that the
pathogenesis underlying malignant transformation is linked to multiple factors of environmental
(unremitting irritation), immunological (avascular scar tissue interfering with lymphocyte mobility), and
genetic nature (elevated protooncogenes). The most common malignancy is an aggressive form of
squamous cell carcinoma, appearing anywhere from 2 to 25 years from time after the initial wound. With
a 2-year survival rate of 66% to 80%, and metastatic rate of 61% (versus those occurring in burn scar 34%),
treatment is wide surgical excision (lymph node dissection is not recommended unless clinical
involvement). 54 If patients refuse surgery or the size location is deemed unresectable, chemotherapy and
radiation may be used.
mebooksfree.net

Questions
1. A 56-year-old woman with a history of hypertension and depression, who sustained a pressure
injury after prolonged immobilization following motor vehicle accident and bilateral femur fractures
14 months ago presents to your outpatient wound clinic for evaluation for closure of her healing
right ischium stage 3 pressure sore. She has lost 7 kg since her accident but is now ambulating with
assistance. On examination, her wound is 6 × 4 × 4 cm with a clean granulating soft tissue base with
no bone exposed. Today’s laboratory test results indicate a white count of 7000, hemoglobin 12.4,
albumin 2.1, and prealbumin 13 mg/dL. Her final cultures show no growth. She is performing wet to
dry packing with normal saline and gauze twice per day. She feels her wound is not progressing and
would like to consider surgical closure. What is the next step?
a. Schedule for surgery at the soonest for split thickness skin graft
b. Obtain MRI to ensure no bone involvement suggesting osteomyelitis first
c. Consult with nutrition for optimization prior to elective surgery
d. Continue local wound care, as a flap in a patient of her position would most likely fail.
e. Schedule for surgery for total ischiectomy to relieve pressure on overlying soft tissues before
attempting soft tissue closure.
2. A 37-year-old man with history of traumatic SCI at T6 undergoes debridement of an ischial
pressure injury with local wound care initiated. The patient spends appropriate time in the recovery
room before being transported to the floor. Within 1 hour of the patient’s arrival there, he complains
of nausea and neck pain. His temperature is 37.4, blood pressure is 190/100, and HR is 59 bpm. What
should be considered first in working up this patient?
a. Increase pain medication postoperatively
b. Add beta blocker as needed for systolic >150 blood pressure control
c. Add antiemetic
d. Administer intravenous dantrolene
e. Check urine output and place Foley catheter
3. A 54-year-old woman with paraplegia since age 24 comes to your clinic with a stage IV pressure
injury of unknown time period; you suspect at least 6 months in duration based on your history and
physical examination, in which you see denuded bone at the base of the wound and pink-
granulating tissue on the periphery. She has been diligent with pressure offloading and wound care
with moisture dressings, but it does not seem to be improving. Which of the following is the most
appropriate next step?
a. Order MRI of the pelvis
b. Schedule for elective flap closure
c. Order CT of the pelvis
d. Schedule for debridement and bone biopsy
e. Discuss long-term palliative care for this wound
4. A 38-year-old woman who works in accounting and spends most of her time in a wheelchair
presents to your clinic with a trochanteric pressure-related sore. After appropriate medical workup
and optimization of nutrition, you decide to cover her wound with a posterior thigh
musculocutaneous flap. What is the chief disadvantage of this flap?
a. Unreliable blood supply
b. Limited amount of skin, fat and, muscle provided
c. Limited upward mobility of the flap
d. Inability to be readvanced if wound recurrence later
mebooksfree.net

e. High rate of donor site morbidity
5. You receive a consult for a 19-year-old boy who underwent a 13-hour liver transplant; following
the case in the ICU, he was noted to have redness and skin breakdown on the left scapula and
sacrum. When you roll him to assess the wounds, you note two well-demarcated areas of redness
and blanching skin with minor skin breakdown involving the epidermis only overlying the tip of the
scapula and the sacrum. There is no drainage or exposed structures. What is the most appropriate
management of this pressure-related injury?
a. Local wound care with placement of soft foam dressing and rigorous pressure offloading
b. Excision of blanching area with placement of wet to dry gauze to be changed daily
c. Excision of blanching area with placement of split thickness skin graft
d. Excision of blanching area with local advancement flaps to close
e. No intervention, encourage discharge from the hospital as soon as possible
1. Answer: c. This patient has a clean wound, which is not infected, and she does not have any
systemic illnesses to preclude her from closure at this time. For wounds of this size and in this
location a skin graft would not be a durable option. She is now ambulatory and the wound has soft
tissue at the base indicating that a total ischiectomy is not required to get this wound healed. She has
poor nutrition indicated by her recent laboratory test results, which will place her at increased risk
for wound-healing complications, and she should have a nutrition consult to improve her nutrition
prior to reconstruction first. Preoperative goals of albumin >3 g/dL and prealbumin >20 mg/dL 

should ideally be attained before performing elective flap closure for ischemic injuries, as studies
have shown low serum prealbumin predicts a poor prognosis for wound healing. Although
reasonable, there is no indication for MRI at this time given the duration and cause of her injury and
that she does not have exposed bone on examination.
2. Answer: e. AD is a medical emergency characterized by severe hypertension. It can be brought on
by wide array of stimuli below the level of the lesion. It can occur intraoperative or postoperatively.
Commonly in a resting patient on the nursing floor, bladder or bowel distension can be the source of
triggering an acute AD event. Therefore, bladder and bowel output should be monitored and
considered when patients with SCI become acutely clinically unstable.
3. Answer: d. Patients with chronic nonhealing wounds in the face of adequate wound care and
medical optimization must be examined and investigated for underlying condition. Any wound
presenting with exposed bone, particularly in a chronic or nonhealing wound should be biopsied to
rule out pathologic involvement and infection.
4. Answer: c. The posterior thigh flap has a very reliable blood supply (first perforating branch from
the profunda femoris artery); it provides generous skin, fat, and muscle and retains the ability to
readvance the flap if needed later. Additionally, medial and lateral donor sites and the gluteal
muscles remain intact for additional flaps if needed later on. Depending on the size of the flap, the
donor site can often be closed primarily, or with a skin graft if too large. The primary disadvantage is
the limited upward mobility of the flap with only 10 to 12 cm of movement, which may necessitate
additional flaps to be utilized if not adequate for larger wounds.
5. Answer: a. This early-stage pressure-related injury is acutely related to his recent surgery and will
likely recover when he is no longer in a confined position for many hours. Iatrogenic pressure-
related injuries such as these are considered never events, and hospitals are no longer reimbursed for
treatments provided for their care when acquired in the hospital setting. The operating room and
ICUs should follow strict guidelines for pressure-offloading surfaces during long operative cases or
in patients who have high risk in critical care settings to avoid these from occurring.
mebooksfree.net

References
Tchanque-Fossuo, CN, Kuzon, WM Jr. An evidence-based approach to pressure sores. Plast Reconstr Surg. 2011;127(2):932-939.
Ricci, JA, Bayer, LR, Orgill, DP. Evidence-based medicine: the evaluation and treatment of pressure injuries. Plast Reconstr Surg.
2017;139(1):275e-286e.
Reddy, M, Gill, SS, Rochon, PA. Preventing pressure ulcers: a systematic review. JAMA. 2006;296(8):974-984.
Russo, CA, Steiner, C, Spector, W. Hospitalizations related to pressure ulcers among adults 18 years and older, 2006: statistical brief #64. Healthcare
Cost and Utilization Project (HCUP) Statistical Briefs. Rockville, MD; 2006.
Cushing, CA, Phillips, LG. Evidence-based medicine: pressure sores. Plast Reconstr Surg. 2013;132(6):1720-1732.
Padula, WV, Mishra, MK, Makic, MB, Sullivan, PW. Improving the quality of pressure ulcer care with prevention: a cost-effectiveness
analysis. Med Care. 2011;49(4):385-392.
Description of NPUAP. National pressure ulcer advisory panel. Adv Wound Care. 1995;8(4 suppl):93-95.
Zaratkiewicz, S, Whitney, JD, Lowe, JR, et al. Development and implementation of a hospital-acquired pressure ulcer incidence tracking
system and algorithm. J Healthc Qual. 2010;32(6):44-51.
Centers for Medicare and Medicaid Services. Medicare program: changes to the hospital inpatient prospective payment systems and fiscal
year 2009 rates; payments for graduate medical education in certain emergency situations; changes to disclosure of physician ownership
in hospitals and physician self-referral rules; updates to the long-term care prospective payment system; updates to certain IPPS-excluded
hospitals; and collection of information regarding financial relationships between hospitals. Final rules. Fed Regist. 2008;73(161):48433-
49084.The publication of these guidelines and changes in Medicare reimbursement for hospital acquired pressure related injuries changed the paradigm
for pressure sore treatment and resulted in a drastically increased emphasis on the prevention and treatment of these wounds in all patients and
facilities across the United States moving forward.
McKinley, WO, Jackson, AB, Cardenas, DD, DeVivo, MJ. Long-term medical complications after traumatic spinal cord injury: a regional
model systems analysis. Arch Phys Med Rehabil. 1999;80(11):1402-1410.
Stal, S, Serure, A, Donovan, W, Spira, M. The perioperative management of the patient with pressure sores. Ann Plast Surg. 1983;11(4):347-
356.
Waterlow, JC. Requirements for specialist training. Lancet. 1985;1(8428):576.
Wang, LH, Chen, HL, Yan, HY, et al. Inter-rater reliability of three most commonly used pressure ulcer risk assessment scales in clinical
practice. Int Wound J. 2015;12(5):590-594.
Braden, BJ, Bergstrom, N. Predictive validity of the Braden scale for pressure sore risk in a nursing home population. Res Nurs Health.
1994;17(6):459-470.
Moore, ZE, Cowman, S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev. 2014;(2):CD006471.
National Pressure Ulcer Advisory Panel. NPUAP Pressure Injury Stages. Available at
clinical-resources/npuap-pressure-injury-stages/ . Accessed November 8, 2018.
Lyder, CH, Wang, Y, Metersky, M, et al. Hospital-acquired pressure ulcers: results from the national Medicare patient safety monitoring
system study. J Am Geriatr Soc. 2012;60(9):1603-1608.
Bennett, RG, O’Sullivan, J, DeVito, EM, Remsburg, R. The increasing medical malpractice risk related to pressure ulcers in the United States. J
Am Geriatr Soc. 2000;48(1):73-81.
Dinsdale, SM. Decubitus ulcers: role of pressure and friction in causation. Arch Phys Med Rehabil. 1974;55(4):147-152.
Landis, EM. The capillary pressure in frog mesentery as determined by micro-
 injection methods. Am J Physiol. 1926;75(3):548-570.In a series
of landmark studies, the concept of the pressure-time relationship and soft tissue destruction was explored. As the pressure exerted on the soft tissue
becomes higher than that of the supplying blood vessels, edema and ischemia occurs, metabolic waste products and free radicals accumulate, and with
time permanent tissue destruction leads to significant defects.
Daniel, RK, Wheatley, D, Priest, D. Pressure sores and paraplegia: an experimental model. Ann Plast Surg. 1985;15(1):41-49.
Schultz, GS, Davidson, JM, Kirsner, RS, et al. Dynamic reciprocity in the wound microenvironment. Wound Repair Regen. 2011;19(2):134-148.
Gerhardt, LC, Strassle, V, Lenz, A, Spencer, ND, Derler, S. Influence of epidermal hydration on the friction of human skin against textiles. J R
Soc Interface. 2008;5(28):1317-1328.
McInnes, E, Jammali-Blasi, A, Bell-Syer, SE, et al. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2011;
(4):CD001735.
Kwok, AC, Simpson, AM, Willcockson, J, et al. Complications and their associations following the surgical repair of pressure ulcers. Am J
Surg. 2018;216(6):1177-1181.This 10-year examinated of the NSQIP database examined complications following repair of ulcers in 1243 cases, and
showed mortality rates on par with hepatobiliary cancer and cardiac surgery risk for death. Elderly age, diabetes and dependency were associated with
increased mortality following pressure ulcer surgery. Flap repair of these ulcers was found to be associated with decreased complications. The overall 30-
day mortality for patients undergoing pressure ulcer surgery was found to be 3%.
Tedeschi, S, Negosanti, L, Sgarzani, R, et al. Superficial swab versus deep-tissue biopsy for the microbiological diagnosis of local infection in
advanced-stage pressure ulcers of spinal-cord-injured patients: a prospective study. Clin Microbiol Infect. 2017;23(12):943-947.This article
examined the concordance rate between taking a superficial swab versus a deep tissue culture in the pressure sores of 116 spinal cord injury patients (a
homogenous population not actively receiving antibiotics at the time of culture); they found a concordance rate of only 22%, with 27% false negative
and 16% false-positives. Thus, concluding superficial swabs are not to be relied on for clinical diagnosis and treatment in advanced ulcers.
mebooksfree.net

Heym, B, Rimareix, F, Lortat-Jacob, A, Nicolas-Chanoine, MH. Bacteriological investigation of infected pressure ulcers in spinal cord-injured
patients and impact on antibiotic therapy. Spinal Cord. 2004;42(4):230-234.
Huang, AB, Schweitzer, ME, Hume, E, Batte, WG. Osteomyelitis of the pelvis/hips in paralyzed patients: accuracy and clinical utility of MRI.
J Comput Assist Tomogr. 1998;22(3):437-443.
Ovington, LG. Advances in wound dressings. Clin Dermatol. 2007;25(1):33-38.
Black, J, Clark, M, Dealey, C, et al. Dressings as an adjunct to pressure ulcer prevention: consensus panel recommendations. Int Wound J.
2015;12(4):484-488.
Singh, A, Halder, S, Menon, GR, et al. Meta-analysis of randomized controlled trials on hydrocolloid occlusive dressing versus conventional
gauze dressing in the healing of chronic wounds. Asian J Surg. 2004;27(4):326-332.
Graumlich, JF, Blough, LS, McLaughlin, RG, et al. Healing pressure ulcers with collagen or hydrocolloid: a randomized, controlled trial. J Am
Geriatr Soc. 2003;51(2):147-154.
Molan, P, Rhodes, T. Honey: a biologic wound dressing. Wounds. 2015;27(6):141-151.
Health Quality Ontario. Management of chronic pressure ulcers: an evidence-based analysis. Ont Health Technol Assess Ser. 2009;9(3):1-203.
Belmin, J, Meaume, S, Rabus, MT, Bohbot, S; Investigators of the Sequential Treatment of the Elderly with Pressure Sores . Sequential
treatment with calcium alginate dressings and hydrocolloid dressings accelerates pressure ulcer healing in older subjects: a multicenter
randomized trial of sequential versus nonsequential treatment with hydrocolloid dressings alone. J Am Geriatr Soc. 2002;50(2):269-274.
Yang, C, Goss, SG, Alcantara, S, et al. Effect of negative pressure wound therapy with instillation on bioburden in chronically infected
wounds. Wounds. 2017;29(8):240-246.
McKanna, M, Geraci, J, Hall, K, et al. Clinician panel recommendations for use of negative pressure wound therapy with instillation. Ostomy
Wound Manage. 2016;62(4):S1-S14.
Orgill, DP, Bayer, LR. Negative pressure wound therapy: past, present and future. Int Wound J. 2013;10(suppl 1):15-19.
Fischer, BH. Topical hyperbaric oxygen treatment of pressure sores and skin ulcers. Lancet. 1969;2(7617):405-409.
Worth, ER, Tettelbach, WH, Hopf, HW. Arterial insufficiencies: enhancement of healing in selected problem wounds. In: Weaver, LK , ed.
Hyperbaric Oxygen Therapy Indications. 13th ed. North Palm Beach, FL: Best Publishing; 2014:25-46.
Adunsky, A, Ohry, A, Group, D. Decubitus direct current treatment (DDCT) of pressure ulcers: results of a randomized double-blinded
placebo controlled study. Arch Gerontol Geriatr. 2005;41(3):261-269.
Burke, DT, Ho, CH, Saucier, MA, Stewart, G. Effects of hydrotherapy on pressure ulcer healing. Am J Phys Med Rehabil. 1998;77(5):394-398.
Kenneweg, KA, Welch, MC, Welch, PJ. A 9-year retrospective evaluation of 102 pressure ulcer reconstructions. J Wound Care. 2015;24(suppl
4a):S12-S21.
Thiessen, FE, Andrades, P, Blondeel, PN, et al. Flap surgery for pressure sores: should the underlying muscle be transferred or not? J Plast
Reconstr Aesthet Surg. 2011;64(1):84-90.
Bamba, R, Madden, JJ, Hoffman, AN, et al. Flap reconstruction for pressure ulcers: an outcomes analysis. Plast Reconstr Surg Glob Open.
2017;5(1):e1187.
Sameem, M, Au, M, Wood, T, et al. A systematic review of complication and recurrence rates of musculocutaneous, fasciocutaneous, and
perforator-based flaps for treatment of pressure sores. Plast Reconstr Surg. 2012;130(1):67e-77e.
Keys, KA, Daniali, LN, Warner, KJ, Mathes, DW. Multivariate predictors of failure after flap coverage of pressure ulcers. Plast Reconstr Surg.
2010;125(6):1725-1734.
Schryvers, OI, Stranc, MF, Nance, PW. Surgical treatment of pressure ulcers: 20-year experience. Arch Phys Med Rehabil. 2000;81(12):1556-
1562.
Yamamoto, Y, Tsutsumida, A, Murazumi, M, Sugihara, T. Long-term outcome of pressure sores treated with flap coverage. Plast Reconstr
Surg. 1997;100(5):1212-1217.Examining 45 ischial and 24 sacral sores in 53 paraplegic patients between 1990 and 1995, the types of flaps were
categorized into fasciocutaneous or myocutaneous/muscle flaps. These investigators found that overall, the ischial sores had a higher recurrence rate
than sacral sores; however, there was no significant difference in the percent pressure sore free survival (%PSFS) between the sites of sores. The group
of the sores reconstructed with the fasciocutaneous flap demonstrated significant or marginally significant better results in the %PSFS compared with
those reconstructed with myocutaneous or muscle flaps. These observations suggested the use of fasciocutaneous flaps provides just as durable, if not
better longterm results in the surgical reconstruction of pressure sores compared to the myocutaneous or muscle flap.
Dakson, A BD, Thibault-Halman, G, Christie, S. Venous thromboembolism and pressure ulcers in acute spinal cord injury: a retrospective
review. JSM Spine. 2016;1(1):1001.
Brem, H, Maggi, J, Nierman, D, et al. High cost of stage IV pressure ulcers. Am J Surg. 2010;200(4):473-477.
Khor, HM, Tan, J, Saedon, NI, et al. Determinants of mortality among older adults with pressure ulcers. Arch Gerontol Geriatr. 2014;59(3):536-
541.
Manzano, F, Perez-Perez, AM, Martinez-Ruiz, S, et al. Hospital-acquired pressure ulcers and risk of hospital mortality in intensive care
patients on mechanical ventilation. J Eval Clin Pract. 2014;20(4):362-368.
Bazalinski, D, Przybek-Mita, J, Baranska, B, Wiech, P. Marjolin’s ulcer in chronic wounds: review of available literature. Contemp Oncol
(Pozn). 2017;21(3):197-202.
mebooksfree.net

C H A P T E R 1 0 0
mebooksfree.net

Gender-Affirming Surgery
William M. Kuzon, Jr and Katherine M. Gast
Key Points
Gender dysphoria, the incongruence between anatomic sex and gender identity, affects 0.6% of the
population, 1.4 million people in the United States.
Treatment of gender dysphoria including mental health, hormonal therapy, puberty suppression,
and gender-affirming surgery is deemed medically necessary by nearly all expert led medical
societies including the American Medical Association and the American Society of Plastic Surgeons.
Chest and genital surgery is often covered by insurance, including Medicare.
WPATH, the World Professional Association for Transgender Health, is an international society with
universally adopted standards of care (SOC) for gender-expansive patients, including prerequisites
prior to hormonal therapy and gender-affirming surgery.
Transfeminine surgery for patients assigned male at birth but identified as women, includes facial
feminization, thyrochondroplasty, breast augmentation, and vaginoplasty.
Transmasculine surgery for patients assigned female at birth but identified as men, includes
mastectomy, metoidioplasty, and phalloplasty.
Multidisciplinary care inclusive of mental health for gender-expansive patients, much like a bariatric
or transplant surgery model, is paramount for good patient outcomes.
Gender dysphoria is the incongruence between one’s experienced and assigned gender, 1 estimated to
affect 0.6% of the population. 2 It is now recognized that gender identity may be nonbinary and patients
may identify as transmasculine, transfeminine, trans (without gender specification), gender queer,
nonbinary, gender expansive, or agender. 3 Table 100.1 provides helpful definitions of gender, sex, and
other terms used throughout this chapter.
TABLE 100.1
Definitions of Gender, Sex, and Other Terms Used in the Care and Treatment of Transgender and Gender Nonconforming Patients
Gender
Internal sense of being a man or woman as defined by culture norms and customs.
Cisgender
Patient with gender identity that matches anatomic sex. Nontransgender patients.
Sex
Physical anatomy, assigned at birth.
Gender dysphoria
Incongruence between gender identity and physical sex resulting in functional impairment:
Separate from sexual orientation
ICD 10 diagnosis code F64
Included in the DSM V
Disorders of sexual
development
Reproductive organs and genitals do not develop as expected. DSD patients may or may not experience
gender dysphoria.
Sexual orientation
The emotional, sexual, romantic attractions one has with other people.
Gender-affirming surgery
Procedures to align a patient’s body and features with their gender identity.
Transfeminine patient
Assigned male at birth, identifies as female or on the feminine end of gender spectrum.
Transmasculine patient
Assigned female at birth, identifies as male or on the masculine end of gender spectrum.
DSD, disorders of sexual development
Patients with gender dysphoria have normal anatomy and hormonal physiology, distinguishing this
patient population from those with disorders of sexual development. Notably, there is now substantial
and accumulating evidence that an individual’s gender identity is determined largely by biological
mebooksfree.net

factors, and sexual orientation is an independent characteristic not directly related to gender identity. 4-6
For gender dysphoric patients, management must be individualized for each patient. The timeline of care
typically follows this order: mental health counseling, hormonal therapy, and lastly, surgery for patients
who desire it. 7 Gender-affirming surgery is recognized as medically necessary and associated with
quality of life and functional improvements by every professional-led medical association, including the
American Society of Plastic Surgeons. 8
Transgender and gender-expansive patients are an underserved and at-risk patient population within
plastic surgery. 9 Patients have impaired access to care and experience discrimination in housing,
employment, and social services. 10-12 Transgender patients have elevated rates of homelessness,
joblessness, estrangement from their families and social support systems, interpersonal violence, suicide,
HIV, and mental health comorbidities. Rates of comorbid mental illness and of suicidal ideation and
suicide attempts greatly exceed those of the general population. 13-15
mebooksfree.net

Official Standards of Care
The WPATH, is an international society of patients, health-care providers, and advocates that issues a
SOC document (current Version 7 is from 2011) to define best practices and to prevent patient harm and
regret. 7 The WPATH SOC define recommended prerequisites prior to hormonal therapy and gender-
affirming surgery procedures (Table 100.2). The SOC have been criticized as authoritative and
paternalistic, and alternative “informed consent” models of care have been advocated. 16-20 Although we
acknowledge that the SOC are a source of controversy, we also strongly support adherence to the
WPATH SOC when providing surgical care to gender-dysphoric patients. This cannot be
overemphasized; Plastic Surgeons cannot independently diagnose gender dysphoria, so the
determination of surgical candidacy for any gender confirming procedure should be made in the setting
of a multidisciplinary team and in accordance with WPATH SOC.
TABLE 100.2
The World Professional Association for Transgender Health Standards of Care Guidelines 7 , a
Procedure
Specifications
Referral(s) b
Hormones
Transfeminine
Breast augmentation
(implants/lipofilling)
Persistent, well-documented
gender dysphoria
One referral (letter)
by a qualified mental
health professional
Not an explicit criterion, but recommended that patients
receive 12 mo postfeminizing hormone therapy.
Orchiectomy d
Persistent, well-documented
gender dysphoria
Two referrals (letters)
by qualified mental
health professionals.
12 continuous months of hormone therapy as
appropriate to patient’s gender goals. Exception if the
patient has medical or personal reasons to not take
hormones. c
Vaginoplasty d
Persistent, well-documented
gender dysphoria
Must be living 12 continuous
months in gender role that is
congruent with gender
identity
Two referrals (letters)
by qualified mental
health professionals
12 continuous months of hormone therapy as
appropriate to patient’s gender goals. Exception if the
patient has medical or personal reasons to not take
hormones. c
Transmasculine
Mastectomy and
creation of male
chest
Persistent, well-documented
gender dysphoria
One referral (letter)
by a qualified mental
health professional
Not a prerequisite
Hysterectomy and
ovariectomy d
Persistent, well-documented
gender dysphoria
Two referrals (letters)
by qualified mental
health professionals
If one letter is from
therapist, the other
should be from
evaluator
12 continuous months of hormone therapy as
appropriate to patient’s gender goals. Exception if the
patient has medical or personal reasons to not take
hormones. c
Metoidioplasty or
phalloplasty d
Persistent, well-documented
gender dysphoria
Must be living 12 continuous
months in gender role that is
congruent with gender
identity
Two referrals (letters)
by qualified mental
health professionals.
If one letter is from
therapist, the other
should be from
evaluator.
12 continuous months of hormone therapy as
appropriate to patient’s gender goals. Exception if the
patient has medical or personal reasons to not take
hormones. c
Reprinted by permission from World Professional Association for Transgender Health. Standards of Care
for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th Version. Elgin, IL:
The World Professional Association for Transgender Health; 2011. WPATH SOC Guidelines can be
accessed at

%202011%20WPATH.pdf.
mebooksfree.net

aStandards of care guidelines for the surgical treatment of gender dysphoria in transgender and gender-nonconforming adults, suggested by
the World Professional Association for Transgender Health. Note that patients should be 18 years of age, able to legally give consent, and
any comorbid psychiatric conditions must be “reasonably well controlled.”
bReferral letters should include:
1. Patient’s identifying characteristics
2. Diagnosis and other psychological evaluation results
3. Details of relationship to patient: duration of care, type of evaluation, type of counseling or treatment
4. Endorsing patient’s application and explaining how they fulfill criteria for surgery
5. Confirmation of informed consent
6. Confirmation of availability for coordination of care
7. Confirmation of adequately controlled mental health concerns
cTo introduce a period of reversible estrogen or testosterone suppression, before the patient undergoes irreversible surgical intervention.
dThough it is not an explicit criterion, it is recommended that these patients also have regular visits with a mental health or other medical
professional.
Note that for all procedures, except when specific variance from the Standards of Care are justified, the patient should be 18 years of age
and legally able to consent to the surgery on their own.
mebooksfree.net

Comprehensive Gender Care
Ideal care for transgender patients requires close communication and collaboration among a diverse
multidisciplinary team; centers for cleft lip and palate, bariatric, or transplant surgery are analogous
models. This is a critical point: close collaboration between team members is vital to good patient
outcomes. 21 Depending on where patients are in their transition, they may need mental health, social
work, pediatric or adult endocrinology, fertility services, and/or surgery if they choose. Patients also need
access to “gender-friendly” providers who can provide permanent hair removal, speech therapy, and
pelvic floor physiotherapy. Organized peer support is also valuable for patients and families. Centers
performing gender-affirming surgery should have resources in all these areas available.
In addition, it is important to provide a supportive environment of care. This population is very sensitive
to misgendering, so it is important to educate all staff who interact with patients to use preferred
pronouns, and, especially if the patient has not yet made a legal name change, preferred first names. For
patients undergoing surgical procedures and who are admitted to hospital, they should be identified and
housed in their expressed gender.
mebooksfree.net

Care of Children and Adolescents
The care of children and adolescents with gender dysphoria requires specialized training and is also
evolving rapidly. Preadolescent children may express gender dysphoria consistent with gender identity
disorder of childhood. 1,22-24 In some studies, 60% or more of these children will “desist” and return to the
gender consistent with their anatomy, 24 although there is not a clear consensus in the literature. 1 For this
reason, surgery is never indicated in children nor advised in the WPATH SOC (see Table 100.2). 7
If gender dysphoria persists into or appears in adolescence and is consistent with a diagnosis of gender
dysphoria of adolescence and adulthood, patients may be candidates for puberty suppression therapy. 25
This typically consists of GnRH agonists that suppress the pulsatile stimulation of the gonads, which is
safe and reversible; cross-hormone therapy at age 15 or 16 may then be initiated later. Hormonal therapy
for transfeminine patients (assigned male at birth, identify as female), includes estrogen and
spironolactone or finasteride (androgen blockers). Hormonal therapy for transmasculine patients
(assigned female at birth, but identify as male) includes testosterone. On a case-by-case basis, with
treatment decisions made among the adolescent, the family, and the multidisciplinary treatment team,
surgical intervention in adolescents may be appropriate. For chest recontouring in transmasculine
adolescents, WPATH SOC recommend a year of testosterone therapy before surgery. 
 The decision to
perform genital surgery on an adolescent, in addition to the WPATH SOC criteria for adults, is again a
case-by-case decision by the multidisciplinary team. This remains a topic of active discussion by
WPATH’s SOC Committee, as poor psychosocial, body image, and mental health outcomes may manifest
in late adolescence.
mebooksfree.net

Gender-Affirming Surgery
Gender-affirming surgeries generally fall within the scope of well-trained plastic surgeons. Table 100.3
outlines the main surgical treatments of gender dysphoria. For transfeminine patients, gender-affirming
surgery often includes facial feminization, thyroid chondroplasty or “tracheal shave,” orchiectomy, breast
augmentation, and vaginoplasty. For transmasculine patients, gender-affirming surgical procedures can
include hysterectomy and oophorectomy, mastectomy, and genital reconstruction (i.e., phalloplasty,
metoidioplasty).
TABLE 100.3
Transfeminine and Transmasculine Gender-Affirming Surgeries That Fall Within the Scope of Plastic Surgery
Transfeminine Surgery
Transmasculine Surgery
Facial feminization surgery
Lower hairline
Shave brow bone +/− posterior reset of the anterior wall of frontal sinus
Rhinoplasty
Malar augmentation
Reduce angle of mandible
Tracheal shave
Laryngoplasty
Voice surgery performed by ENT
Breast augmentation
Mastectomy
Periareolar
Circumareolar
Inferior pedicle
Double-incision free nipple graft
Orchiectomy
Hysterectomy
+/− Salpingo-oophorectomy
Vaginoplasty
Penile inversion (most common)
Sigmoid
Metoidioplasty
Phalloplasty
mebooksfree.net

Transfeminine Surgery
Facial Feminization
Human beings are accustomed to determining the gender of an individual simply by looking at them
while clothed. This is possible because, in addition to obvious morphologic differences in the breasts and
body, there are major differences in both skeletal and soft tissue morphology that distinguish the cis-
female from the cis-male face. 26 An incongruence between their facial morphology and their feminine
gender is a source of dysphoria for many transwomen who find it difficult to “pass” in society with a
distinctly male face. The goal of facial feminization surgery is to alter the craniofacial bony skeleton and
soft tissues of the face to achieve a facial appearance that is easily identified as female rather than male.
mebooksfree.net

Female Facial Morphology
Masculine faces have been described as being square or rectangular, with a tall forehead, high hairline, a
pronounced posterior sloping forehead contour, and prominent supraorbital ridges. Masculine faces tend
to have wide and prominent mandibular angles, a square chin, a long upper lip, and a relatively acute
nasolabial angle. In contrast, feminine faces have been described as oval-shaped, with a shorter, vertically
oriented forehead and lower hairline, minimal supraorbital ridges, a shorter upper lip, narrower
mandibular angles, a more obtuse nasolabial angle, and a more pointed chin. A masculine-appearing
nose is generally larger and “less delicate” than the average feminine nose. There are multiple other
differences between the masculine and feminine craniofacial skeleton and soft tissue envelope. To achieve
optimal facial feminization, a careful analysis of each patient’s facial features and a comprehensive,
individualized surgical plan developed. Because the prominent male supraorbital ridge and robust
mandible most often require significant bony resection and recontouring, surgeons performing facial
feminization must be skilled in maxillofacial and craniofacial surgical procedures. 27
mebooksfree.net

Preoperative Evaluation
All of the sex-specific characteristics noted above should be carefully assessed on physical examination.
Most importantly, a thorough discussion with the patients should define their perception of their facial
features and their desired changes. For patients undergoing forehead recontouring, a lateral
cephalograph or maxillofacial computed tomography scan should be obtained. This is essential to
determine the thickness of the frontal bone over the frontal sinus and to gauge the degree of supraorbital
reduction that will be necessary. If the frontal bone is sufficiently thick and the setback required is
modest, burring of the supraorbital ridges may be sufficient. If the frontal bone is thin and/or if the
setback required is significant, the surgeon must be prepared to do a formal frontal sinus recession,
removing the anterior table of the frontal sinus in total, performing osteotomies on the excised segment of
bone, and then replacing and rigidly fixing the bone segments in a reshaped, feminine configuration. If
rhinoplasty, brow lifting, or blepharoplasty are to be performed (Figure 100.1), the usual analysis of nasal
airflow and anatomy, dry eye, negative orbital vector, and so on should be done. If mandibular
recontouring or height reduction is planned, an analysis of occlusion and consideration of an X-ray to
identify the mental foramen and inferior alveolar nerve position are important.
mebooksfree.net

FIGURE 100.1 Facial feminization. Preoperative (A, B) and 6-month postoperative (C, D) photos of a patient who underwent
feminizing brow lift, forehead and supraorbital ridge recontouring, and septorhinoplasty.
mebooksfree.net

Forehead Feminization
Forehead feminization generally includes both lowering the hairline and reducing the prominence of and
reshaping the supraorbital ridges. A pretrichial incision can be used to correct widow’s peak and bring
the hairline forward with posterior scalp advancement and forehead skin excision. This incision can serve
as the access point for a bony brow reduction with lateral burring of the supraorbital rims, burring or
formal recession of the anterior table of the frontal sinus, and brow lift. Hair grafting can help disguise
the scar and contour the hairline.
mebooksfree.net

Midface Feminization
Malar implants or fat grafting can help define the cheekbones and feminize the midface. A rhinoplasty
should focus on correcting a dorsal hump, osteotomies to narrow the upper vault, cephalic trim to rotate
the nasal tip and create a supratip break, and interdomal sutures to create more tip definition.
mebooksfree.net

Feminization of the Mandibular Contour and Lower Face
An upper lip lift, done through a gull-wing excision of skin along the nasal sill, can provide incisal tooth
show at rest and increase the fullness of the vermillion. A narrowing genioplasty, most commonly
through a transverse and vertical wedge excision osteotomy, reduces the prominence of the chin. The
mandible angles can be reduced through osteotomies or burring through intraoral access incisions. If
appropriate, reduction of the total mandibular height can be performed via resection of the entire inferior
border of the mandible.
mebooksfree.net

Thyrolaryngoplasty
The laryngeal prominence of the thyroid cartilage, or Adam’s apple, is a distinctly masculine feature that
is often noticeable on profile of transfeminine patients. The thyroid cartilage is connected to the superior
hyoid bone through thyrohyoid membrane and to the inferior cricoid cartilage through the cricothyroid
ligaments. The thyroid cartilage consists of paired lamina with a central superior thyroid notch and
midline laryngeal prominence. The cartilage is more prominent in men because of a more acute angle (90°
versus 120°) between the paired lamina.
Reduction of the prominence of the thyroid cartilage, also erroneously referred to as a “trach shave”
(Figure 100.2), should be performed through a submental incision to leave a scar that is not visible on
frontal view. Dissection should expose the superficial surface of the thyroid cartilage and can be aided by
lighted retractors or endoscopic instruments. The location of the anterior commissure of the vocal cords
can be determined by passing a flexible laryngoscope, observing the emergence of a needle passed
through the thyroid cartilage, and marking that location with methylene blue. The “Adam’s apple” is
then reduced by shaving the external surface of the thyroid cartilage down until a reasonable contour is
achieved. In adults, the thyroid cartilage is frequently calcified, so the use of a bur or rongeurs may be
necessary. The resection should be conservative to avoid vocal cord injury.
mebooksfree.net

FIGURE 100.2 Thyroid chondroplasty, or “tracheal shave.” Preoperative (A, B) and postoperative (C, D) photos of feminizing
thyrochondroplasty to eliminate appearance of the Adam’s apple, a commonly denoted masculinizing feature. E. Intraoperative
photo of thyroid cartilage just after cartilage trim. Approach should be made through a submental incision to minimize scarring.
mebooksfree.net

Voice Pitch Alteration
The average pitch of the female voice is higher than that of the male voice, so the field of vocal pitch
alteration surgery is rapidly evolving. 
 A number of procedures have been described, 28 but the most
commonly performed contemporary procedures involve endoscopic, laser-assisted fusion of the anterior
vocal cords. This moves the anterior commissure posteriorly and shortens vocal cord length, effectively
raising the pitch of the voice. These specialized procedures require subspecialty training and are best
performed by surgeons certified by the American Board of Otolaryngology/Head and Neck Surgery.
mebooksfree.net

Breast Augmentation
Feminizing breast surgery in transfeminine patients most often requires augmentation with an implant.
Fat grafting, or lipofilling, has been described and may be an option for modest augmentation, but patient
goals and chest wall morphology usually requires an alloplastic device. Breast augmentation, as in
cisgender women, involves placement of a silicone- or saline-filled device through an incision in the
inframammary fold in either the subpectoral or subglandular position.
Preoperatively, patients over 40 years of age on feminizing hormones should have a screening
mammogram and assessment of breast cancer risk with complete family history. WPATH SOC requires
one letter of readiness from a mental health professional prior to surgery and 1 year of estrogen therapy
for breast development is recommended. No duration of “real-life experience” or living full time in the
female gender role is required. Holding estrogen prior to surgery is recommended to prevent
perioperative venous thromboembolism (VTE) given the elevated risk of VTE in transfeminine patients
on hormonal therapy. 29,30
Preoperative physical examination should note the location of the nipples on the chest wall, which is
often more lateral than cisgender women. The sternum and chest wall is also wider in transgender
women. The implants must be placed with the nipple centered on the implant, so it is difficult to achieve
cleavage in the midline in bras and clothing. Patients should be counseled about this at time of
consultation. The inframammary fold is higher and more transverse in male chests; the patient’s goals of
size and shape should be discussed, and the surgeon should estimate the upper limit of implant size that
is achievable with the existing skin envelope. Often, breasts are constricted and tuberous appearing,
which may necessitate scoring of the parenchyma at time of augmentation to redrape the parenchyma
over the implant. Choice of subpectoral or subglandular position is a choice between the surgeon and
patient. The subpectoral plane creates a more natural slope of the breast mount superiorly but limits the
medial extent of the implant, especially if the patient has a wide sternum. The subglandular plane,
although carrying a higher risk of capsular contracture, provides greater definition of the breast mount
and may be preferable in patients with a broad pectoralis major muscle.
Our preferred approach is through a 6-cm inframammary fold (IMF) incision at the location of the desired
IMF, which may be lower than the existing fold. The new location of the IMF should be determined based
on the diameter of the implant to be placed, placing the nipple at the most projecting aspect of the breast
mound. Markings in the preoperative area should include sternal notch, midline, current IMF, desired
IMF, breast base width, and limits of the pocket dissection. If subpectoral position is selected, complete
release of the pectoralis major origin inferiorly should be performed with weakening of the medial sternal
attachments.
Postoperative care following transfeminine breast augmentation is similar to that of cis-gender women. A
superior strap can be considered to keep implants low in the pocket in subpectoral augmentations. If
significant IMF work is done, a postoperative underwire bra can help reinforce that position to prevent
dropping of the implant. Results of breast augmentation are presented in Figure 100.3.
mebooksfree.net

FIGURE 100.3 Breast augmentation. Preoperative (A, B) and Postoperative (C, D) photos of transfeminine breast
augmentation via an inframammary approach, placing smooth, round implants in the subpectoral position.
mebooksfree.net

Vaginoplasty
Transfeminine gender-affirming bottom surgery creates a neoclitoris from the dorsal glans penis, labia
minora from the prepuce or distal penile shaft skin, and labia majora from scrotal skin with removal of
the erectile tissue of the penis, bilateral orchiectomy, and creation of a vagina (Figure 100.4). The vagina
may be lined with inverted penile shaft skin (the penile inversion vaginoplasty technique, or Amsterdam
procedure) or sigmoid colon (most often reserved as a rescue operation in cases of vaginal stenosis). 31
FIGURE 100.4 Penile inversion vaginoplasty. Preoperative (A) and postoperative (B) photos of transfeminine penile inversion
vaginoplasty. Patients must continue to dilate or engage in penetrative intercourse to maintain depth and prevent neovaginal
contraction.
mebooksfree.net

Preoperative Considerations
The WPATH SOC guidelines dictate that prior to vaginopalsty surgery, patients must have two letters of
readiness from independent mental health professionals, be on estrogen therapy for 1 year, and live in
their congruent female gender role (formerly known as “real-life experience”) for 1 year (see Table 100.2).
Vaginoplasty surgery is sterilizing, so discussion of preserving fertility through banked sperm must take
place, especially for young patients. Patients should be 18 years old, with exceptions made when
appropriate. Postoperatively, most patients are able to achieve orgasm with stimulation of the neoclitoris.
Many also achieve orgasm with stimulation of the prostate with penetration.
Patients should perform permanent hair removal with either laser (most effective in patients with fair
skin and dark hair) or electrolysis. Hair around the circumference of the base of the penis and the
posterior scrotum must be cleared as this tissue will line the introitus and posterior vaginal wall. The
duration of hair removal depends on patient’s hair pattern and response to the hair removal sessions.
Typically, this takes 3 to 6 months. Estrogen is held 3 weeks prior to surgery while the patient is on
modified activity restrictions postoperatively to lower the risk of VTE. And a bowel prep is performed the
day before surgery to clear the rectum of stool and lower the risk of rectal perforation (2% incidence) and
rectovaginal fistula (around 1%). 32
mebooksfree.net

Penile Inversion Vaginoplasty Technique
The penile inversion vaginoplasty procedure begins with elevation of a posterior perineal flap on skin
that has previously been cleared of hair. The scrotal skin is split up the midline through the raphe to the
base of the penis. A bilateral orchiectomy is performed with ligation of the spermatic cords at the level of
the external inguinal ring; testicles should be sent to pathology for evaluation. A space for the vagina is
dissected between the urethra and the rectum with sharp and then blunt dissection along the prerectal
fascia. To be sure of not entering the rectum, the surgeon’s left hand can be placed in the rectum while
making the tunnel with the right, feeling the anterior wall of the rectum between their two hands. The
neovaginal tunnel should be developed up to the peritoneal reflection. One can instill betadine into the
rectum with a moist sponge in the neovagina. Any evidence of betadine on the sponge will indicate a
water leak and rectal injury in need of repair. A circumferential incision is then made 2 cm proximal to
the glans penis and the penis is then degloved superficial to Buck fascia. The penis is then pulled through
the skin tube and the mons pubis is undermined for 8 to 10 cm to facilitate pullback of the penile shaft
skin to line the neovagina. The neoclitoral flap is then raised from a W-shaped dorsal glans penis flap,
incorporating the distal penile shaft skin as associated labia minora flaps. The neoclitoral flap is based on
the dorsal penile artery, nerve, and associated veins. The neurovascular bundle is within Buck’s fascia,
and it is peeled off the tunica albuginea of the corpora distal to proximal with sharp dissection. The
pedicle is dissected to the level of the pubic symphysis. A Foley catheter is placed in the urethra and the
corpus spongiosum is separated from the paired corpora cavernosa. The corpora cavernosa are then
separated, clamped, divided, and suture ligated in the midline. The neoclitoral flap is inset to the stumps
of the corpora and the urethra is shortened and inset just posterior to the clitoris. The labia minora flaps
are sutured around the neourethral edge to form a vulva. The central penile skin tube is inverted and
pulled back. The scrotal skin is fashioned into labia majora with placement of incision in the groin crease.
The penile skin tube is then lengthened with full thickness skin graft from the extra scrotal skin and
finally a vaginal pack is placed with drains to remain in place for 5 to 7 days.
mebooksfree.net

Postoperative Care and Management of Complications
Postoperative care includes modified activity of shuffling between chair and bed while the pack is in
place and chemoprophylaxis for deep venous thrombosis (DVT). Following removal of the pack, drains,
and Foley, the patient is taught to dilate and perform three times daily vaginal rinses. In addition to those
seen with any major surgical procedure, complications of vaginoplasty include wound dehiscence and
tissue loss (25%–39%), urethral stenosis and/or divergent urinary stream (20%–55%), vaginal or introital
stenosis (6%–27%), pelvic floor spasm or dyspareunia (2%, which may require referral to a pelvic floor
physiotherapist), and rectovaginal fistula (0.01%–2%). 32-34 Most series report a 20% or higher rate of
revisionary surgery, especially for divergent urinary stream and aesthetics. 32 Speculum examinations
should be performed in clinic to assess healing of the internal lining of the vagina. If areas of hypertrophic
granulation tissue develop, then spot treatment with silver nitrate is helpful. If patients should develop
malodorous vaginal secretions in the immediate postoperative period, suspicion must be high for a
rectovaginal fistula. Imaging with per rectum contrast can help diagnose a fistula. If a fistula develops,
the patient must have a temporary diverting ostomy for several months and keep dilating. If the patient
stops dilating, the vaginal vault will completely contract down. A secondary gracilis flap may be
considered in refractory cases of rectovaginal fistula.
Patients must dilate for life or the vagina will slowly contract and they will lose depth. Patients will need
to use lubricant for penetrative intercourse and are at elevated risk for urinary tract infections with a
shorter urethra. The prostate is not removed and patients will need prostate cancer screening with a per
vagina prostate examination beginning at the age of 50.
mebooksfree.net

Transmasculine Surgery
Mastectomy
Top surgery, or gender mastectomy, is a commonly requested operation among transmasculine patients.
Patients often wear binders, very tight compressive garments, to flatten their chests and appear masculine
in clothing. They report significant dysphoria related to their breasts, with resulting impairment in social
and emotional function. 35 One letter of readiness is required per WPATH SOC, but no duration of
testosterone therapy is needed prior to surgery in adults. Agender, gender fluid, or gender expansive
patients who do not desire hormonal therapy may need top surgery owing to dysphoria related to their
breasts.
mebooksfree.net

Preoperative Considerations
Complete patient medical, surgical, social, and family histories should be obtained with emphasis on risk
factors for breast cancer. Patients with strong family histories of breast cancer should be referred to a
breast center for assessment of risk and potential imaging. If patients truly desire risk-reducing
mastectomies for future breast cancer risk, this is a different operation and should be performed by a
breast surgeon. Top surgery is a cosmetic mastectomy and breast tissue is left behind. Patients should be
screened accordingly for cancer with clinical examinations and mammography after the age of 40
postoperatively. There is no need to discontinue testosterone therapy in the perioperative period as
studies have not shown any effect on wound healing, bleeding, or DVT risk in cisgender men. 36
mebooksfree.net

Surgical Planning
Degree of breast tissue, volume of parenchyma to be resected, skin redundancy, and ptosis are all factors
that determine optimal technique. 37 Algorithms have been published to help determine optimal surgical
technique, 38 but modifications should be made based on surgeon and patient preference.
mebooksfree.net

Periareolar Mastectomy
Patients with small breast volume with limited skin are candidates for a periareolar mastectomy with a
small incision along the inferior areola border from 9 o’clock to 3 o’clock. The tissue is directly excised
through this incision, first dissecting planes along the breast capsule to the inframammary fold, medial,
lateral, and superior borders of the breast. The parenchyma is elevated off the pectoralis major muscle
and removed. The inframammary fold is ablated and scored to remove any feminine definition of breast
borders. Liposuction can be used to further contour the chest, including lateral chest side wall and
preaxillary fat. Drains are placed through separate stab incisions and the patient is placed in a
compression vest. This technique limits the ability to reposition the nipples to a more masculine location
on the chest wall, but skin recoil slightly reduces the diameter of the nipple areolar complex (NAC). The
advantage of this technique is a favorable inferior periareolar scar that may be unnoticeable when
shirtless (Figure 100.5).
mebooksfree.net

FIGURE 100.5 Periareolar mastectomy. Preoperative (A, B) and postoperative (C, D) photos of transmasculine gender
mastectomy using the periareolar incision technique. Ideal candidates for this procedure have a small breast size (A cup),
grade 0-I ptosis, and good tissue elasticity.
mebooksfree.net

Circumareolar Mastectomy
In patients with modest skin excess who desire a limited scar technique, a concentric-circle, circumareolar
approach, with resizing of the NAC, and small donut skin excision may be performed. The new diameter
of the NAC should be measured with maximum skin resection width of 2 cm. The parenchyma is excised
directly through a full thickness incision on the inferior areola border, and the intervening skin to be
removed is deepithelialized. The NAC survives on a deepithelialized dermal pedicle based superiorly.
Following completion of the parenchyma resection along the breast capsule, liposuction is used through a
separate stab incision along the inframammary fold to contour the chest wall superiorly and laterally. The
inframammary fold is undermined and scored through the open incision.
Closure of the donut incision is achieved with a spoke wheel pattern of 2-0 polydioxanone suture to help
distribute skin excess and relieve tension on the closure. The important thing is to prevent undue tension
on this scar, as it tends to spread due to forces in all directions. As in the periareolar approach, the ability
to relocate the nipple into a more lateral masculine position is limited.
mebooksfree.net

Double Incision with Free Nipple Grafting
Most patients with significant breast volume and long-term use of a binder require a double-incision free
nipple grafting technique to adequately remove excess skin and contour the chest (Figure 100.6). The first
incision should be located just inferior to the IMF to prevent superior displacement in closure. The second
incision is on top of the breast and generally designed to be straight across. In closure, the incision should
be straight or, if the patient prefers, slightly curved downward. A lateral upward extension along the
lateral border of the pectoralis may be used to help camouflage the lateral scar. The nipples are taken off
as full thickness grafts either as a central piece around the nipple papule or as a two-piece graft of areola
and small piece of papule if patient desires reduction of papule diameter. The nipple size should be
approximately 2.4 cm × 2.0 cm and oval shaped.
mebooksfree.net

FIGURE 100.6 Double-incision mastectomy with free nipple grafting. Preoperative (A, B) and postoperative (C, D)
photograohs showing transmasculine mastectomy using the double-incision with free nipple grafting technique. Candidacy
selection for this method includes patients of various breast sizes, grade II ptosis and above, and moderate to poor tissue
elasticity.
The inferior incision is made first and the breast tissue is undermined superficial to the pectoralis major
fascia to the superior border of the breast. The superior breast incision is then made and dissection carried
down to the breast capsule. All subcutaneous fat should be preserved on the superior mastectomy flap
mebooksfree.net

and dissection carried up to the superior border of the breast. A small amount of parenchyma is left
superiorly to retain some contour, which appears like pectoralis major development, and the remaining
parenchyma is then resected. Drains are placed through separate stab incisions inferior and lateral on the
chest wall. The IMF is then obliterated and scored to remove the feminine contour of the inferior breast.
The incision is then closed in three layers, Scarpa fascia, deep dermal, and subcuticular. The patient is
then placed in the seated position, and sterile stickers (labels for medications on the field) are used to
estimate nipple position along the lateral inferior border of the pectoralis major muscle. The patient is
then placed back in the supine position and the nipple inset area is marked as a transverse ellipse
2.4 × 2.0 cm. This area is deepithelialized and the thinned nipple graft sutured in place. A bolster dressing
is then secured.
mebooksfree.net

Postoperative Care
Drains are removed within 1 week and bolsters removed at 1 week. The patient is kept in a compression
vest for 3 weeks postoperatively with modified activity restrictions. Aggressive scar management with
massage and silicone sheeting at night at 3 weeks postoperatively helps prevent bothersome hypertrophic
scars. The breast tissue should all be sent to pathology and results reviewed with the patient, regardless
of age. Revisionary surgery is relatively common, with incidence approximately 40% 39 in general, any
decision to revise the scar or perform liposuction to improve contour should be delayed until 4 to
6 months postoperatively for postoperative edema to completely resolve.
mebooksfree.net

Phalloplasty
In properly selected transmale patients, phalloplasty may be indicated. Phalloplasty procedures have
specific goals including constructing reasonable male anatomy to affirm gender identity, preservation of
erogenous and orgasmic sensibility, the ability to stand to urinate, and the potential for penetrative
intercourse. In reality, achieving all of these goals is challenging and, although current reconstructive
strategies all employ similar principles, there is wide variation among surgeons in the specifics of
phalloplasty procedures. The choice of a one- or multiple-staged approach, which specific flaps are used
for phallic and urethral reconstruction, the methods for reconstruction of the pars fixa of the urethra, and
strategies to restore or preserve erogenous sensibility vary considerably among surgeons and centers;
there is no hard evidence supporting one specific approach for phallic construction.
This large variation in the specifics of phalloplasty procedures is principally related to the large
cutaneous surface of the male phallus, necessitating a large cutaneous donor site and because of the
complexity and difficulty of reconstructing the pars fixa and the penile urethra. 40
Complications of urinary stricture and fistula are prevalent. Considerable variation among centers has
resulted from attempts to improve on these high urologic, flap-related, and prosthetic complication rates,
ranging from 33% to 77% in large case-series. 41,42 Regarding donor-site selection, an individualized
discussion with each patient regarding the acceptance of, and the location of, a large cutaneous donor-site
scar is essential. Because Plastic Surgeons are not trained in urethral reconstruction or the management of
urethral strictures and fistulas, we believe it is mandatory that a qualified reconstructive urologist is
involved in each phalloplasty that involves urethral reconstruction. It therefore becomes a shared
decision between the Plastic Surgeon and the Urologist regarding urethral reconstruction. That, along
with the lack of consensus in the literature, is the basis of the variation in methods for urethral
reconstruction.
Transmasculine patients desiring a phalloplasty will also generally undergo hysterectomy,
oophorectomy, and vaginectomy. This can be done at the time of phalloplasty or done as a separate
procedure several months beforehand.
mebooksfree.net

Surgical Staging
Reconstruction of the male external genitalia is always performed in multiple stages. There is, however,
no “standard” sequence. Hysterectomy, oophorectomy, and vaginectomy are often performed as stand-
alone procedures several months in advance of the phalloplasty. There is accumulating evidence that this
may reduce the incidence of urethral leaks into the cavity left by the vaginectomy, but some centers will
still do the vaginectomy at the time of phalloplasty. Many centers will perform a urethral lengthening or
even a formal metoidioplasty (see below) to establish the pars fixa urethra in advance of formal
phalloplasty, either synchronous with, or as a separate stage from the vaginectomy. The formal
phalloplasty, usually a free tissue flap transfer procedure, is then performed. If a pars fixa reconstruction
has not been done in a prior stage, it is done at the time of the formal phalloplasty. Reconstruction of the
penile urethra can be done using the classic “tube within a tube” single-flap technique, using two
separate flaps for urethra and for phallic skin, or by prefabricating a urethra within the penile flap in
advance. Many centers perform a coronaplasty and begin scrotal construction at the time of phalloplasty,
although this is not universal. Scrotoplasty and insertion of testicular prosthesis are done once the
phalloplasty and urethral reconstruction are healed for several months. If penile prosthesis for erectile
function are to be placed, this is always done in a delayed stage, typically no sooner than 1 year after the
phalloplasty.
This myriad of approaches to staging underscores the difficult and the as-yet imperfectly resolved
challenge of reconstruction of functional male genitalia. Below, we will describe the general approach for
a single-stage, one-flap phalloplasty, followed by a discussion of some specific alternatives. A brief
description of historical flap design and utilization is outlined in Table 100.4.
TABLE 100.4
Penile Reconstruction: Free-Flap Utilization Methods a
Year
Donor Site
Described As
Description
Downfalls
1936
Abdomen
Classic method
Use of pedicled oblique to create tube for
neophallus
No neourethra
1946
Abdomen
Tube within a
tube
Neophallus with neourethra using a
multistage approach.
Scarring; insensate neophallus
1972
Groin
(+below
waist)
Branches of femoral and saphenous
systems are used for recipient free-flap
vessels
Scarring, insensate neophallus, unsatisfactory
cosmetic results
1982
Radial artery
free flap
Updated tube
within a tube
design
Flaps from radial artery used for tube
design.
Scarring, difficult to create sustainable corona ridge
and shape neophallus, still relatively high
complication rate
2006
Anterolateral
thigh flap
Pedicled to
groin
May be used as outer phallus with ulnar
or radial artery flap for urethral
reconstruction
May not be option in patients with thick thighs
aHistorical account of donor-site location and free-flap reconstruction methods in the creation of the neophallus for transmasculine gender-
affirming surgery.
mebooksfree.net

Single-Stage, One-Flap Phalloplasty
This approach, using the radial forearm free flap, is arguably the most commonly employed strategy at
the present time. It is also possible to perform phallic construction with an anterior-lateral thigh (ALT)
flap, although the thickness of that flap in most patients makes it difficult to produce a tube-within-a tube
structure without constructing an unduly large phallus. Below, the radial forearm flap procedure is
described; using ALT would be analogous.
The patient is prepared for surgery according to the general guidelines discussed above. Specific to this
procedure, a suprapubic urinary catheter is required. For the portion of the flap that will become the
urethra, permanent hair removal is mandatory preoperatively to prevent future strictures. Preoperative
examination focuses on examination of the forearm and an Allen’s test to ensure perfusion of the hand
based on the ulnar artery alone. The flap is planned as a “tube-within-a-tube.” The dimensions of the flap
account for penile length (average erect length of the male penis is 5.75 inches [about 15 cm]), the inner
circumference of the urethra (3–4 cm), and the external phallic skin (at least 15 cm). This therefore
requires a very large skin flap, 15 × 18 cm minimum, on the forearm. The flap is based on the radial artery
and its venae commitans, with the ulnar forearm becoming the urethral portion. The cephalic vein, and
the medial and lateral antebrachial cutaneous nerves are harvested with the flap. A strip of the skin
surface is deepithelialized to separate the urethra and phallic skin, and the urethral portion is tubed over
a Foley catheter. The remaining flap skin is now sutured around the urethral portion and to the distal
urethra. Some centers will also perform a primary glansplasty at this point, although reports of necrosis
of the flap distal to the coronal incision argue for delaying the glansplasty for a later stage. After flap
transfer, the donor defect is closed with a skin graft.
Preparation of the recipient site can occur synchronously with flap elevation. Again, there are multiple
variations in the specifics, but the basic elements include the following:
1. Preparing recipient vessels for the free flap, typically in the groin using branches of the femoral and
saphenous systems,
2. Lengthening the female urethra to create the pars fixa urethra of the male. Vaginal mucosal turnover
flaps, labia minora flaps, and buccal mucosal grafts have all been employed in various combinations
for this purpose
3. Deepithelializing the clitoris after release of the chordee and harvesting one of the clitoral nerves for
coaptation to a flap nerve
4. Beginning scrotal reconstruction with V-Y and/or transposition flaps of the labia majora
The still-innervated clitoris at the base of the neophallus provides for erogenous sensation; tactile
sensation on the phallus is provided through the medial and lateral antebrachial cutaneous nerve
coaptations to the clitoral and ilioinguinal nerves. This approach preserves erogenous and orgasmic
sensibility in nearly 100% of patients.
The radial forearm flap is then transferred to the recipient site and positioned so that the clitoris is at the
base of the neophallus. The urethral coaptation is performed leaving a Foley catheter in place. The flap is
reinnervated by coapting one of the flap nerves (typically the LABC) to the selected clitoral nerve and the
other flap nerve to a local cutaneous nerve, generally the ilioinguinal nerve. The flap is revascularized via
microvacular anastomoses, and the remaining local incisions are closed. Postoperative care is as for any
free-tissue transfer with urinary drainage via the suprapubic catheter. The Foley catheter is left in the
reconstructed urethra for 3 to 6 weeks before a cystoscopy and/or urethrogram verify urethral integrity.
The advantages of this approach are the reliable anatomy and robust vascularity of the radial forearm
flap, the ability to perform a one-stage construction of the phallus and urethra, excellent return of tactile
mebooksfree.net