Phẫu Thuật Tạo Hình (Tập 4): Chi Dưới, Thân Mình Và Bỏng – Neligan (2018)

312.e1
Reconstruction of male genitalia in the female-to-male (FTM) transsexual
D
(D) Tubing (inner tube) of the urethra.
Fig. 13.24, cont’d

313
Reconstruction of male genitalia in the female-to-male (FTM) transsexual
operation. Monstrey et al. however, early in their series and in
order to reduce the number of surgeries, performed a (sort of)
all-in-one procedure, which included a subcutaneous mastec-
tomy (SCM) and a complete genito-perineal transformation.79
However, later in their series they performed the SCM first
most often in combination with a total hysterectomy and
oophorectomy.
The reason for this change in protocol was that lengthy
operations (>8 h) resulted in considerable blood loss and
increased operative risk.81 Moreover, an aesthetic SCM
is not to be considered 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 include the use of a technique that
can be replicated with minimal complications. In this respect,
the RFF 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 a (aesthetic)
glans-plasty at the distal end of the flap. The final cosmetic
outcome of a radial forearm phalloplasty is a subjective deter-
mination, but the ability for most patients to shower with
other men or go to the sauna is the usual cosmetic barometer
(Fig. 13.25).
The potential aesthetic drawbacks of the RFF are the need
for a rigidity prosthesis, flattening of the reconstructed corona,
and possibly some volume loss over time.
Tactile and erogenous sensation
Of the various flaps used for penile reconstruction, the RFF
has the best sensitivity.82,83 Monstrey et al.79 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 is always placed directly below
the phallic shaft. Later manipulation of the neophallus allows
for stimulation of the still-innervated clitoris.
has been previously prepared and marked by the urologist –
to restore erogenous sensation. The clitoris is usually denuded
and buried underneath the penis, thus keeping the possibility
for stimulation during sexual intercourse.
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.
All patients receive a suprapubic urinary diversion. They
then remain in bed for 1 week, and the transurethral catheter
is removed after 10 days if no major local wound healing
problems are present. The patient starts voiding at day 12, and
the suprapubic catheter is removed at day 14 if no substantial
residual urine (>100 mL) is present. The average hospital stay
for the phalloplasty procedure is 2.5 weeks.
Tattooing of the glans can be performed after a 2–3 month
period, before sensation returns to the penis. Implantation of the
testicular prostheses can be performed after 6 months, but it is
typically done in combination with the implantation of a penile
erection prosthesis, 1 year after the operation, once penile sensitiv-
ity is completely restored and has reached the tip of the penis.
Ideal goals
The ideal goals or requirements of a penile reconstruction
have been described by Hage and De Graaf80 and include the
following challenges: (1) a one-stage procedure that can
be predictably reproduced, (2) an aesthetically acceptable
phallus, (3) a phallus that has both tactile and erogenous
sensibility, (4) a competent neo-urethra to allow voiding while
standing, (5) minimal complications, (6) an acceptable donor
site morbidity, (7) a natural-looking scrotum, and (8) enough
phallic bulk to tolerate the insertion of a prosthetic stiffener
allowing sexual intercourse. What can be achieved with the
RFF phalloplasty technique?
A one-stage procedure
It has been accepted that a complete penile reconstruction
with erection prosthesis can never be performed in one single
G
H
(G) Immediate
postoperative result of the penis. (H) The
donor site on the arm.
Fig. 13.24, cont’d

314
SECTION II
CHAPTER 13 • Reconstruction of male genital defects
Fig. 13.25  Late postoperative results of
radial forearm phalloplasties.
A
B
C
After 1 year, all patients in Monstrey et al.’s series79 had
regained tactile sensitivity in their penis, which is an absolute
requirement for safe insertion of an erection prosthesis.82
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).84
Voiding while standing
For biologic males as well as for FTM transsexuals undergo-
ing a phalloplasty, the ability to void while standing is a high
priority.85 Unfortunately, the reported incidences of urologic
complications, such as urethrocutaneous fistulas, strictures,
and hairy urethras, are extremely high in all series of phal-
loplasties, even up to 80%.34 For this reason, certain (well-
intentioned) surgeons have even stopped reconstructing a
complete neo-urethra.76,78
Although Monstrey et al.79 reported a 41% (119/287) uro-
logic complication rate, the majority of these early fistulas
closed spontaneously and ultimately all patients were able to
void through the newly reconstructed penis. Since it is
unknown how the new urethra – an, on average, 16 cm skin
tube – will affect bladder function in the long term, lifelong
urologic follow-up was strongly recommended for all these
patients.86
Minimal morbidity
Complications following phalloplasty include the general
complications such as minor wound healing problems in
the groin area or (minor) pulmonary embolism despite ade-
quate prevention (interrupting hormonal therapy, fractioned
heparin SC, and elastic stockings). A vaginectomy is usually
considered a particularly difficult operation with a high risk
of postoperative bleeding, but in Monstrey et al.’s series no
major bleedings were seen.81 Two early patients displayed
symptoms of nerve compression in the lower leg, but after
reducing the length of the gynecologic positioning to under
2 h, this complication never occurred again. Apart from the
urinary fistulas and/or strictures, most complications of the
radial forearm phalloplasty are related to 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 many microsur-
geons and transgender surgeons no longer perform elective
microsurgical penile reconstruction on patients who fail to
quit smoking 1 year prior to their surgery.
No functional loss and minimal scarring in the donor area
The major drawback of the RFF has always been the unat-
tractive donor site scar on the forearm (Fig. 13.26). Selvaggi
et al. conducted a long-term follow-up study87 of 125 radial
forearm phalloplasties to assess the degree of functional loss
A
Fig. 13.26  Late result of the donor site at the forearm.
B

315
Reconstruction of male genitalia in the female-to-male (FTM) transsexual
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 smaller flaps as used in head and
neck reconstruction. 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.
Suprafascial flap dissection, full-thickness skin grafting, and
the use of dermal substitutes may improve the forearm scar.
Normal scrotum
For the FTM patient, the goal of creating natural-appearing
genitalia also applies to the scrotum. As the labia majora are
the embryologic 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 reminis-
cent of the female genitalia. Selvaggi in 2009 reported on a
novel scrotoplasty technique that combines a V-Y plasty with
a 90° turning of the labial flaps resulting in an anterior trans-
position of labial skin (Fig. 13.27). The excellent aesthetic
outcome of this male-looking (anteriorly located) scrotum, the
functional advantage of fewer urologic complications, and the
easier implantation of testicular prostheses make this the
technique of choice.88
Sexual intercourse
In a radial forearm phalloplasty, the insertion of an erection
prosthesis is required in order 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 initially never used in our patients. Hoebeke
et al., in the largest series to date on erection prostheses after
penile reconstruction, only used the hydraulic systems avail-
able for impotent men.89 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. In another study, it was demon-
strated that patients with an erection prosthesis were more
able to attain their sexual expectations than those without
prosthesis (Fig. 13.28).90
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.
Nowadays some newer semirigid devices are available
with less risk of perforation. These therefore have become an
option for implantation after phalloplasty.
Conclusion
The authors in this review article conclude that the radial
forearm phalloplasty is a very reliable technique for the con-
struction, usually in two stages, of a normal-looking penis
that allows the patient to void while standing and also to
experience sexual satisfaction.
A
Fig. 13.27  Reconstruction of a lateral looking scrotum with two transposition flaps
before and after implantation of prostheses.
B
The main disadvantages of this technique are the rather
high number of initial fistulas, the scar on the forearm, and
the potential long-term urologic complications.
Alternative phalloplasty techniques
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 ALT flap, which can be used both as a
free flap91 or rather as a pedicled flap (S. Suominen, pers.
comm. 1994),41,92 therefore avoiding the problems related to
microsurgical free flap transfer (see above).
The pedicled ALT flap represents the best alternative for
penile reconstruction because as a pedicled flap it does not
require any microvascular anastomosis, it can be reinnervated
like the RFF, and its donor site morbidity is limited to the donor
site scar that requires skin grafting and is more easily concealed.

316
SECTION II
CHAPTER 13 • Reconstruction of male genital defects
coaptation (Fig. 13.29D). Then the medial or lateral incision is
performed – according to the surgeon’s preferences – and
suprafascial dissection is carried out until the perforator is
identified. Once perforator dissection is completed, the flap
is harvested circumferentially (Fig. 13.29E). In most cases it is
sufficient to tunnel the flap underneath the rectus femoris and
then under a subcutaneous tunnel to the groin. Both tunnels
should be as wide as possible. If additional length is required,
the pedicle can be dissected more proximally with sacrifice of
the vascular branch to the rectus femoris and also tunneled
underneath the sartorius muscle that – in cases of short ped-
icles – will act as a sling and cause pedicle compression. Once
the flap is tunneled and the pedicle is checked (Fig. 13.29F),
the flap is wrapped around the reconstructed urethra (see
below) and shaped. The coronoplasty is performed 10 days
after the operation due to the different vascularization of the
ALT compared to the RFF.
The major drawback of the ALT flap is that, unless the
patient is extremely thin, the tube-within-a-tube technique
cannot be used for urethra reconstruction.
An inner urethral tube can be provided by prefabricating
the ALT flap with a split-thickness skin graft. The skin-grafted
area should have a width of at least 5 cm to provide an ade-
quate inner tube and prevent future stricture. Still, the quality
of the inner urethral tube when lined with skin grafts might
be inferior compared to normal skin, resulting in a higher rate
of urologic complications (strictures and fistulas) when com-
pared to a RFF tube-within-tube phalloplasty. The shape of a
prefabricated ALT phalloplasty is comparable with or even
somewhat better than the RFAF phalloplasty if the patient is
not too fat and the flap is defatted. This technique can be an
excellent backup in redo phalloplasties and in cases when no
forearm is available.
To overcome this problem the ALT has either been used
alone without urethral reconstruction or combined with a
second flap for the inner urethral tube. However, to date, there
is no extensive report on this technique apart from one case
series and a few case reports.94–98 We have performed more
than 80 phalloplasties with an ALT flap (unpublished data)
and – as the ability to void while standing is an essential
requirement of a phalloplasty – we have worked on an effec-
tive technique of urethral reconstruction. We will go through
all the potential alternatives available.
The fabrication of an inner tube for urethral conduit makes
the ALT flap procedure in reconstruction of a phallus more
complex, especially in the biologically female transman, while
in most bladder extrophy patients the inner tube is not neces-
sary as they have a urinary diversion.
As outlined earlier, a tube-within-a-tube, similar to the
conventional RFAF phalloplasty procedure, can also be con-
structed in the case of a pedicled ALT flap, but only in very
thin individuals. In most cases, however, the subcutaneous fat
is too thick and another technique must be chosen to recon-
struct the inner urethral tube.
The use of well-vascularized tissue is necessary. Therefore
the inner tube is best made with another flap. A pedicled
peritoneal flap, elevated together with the posterior rectus
fascia pedicled on a branch of the deep inferior epigastric
artery pedicle99 has been tried in order to reconstruct a urethral
conduit, but this was not suitable:41,100 the inner peritoneal
lining easily causes fibrosis resulting in permanent oblitera-
tion of the lumen.100
A
Fig. 13.28  After implantation of an erection prosthesis.
B
Accurate patient selection is mandatory. Candidates for
this technique are patients that:
■ Have a pinch test of less than 2 cm in the lateral thigh
■ Do not wish to have a forearm scar
■ Would accept the scar on the thigh
■ Have an insufficient ulnar artery on Allen’s test
■ Have an adequate, possibly septocutaneous, perforator
on angio-CT (or MRI).
We routinely perform a preoperative CT scan to choose the
best side for harvest of the ALT flap.93 The distal most perfora-
tor is chosen, and the flap is drawn with the perforator lying
close to its proximal margin (Fig. 13.29A) in order to gain
pedicle length for tensionless transfer to the pubic area. The
proximal incision is performed first, and two sensory branches
of the lateral femoral cutaneous nerves are isolated for sensory

317
Reconstruction of male genitalia in the female-to-male (FTM) transsexual
Another option could be a pedicled groin flap, turned 180° on
its pedicle and transferred to the pubic area, with the proximal
part of its pedicle buried subcutaneously. The donor scar can be
closed primarily. Because of the thickness of the flap, the same
objections can be made as mentioned with the tube-within-a-
tube technique and a bulk is left where the pedicle is tunneled.
Eventually, we discovered our current standard technique: a
pedicle superficial circumflex iliac (artery) perforator (SCI (A)
P) can be harvested as an ultrathin flap but pedicled. This flap
has been described bilaterally for total penile reconstruction,
but it carries the major disadvantage of not being sensate, thus
making it impossible to safely wear an erectile prosthesis.101
The SCIAP allows combination of two pedicled perforator
flaps (Fig. 13.29A), sensate ALT and SCIAP, without prolong-
ing operative time because the SCIAP flap can be harvested
and tubed in the lithotomy position during the urologic part
(Fig. 13.29B & C). Then the patient is put back in the supine
position, the SCIAP is sutured to the elongated urethra, and
A
B
C
D
Fig. 13.29  (A) Preoperative drawings of the anterolateral thigh/superficial circumflex iliac artery perforator (ALT/SCIAP) phalloplasty. The ALT is planned based on the
angio-CT findings. The SCIAP flap is planned contralaterally to the ALT with a distal “V” shaped tip to compensate for scar retraction at the junction between the pars fixa
and the phallic urethra. (B) The SCIAP flap at the end of pedicle dissection (left is lateral, the fish hooks are placed caudally). The green backgrounds are placed underneath
the SCIAP (lateral) and the superficial vein (medial). There is always a superficial vein draining the skin of the SCIAP, which is only kept when it does not interfere with flap
rotation. (C) A caudal view of the elevated SCIAP flap shows how thin the flap can be. After elevation the tip and margins of the flap can be further trimmed. Having such a
thin flap for urethral reconstruction is very important, especially in the female-to-male (FTM) transgender patient, whose ALTs are usually thicker than in biologic males.  
(D) Once the patient is put back in the supine position, harvesting of the ALT flap is begun. Prior to that, the tubed SCIAP flap is sutured to the pars fixa of the urethra and
wrapped in wet gauze while the donor site is closed primarily. The dissection of the ALT flap (right is cranial, top is medial, the knee is on the left side) is begun with
proximal incision and identification of two branches of the lateral femoral cutaneous nerve.
Continued

318
SECTION II
CHAPTER 13 • Reconstruction of male genital defects
(E) Same view as Fig. 13.29D. The flap is reflected medially. Pedicle dissection is completed. The retractor separates the rectus femoris and the vastus
lateralis muscle. The pedicle between them is evidenced by a green background. The perforator ran for a short distance inside the muscle in this particular case. Between
the fishhooks and the retractor a small amount of muscle fiber has been divided to allow for pedicle transfer. Next to it and medially, the intact motor nerve to the vastus
lateralis can be seen. Two green backgrounds are placed on the undersurface of the flap with the sensory nerves lying on top of them. (F) This caudal view shows the ALT
flap after tunneling and before tubing (top is cranial, right is left on the patient’s body). The ALT is lying with the skin on the pubic skin; its undersurface is visible with the
tubed SCIAP lying on top of it. At this point the ALT will be sutured around the SCIAP. Any undue tension should be avoided and postoperative edema anticipated. Any
tension might potentially compromise the flaps. In the case of doubt, a split-thickness skin graft can be placed between the two edges of the ALT in the ventral (less visible)
surface of the penis. (G) Bird’s eye view of the reconstructed penis (left is cranial, top is right) nerve coaptations are the last step to correctly estimate length as the shorter
the nerve stump, the faster reinnervation. Two green backgrounds are placed underneath the coapted nerves: the one above is coapted to the right dorsal clitoral nerve, the
one below to one of the ilio-inguinal nerves. (H) Before and after closure the flap must always be checked because any undue tension or compression on the pedicle must
be avoided. A slightly pinker flap with a slightly faster refill like the one shown in this picture is – however – extremely common with pedicled perforator flaps and should
not be a cause for concern.
F
G
H
E
Fig. 13.29, cont’d

319
Reconstruction of male genitalia in the female-to-male (FTM) transsexual
J
K
L
(I–K) One-year
postoperative result before erectile prosthesis
implantation. Front, lateral, and three-quarters
view. Showing the end result, the flap’s donor
site on the left thigh, the skin graft donor site on
the right thigh, and the barely visible SCIAP flap
donor site scar on the right groin. (L) Frontal
view of the tip of the penis. The external urinary
meatus stays patent and allows effective voiding.
Fig. 13.29, cont’d
I
the ALT is harvested and transferred (Fig. 13.29D–H). Nowa-
days, unless there are bilateral groin scars, this is our first
choice for urethral reconstruction in combination with an ALT
phalloplasty (Fig. 13.29I–L).
A good though demanding alternative is a narrow free
RFAF. This flap is thin and very well vascularized (Fig.
13.30). The results of this combined (pedicled ALT + free
RFAF) phalloplasty procedure were similar to the results
of the RFAF (only) phalloplasty with regard to the urologic
complication rate and were even more pleasing from an
aesthetic point of view. The resulting scar on the arm is
small and located on the inner side (Fig. 13.30). This scar
is easily concealed and acceptable for most FTM transsexu-
als willing to avoid the circumferential scar. The scar on the
leg, although conspicuous, never poses a problem for these
patients as it can be more easily hidden than the scar on

320
SECTION II
CHAPTER 13 • Reconstruction of male genital defects
A
B
C
D
E
F
Fig. 13.30  (A,B) Dissection of a narrow free vascularized radial forearm used for the urethra. (C) The radial forearm flap urethra is ready to be transferred to the pubic area.
(D) Dissection of the anterolateral thigh (ALT) flap that will be used to wrap around the urethra. (E) Radial forearm flap (RFAF) urethra and ALT wrap-around put into position
in the pubic area. (F) After coronoplasty and grafting of the donor area.
the arm, which is sometimes considered “the signature” of a
phalloplasty procedure. Obviously, this procedure becomes
more complex as it combines two flaps, one of which is a free
microvascular flap.
Fibular flap and muscle flaps
There have been several reports on penile reconstruction with
the fibular flap based on the peroneal artery and the peroneal
vein.102–103 This flap 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 of this technique are
the poor quality of flap sensation, 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.

321
Summary
G
H
I
Alternative techniques also employ innervated muscle
flaps like the free latissimus dorsi104 and the bilateral pedicled
gracilis flap.105 Both techniques enable contraction of the
penis, which is present from the beginning with the gracilis
and needs nerve regeneration with the latissimus dorsi.
However, no skin sensation is restored, and urethral recon-
struction, if attempted, needs multiple stage techniques. These
muscle flaps are not reported to have protective skin sensitiv-
ity, and subsequently they are not reported to host a penile
prosthesis. Vesely104 reports that 42% of patients have sexual
intercourse because muscle contraction allows the penis to
stiffen and move during sexual intercourse.
(G–I) Results after 3 months: the donor site on the inner aspect of the arm is
inconspicuous and the donor site on the leg can easily be covered, even with shorts.
Fig. 13.30, cont’d
Summary
The importance of a multidisciplinary
approach
Gender reassignment, particularly reassignment surgery,
requires close cooperation between the different surgical
specialties. In phalloplasty, the collaboration between the
plastic surgeon, the urologist, and the gynecologist is essen-
tial.106 The actual penile reconstruction is typically performed
by the plastic and reconstructive surgeon, but, in the long

322
SECTION II
CHAPTER 13 • Reconstruction of male genital defects
6. Mitchell ME, Bägli DJ. Complete penile disassembly for epispadias
repair: the Mitchell technique. J Urol. 1996;155(1):300–304. The
authors present their technique for epispadias repair in the context of a
case series. Phallic disassembly into the urethral plate and bilateral
hemicorporeal glandular bodies are the basis for their reconstruction.
10. Lee PA, Houk CP, Ahmed SF, et al. Consensus statement on
management of intersex disorders. International Consensus
Conference on Intersex. Pediatrics. 2006;118(2):e488–e500. This paper
represents the responses of 50 international experts to a series of
literature-based questions. Topics ranging from diagnosis to medical and
surgical management, as well as the important role of psychosocial
support, are discussed.
24. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg. 1972;25:3.
33. Hurwitz DJ, Swartz WM, Mathes SJ. The gluteal thigh flap: a
reliable, sensate flap for the closure of buttock and perineal
wounds. Plast Reconstr Surg. 1981;68:521. The authors describe the
results of anatomic dissections detailing the gluteal thigh flap’s
neurovascular morphology. A case series demonstrating the clinical
utility of the flap is also presented.
38. Orticochea M. A new method of total reconstruction of the penis.
Br J Plast Surg. 1972;25:347–366.
42. Cohen BE, May JW, Daly JS, et al. Successful clinical replantation
of an amputated penis by microneurovascular repair. Plast Reconstr
Surg. 1977;59:276.
55. Eke N. Fournier’s gangrene: a review of 1726 cases. Br J Surg.
2000;87:718. This is a meta-analysis of Fournier’s gangrene publications
from 1950–99. The authors investigate trends in diagnosis and
management and conclude that while precise definitions vary, treatment
is based on clinical presentation.
70. Hester TR Jr, Nahain F, Beeglen PE, et al. Blood supply of the
abdomen revisited, with emphasis on the superficial inferior
epigastric artery. Plast Reconstr Surg. 1984;74(5):657–666.
73. Chang TS, Hwang YW. Forearm flap in one-stage reconstruction of
the penis. Plast Reconstr Surg. 1984;74:251–258. Single stage free
forearm-based penile reconstruction is described in this case series.
79. Monstrey S, Hoebeke P, Selvaggi G, et al. Penile reconstruction: is
the radial forearm flap really the standard technique? Plast
Reconstr Surg. 2009;124:510–518.
Access the complete reference list online at

term, the urologist’s role may be the most important for
patients who have undergone penile reconstruction, especially
because the complication rate is rather high, particularly with
regard to the number of urinary fistulas and urinary strictures.
The urologist also reconstructs the fixed part of the urethra
and is generally the best choice for implantation and follow-up
of the penile and/or testicular prostheses. The urologist also
addresses later sequelae, including stone formation. More-
over, the surgical complexity of adding an elongated conduit
(skin-tube urethra) to a biologic female bladder, and the long-
term effects of evacuating urine through this skin tube,
demand lifelong urologic follow-up.
Therefore professionals who unite for the purpose of creat-
ing a gender reassignment program should be aware of the
necessity for a strong alliance, mainly between the plastic
surgeon and the urologist, which is an absolute requisite for
consistently obtaining the best possible results. In turn, the
Bonus images for this chapter can be found online at

Fig. 13.10 Buried penis: retraction of the peripenile and pubic fat reveals a
normal size penis.
Fig. 13.13 (D–F) A Cavi-Care dressing is applied around the skin graft (poured
out in a cylinder form around the penis), and this dressing will stay for 1 week.
Fig. 13.15 (B) After penile elongation with release of the suspensory ligament
and coverage of the distal part of the penis with buccal mucosa. (C) Result of
glans reconstruction using buccal mucosa.
Fig. 13.22 (C) Creation of the flaps for the scrotoplasty. (F) Closure of the skin
and final result.
Fig. 13.24 (D) Tubing (inner tube) of the urethra.
surgeons must commit to the extended care of this unique
population that, by definition, will continue well into the
future.

322.e1
References
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4. Hinman F Jr. Anatomy of the external genitalia. In: Ehrlich RM,
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11. Boemers TM, De Jong TP. The surgical correction of buried penis:
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33. Hurwitz DJ, Swartz WM, Mathes SJ. The gluteal thigh flap: a
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36. Yii NW, Niranjan NS. Lotus petal flaps in vulvo-vaginal
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37. Gilbert DA, Horton CE, Terzis JK, et al. New concepts in phallic
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38. Orticochea M. A new method of total reconstruction of the penis.
Br J Plast Surg. 1972;25:347–366.
39. Horton CE, McCraw JB, Devine CJ, et al. Secondary reconstruction
of the genital area. Urol Clin North Am. 1977;4:133–141.
40. Santanelli F, Scuderi N. Neophalloplasty in female-to-male
transsexuals with the island tensor fasciae latae flap. Plast Reconstr
Surg. 2000;105:1990.
41. Ceulemans P. The pedicled anterolateral thigh (ALT) perforator
flap: a new technique for phallic reconstruction. XIX Biennial
Symposium of the Harry Benjamin International Gender
Dysphoria (HBIGDA) Association, Bologna/Italy, April 2005.
42. Cohen BE, May JW, Daly JS, et al. Successful clinical replantation
of an amputated penis by microneurovascular repair. Plast Reconstr
Surg. 1977;59:276.
43. Tamai S, Nakamura Y, Motomiya Y. Microsurgical replantation of a
completely amputated penis and scrotum. Plast Reconstr Surg.
1977;60:287.
44. Ehrich WS. Two unusual penile injuries. J Urol. 1929;21:239.
45. Jordan GH. Initial management and reconstruction of male
amputation injuries. In: McAninch JW, ed. Traumatic and
Reconstructive Urology. Philadelphia: WB Saunders; 1996:673–681.
46. Janecka IP, Romas NA. Microvascular free transfer of the human
testes. Plast Reconstr Surg. 1979;63:42.
47. Martinis FG, Nagler HM. Testicular autotransplantation. Atlas Urol
Clin North Am. 1996;4:95.
48. Hu W, Lu J, Zhang L, et al. A preliminary report of penile
transplantation. Eur Urol. 2006;50(4):851–853.
49. Netto J. Doctors claim first successful penis transplant. CNN.
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322.e2
SECTION II
CHAPTER 13 • Reconstruction of male genital defects
51. Gallagher J. South Africans perform first ‘successful’ penis
transplant. BBC News. March 13, 2015. [Online] Available from:
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52. Dubernard J-M. Penile transplantation? Eur Urol. 2006;50(4):
664–665.
53. Hoebeke P. Re: Weilie Hu, Jun Lu, Lichao Zhang, et al. A
preliminary report of penile transplantation. Eur Urol. 2006;50:851–
853. Eur Urol. 2007;51(4):1146–1147.
54. Zhang LC, Zhao YB, Hu WL. Ethical issues in penile
transplantation. Asian J Androl. 2010;12(6):795–800.
55. Eke N. Fournier’s gangrene: a review of 1726 cases. Br J Surg.
2000;87:718. This is a meta-analysis of Fournier’s gangrene publications
from 1950–99. The authors investigate trends in diagnosis and
management and conclude that while precise definitions vary, treatment
is based on clinical presentation.
56. Vick R, Carson C. Fournier’s Disease. Urol Clin North Am.
1999;26:841.
57. Eicher W. Surgical treatment of female-to-male transsexuals. In:
Eicher W, ed. Plastic Surgery in the Sexually Handicapped. Berlin:
Springer; 1989:106–112.
58. Perovic SV, Djordjevic ML. Metoidioplasty: a variant of
phalloplasty in female transsexuals. BJU Int. 2003;92(9):981–985.
59. Hage JJ, van Turnhout AA. Long-term outcome of metaoidioplasty
in 70 female-to-male transsexuals. Ann Plast Surg. 2006;57(3):
312–316.
60. Duckett JW Jr. Transverse preputial island flap technique for repair
of severe hypospadias. Urol Clin North Am. 1980;7(2):423–430.
61. Laub DR, Eicher W, Laub DR II, et al. Penis construction in
female-to-male transsexuals. In: Eicher W, ed. Plastic Surgery in the
Sexually Handicapped. Berlin: Springer; 1989:113–128.
62. Biemer E. Bedeutung und fortschritte der chirurgischen
geslechtsumwandlung. Münch Med Wochenschr. 1988;130:480–482.
63. Bogoras N. Über die volle plastische wiederherstellung eines zum
koitus fähigen penis (peniplastica totalis). Zentralbl Chir.
1936;22:1271–1276.
64. McIndoe A. Deformities of the male urethra. Br J Plast Surg.
1948;1:29–47.
65. Maltz M. Maltz reparative technic for the penis. In: Maltz M, ed.
Evolution of Plastic Surgery. New York: Froben Press; 1946:278–
279.
66. Gillies H, Millard DR Jr. The Principles and Art of Plastic Surgery.
Vol. 2. London: Butterworth; 1957:368–384.
67. Biber SH. A method for constructing the penis and scrotum.
Presented at the VIth International Symposium on Gender
Dysphoria, San Diego, 1979.
68. Snyder CC. Intersex problems and hermaphroditism. In: Converse
JM, ed. Reconstructive Plastic Surgery. Philadelphia: WB Saunders;
1964:2078–2105.
69. Snyder CC, Browne EZ Jr. Intersex problems and
hermaphroditism. In: Converse JM, ed. Reconstructive Plastic
Surgery. 2nd ed. Philadelphia: WB Saunders; 1977:3941–3949.
70. Hester TR Jr, Nahain F, Beeglen PE, et al. Blood supply of the
abdomen revisited, with emphasis on the superficial inferior
epigastric artery. Plast Reconstr Surg. 1984;74(5):657–666.
71. Hoopes JE. Surgical construction of the male external genitalia.
Clin Plast Surg. 1974;1(2):325–334.
72. Exner K. Penile reconstruction in female to male transsexualism: a
new method of phalloplasty. Xth International Congress on Plastic
and Reconstructive Surgery, Madrid, 1992.
73. Chang TS, Hwang YW. Forearm flap in one-stage reconstruction of
the penis. Plast Reconstr Surg. 1984;74:251–258. Single stage free
forearm-based penile reconstruction is described in this case series.
74. Song R, Gao Y, Song Y, et al. The forearm flap. Clin Plast Surg.
1982;9:21.
75. Harashima T, Ionque T, Tanaka I, et al. Reconstruction of penis
with free deltoid flap. Br J Plast Surg. 1990;43:217–222.
76. Hage JJ, Bouman FG, de Graaf FH, et al. Construction of the
neophallus in female-to-lake transsexuals: the Amsterdam
experience. J Urol. 1993;6:1463–1468.
77. Sadove RC, Sengezer M, McRobert JW, et al. One-stage total penile
reconstruction with a free sensate osteocutaneous fibula flap. Plast
Reconstr Surg. 1993;92(7):1314–1325.
78. Felici N, Felici A. A new phalloplasty technique: the free
anterolateral thigh flap phalloplasty. J Plast Reconstr Aesthet Surg.
2006;59:153–157.
79. Monstrey S, Hoebeke P, Selvaggi G, et al. Penile reconstruction: is
the radial forearm flap really the standard technique? Plast
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80. Hage JJ, De Graaf FH. Addressing the ideal requirements by free
flap phalloplasty: some reflections on refinements of technique.
Microsurgery. 1993;14:592–598.
81. Weyers S, Selvaggi G, Monstrey S, et al. Two-stage versus
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82. Selvaggi G, Monstrey S, Ceuleman P, et al. Genital sensitivity after
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83. De Cuypere G, T’Sjoen G, Beerten R, et al. Sexual and physical
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84. Hage JJ, Bout CA, Bloem JJ, et al. Phalloplasty in female-to-male
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85. Matti B, Matthews R, Davies D. Phalloplasty using the free radial
forearm flap. Br J Plast Surg. 1988;41:160–164.
86. Hoebeke P, Selvaggi G, Ceulemans P, et al. Impact of sex
reassignment surgery on lower urinary tract function. Eur Urol.
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87. Selvaggi G, Monstrey S, Hoebeke P, et al. Donor site morbidity of
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88. Selvaggi G, Hoebeke P, Ceuleman P, et al. Scrotal reconstruction in
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89. Hoebeke P, De Cuypere G, Ceulemans P, et al. Obtaining rigidity
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90. Hoebeke P, Decaestecker K, Beysens M, et al. Erectile implants in
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91. Felici N. Phalloplasty with free anterolateral thigh flap. XIX
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92. Ceulemans P, Hoebeke P, Buncamper M, et al. The pedicled
anterolateral thigh flap in phalloplasty procedures. 19th EURAPS
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93. Sinove Y, Kyriopoulos E, Ceulemans P, et al. Preoperative planning
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94. Mutaf M, Isik D, Bulut Ö, Büyükgüral B. A true nonmicrosurgical
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95. Morrison SD, Son J, Song J, et al. Modification of the tube-in-tube
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96. Spyriounis PK, Karmiris NI. Partial penile reconstruction
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2001;101:200–209.

SECTION II • Trunk Surgery
14 
Reconstruction of acquired vaginal defects
Leila Jazayeri, Andrea L. Pusic, and Peter G. Cordeiro
SYNOPSIS
■ Acquired vaginal defects are most commonly the result of oncologic
resections.
■ The classification of acquired vaginal defects, based on anatomic
location, is defined.
■ Current approaches to reconstruction of these defects most commonly
involve local or regional flaps.
■ Flap selection, based on defect type, is described.
■ Surgical technique for commonly indicated flaps is described.
■ A cautious approach to postoperative management, as well as careful
adjustment of patient expectations, is critical in the care of these
patients.
Access the Historical Perspective section online at

Introduction
Acquired vaginal defects most commonly result from the resection
of pelvic malignant neoplasms. Advanced colorectal carcinomas
frequently involve the posterior vaginal wall, and carcinoma of
the bladder may extend into the anterior vaginal wall. Primary
tumors of the vaginal wall may also result in any number of
vaginal defects. Local extension or recurrence of uterine or cervi-
cal malignant neoplasms can necessitate pelvic exenteration and
total vaginal resection. Trauma or burns to the vaginal area may
also result in vaginal distortion; however, the relatively protected
position of the vagina makes these deformities much less common.
Irrespective of their etiology, vaginal defects may range
from a small mucosal defect to total circumferential loss. In
addition, tumor ablation may necessitate the resection of
nearby pelvic contents and/or vulvar and perineal tissue. The
subsequent pelvic dead space or resulting perineal defects are
critical considerations in the final reconstruction.
Anatomic considerations
The close anatomic relationship between bladder, vagina, and
rectum needs to be appreciated by the reconstructive surgeon.
Ligamentous support of these organs is interrelated, and
surgical dissection of any one structure may lead to prolapse
and herniation of the remaining components. In addition,
pelvic exenteration may disrupt or devascularize the pelvic
floor musculature. The pelvic sidewalls define a fixed ana-
tomic space that, once cleared of the pelvic organs, will either
delineate a dead space or invite small-bowel prolapse and
adhesions.
The vagina is essentially a distensible cylindrical pouch
(Fig. 14.1). Normal length is 6–7.5 cm along its anterior wall
and 9 cm along the posterior wall.7 It is constricted at the
introitus, dilated in the middle, and narrowed near its uterine
extremity. In its normal anatomic position, the vagina tilts
posteriorly as it extends up into the pelvis, forming a 90° angle
with the uterus. Careful orientation of the neovagina is impor-
tant to successful reconstruction and ultimate sexual function.
The introitus is a frequent site of contracture after reconstruc-
tion, and any distortion of its normal position relative to other
structures, such as the urethral orifice, perineal body, and
anus, should be addressed. If no resection of the external
vulva and perineum is required, great care must be taken to
avoid their distortion because this may also have an impact
on sexual function and body image.
Diagnosis
The classification of acquired vaginal defects is based on their
anatomic location (Fig. 14.2). This classification will help to
guide reconstructive efforts. There are two basic types of
vaginal defect: partial (type I) and circumferential (type II).
These basic types can be further subclassified. Type IA defects
are partial and involve the anterior or lateral wall. These
defects may result from the resection of urinary tract

323.e1
Historical perspective
Historical perspective
Whereas small partial vaginal defects are common and usually
repaired primarily, larger defects caused by ablative surgeries
such as abdominal perineal resections (APRs) and pelvic
exenterations usually require flap reconstruction.
APRs are performed for very low rectal tumors. In this
procedure, the entire rectum, anal canal, and anus are
removed, and a permanent colostomy is created. Perineal
wound complications such as delayed healing and infection
are common in these patients, especially those who have
undergone irradiation. Major wound complications have
been reported in 14–41% of patients following APR when
defects have been closed primarily.1 When APR was first
described in 1908, the perineal wound was left open and
allowed to heal by secondary intention.2 This approach led to
serious morbidity associated with delayed wound healing
and was subsequently replaced by primary closure with
suction drains and then delayed reconstruction. This approach
was also problematic, especially for irradiated wounds as
these often broke down and delayed reconstruction was dif-
ficult. Today, immediate local or regional flaps are the most
common approach to managing these large APR defects.
Pelvic exenteration may be required when rectal cancers
have invaded adjacent structures such as the uterus or bladder.
In these cases, a partial or total vaginectomy is often neces-
sary. When pelvic exenteration was first performed in the
1940s, the operative mortality was greater than 20%.3 Today,
perioperative mortality is 3–5%.4,5 The historical approach to
these defects is similar to that of the APR defect: wounds are
left open to heal by secondary intention, or primary closure
over drains with delayed reconstruction if the wound is
breaking down. Today, many pelvic exenteration defects are
immediately reconstructed using flaps. Despite the change in
approach to these defects, there remains significant morbidity
in more than 50% of patients.4 Even with immediate flap
reconstruction to improve vascularity and to decrease dead
space, infection may occur in 9–11% and delayed wound
healing in up to 46%. Other significant complications include
intestinal adhesions, fistulas, and pelvic herniation.6

324
SECTION II
CHAPTER 14 • Reconstruction of acquired vaginal defects
IIA defects are circumferential defects involving the upper
two-thirds of the vagina. These defects are typically the result
of uterine and cervical diseases. Type IIB defects are circum-
ferential, total vaginal defects that are commonly the result of
pelvic exenteration. These defects result in considerable soft-
tissue loss, dead space, as well as distortion of the introitus.
In addition to the vaginal defect one must consider the
extent of the pelvic dead space in ablative surgeries such as
APRs and pelvic exenterations. In an APR the entire rectum
anal canal and anus are removed and a permanent colostomy
is created. When pelvic exenteration is performed, all the
organs from the pelvic cavity are removed. The urinary
bladder, urethra, rectum, and anus are removed in addition
to the vagina, cervix, uterus, fallopian tubes, ovaries, and, in
some women, the vulva, and in men, the prostate. In this
procedure both a colostomy and urinary diversion are created.
Patient selection/preoperative
considerations
Successful management of patients undergoing vaginal
reconstruction is dependent upon a multidisciplinary
approach. The oncologic and reconstructive surgeons need to
communicate well in terms of both the expected defect and
the reconstructive options that are available to that specific
patient. The anesthesia team needs to be well advised of the
nature of the procedure and the hemodynamic stress that can
be expected intraoperatively. Also, early involvement of a
psychiatrist and a sex therapist may be warranted.
The radiation oncologist is an important participant in
the overall treatment plan. Many patients have had previous
radiotherapy, and others may be receiving intraoperative
radiotherapy or placement of a brachytherapy cannula.
The radiotherapy plan has important implications for the
choice of flap as both the recipient and donor sites can be
affected by radiation injury. In addition, the medical oncolo-
gist should be involved with the decision-making as many
patients may receive pre- and postoperative chemotherapy.
Surgical procedures should be timed to minimize the effects of
chemotherapy on wound healing, as well as to avoid unneces-
sary delays in starting chemotherapy protocols.
Most important to the success of the reconstruction is the
full and informed involvement of the patient and her family.
It is important to be specific about the goals of vaginal recon-
struction with patients, which include effective wound healing
and restoration of body image and sexual function8 (Box 14.1).
For those women motivated to preserve sexual function, a
comprehensive program of sexual rehabilitation may be
malignant neoplasms or primary malignant neoplasms of the
vaginal wall. Type IB defects are partial and involve the
posterior wall. These defects, which tend to be the most
common type of vaginal defect requiring reconstruction,
result primarily from extension of colorectal carcinomas. Type
Fig. 14.1  Vaginal vault. A, anterior; P, posterior.
A
P
Fig. 14.2  Classification system of acquired vaginal defects. (A) Type I: partial
defect. (B) Type II: circumferential defect. A, anterior; P, posterior.
A
B
TYPE I: PARTIAL DEFECT
A
P
A
P
A
P
A
P
A
P
TYPE II: CIRCUMFERENTIAL DEFECT
Upper two-thirds
Total
Anterior wall
Posterior wall
Lateral wall
BOX 14.1  The major goals of vaginal reconstruction
• To promote effective wound healing, facilitating postoperative
radiation therapy and chemotherapy
• To decrease pelvic dead space, thus decreasing fluid loss,
metabolic demands, and infection
• To restore the pelvic floor, preventing herniation and small-bowel
fistula
• To re-establish body image
• To re-establish sexual function

325
Treatment/surgical technique
lateral to the hair-bearing labia majora, and may be designed
to measure 9 × 4 cm to 15 × 6 cm.15,16 The posterior skin margin
is marked at the level of the posterior fourchette (Fig. 14.4A).
The skin, subcutaneous tissue, deep fascia of the thigh, and
epimysium of the adductor muscles are raised (Fig. 14.4B).
Posteriorly, the base of the flap is undermined at the subcuta-
neous level to facilitate rotation and insetting. Depending on
the defect, unilateral or bilateral flaps may be developed (Fig.
14.4C). The flaps may be inset by tunneling under the labia
majora or by division of the labia at the level of the fourchette.
The donor site is closed primarily (Figs. 14.4D & 14.5).
Type IB defects, which encompass the posterior vaginal
wall, frequently require greater soft-tissue bulk to fill the dead
space made by resection of the rectum. Here, the preferred
choice is the pedicled rectus myocutaneous flap. This highly
reliable flap provides both large surface area and large volume,
and the skin can be used to replace the entire posterior vaginal
wall. The healthy muscle and subcutaneous tissue bring well-
vascularized tissue to the pelvis, obliterate dead space, and
separate the contents of the abdominal cavity from the zone of
injury. When used for vaginal reconstruction, the flap is based
on the deep inferior epigastric vessels that arise from the
external iliac arteries and enter the rectus muscle along its
posterolateral surface 6–7 cm above its insertion on the pubis
(Fig. 14.6). In planning the flap, one must ensure that these
vessels are not divided as part of the cancer resection. One
must also ensure that the muscle itself is not violated during
placement of the stoma. In addition, good communication
between the reconstructive surgeon and the colorectal surgeon
warranted. Ratliff et al. investigated sexual adjustment after
vaginal reconstruction with gracilis myocutaneous flaps and
found that, although 70% of patients were judged to have a
physically adequate vagina, fewer than 50% resumed sexual
activity.9 Absence of pleasure (37%), problems with vaginal
dryness (32%), excess secretions (27%), self-consciousness
about ostomies (40%), and self-consciousness about nudity in
front of their partner (30%) were the most frequent concerns.
Preoperative and postoperative counseling, in addition to
postoperative rehabilitation strategies (vaginal dilators, lubri-
cants, and topical estrogens) have been suggested as the best
way to influence these outcomes positively and give patients
the best hope of functional and psychological recovery.8,10 The
psychologist and sex therapist should be an integral part of
the ablative–reconstructive team. In addition, at most tertiary
care institutions, specialized nursing teams can help the
patient and her family prepare for the psychological distress
that they may experience.
Treatment/surgical technique
There are five basic goals in vaginal reconstruction (Box 14.1).
Selection of the optimal reconstructive method to achieve these
goals is based on the type of defect and the characteristics of
the patient. Small defects that can be closed without tension
will ideally be closed primarily. In the case of the irradiated
wound, however, one must proceed cautiously with primary
closure. Rarely is skin grafting alone an adequate alternative
for oncology patients.
Proceeding along the reconstructive ladder, regional flaps
continue to be the most frequently used and effective proce-
dures. Many flaps have been described, none of which are
ideal for all defect types (Table 14.1).11–17 To simplify surgical
decision-making, a reconstructive algorithm has been devel-
oped on the basis of defect type (Fig. 14.3).18
Type IA defects, which involve only the anterior or lateral
vaginal walls, usually require little tissue bulk and small to
moderate surface coverage. The modified Singapore (vulvo-
perineal or pudendal thigh) fasciocutaneous flap is ideal in
this setting.15,16 It provides a highly vascularized, reliable, and
pliable flap that conforms well to the surface of the vaginal
cylinder. This flap is based on the posterior labial arteries and
innervated by perineal branches of the posterior cutaneous
nerve of the thigh.19 The flaps are raised in the thigh crease,
Table 14.1  Previously described flap options for vaginal
reconstruction
Defect type
Flap option
IA
Singapore (i.e., pudendal fasciocutaneous)
IB
Pedicled rectus myocutaneous
Pedicled rectus musculoperitoneal
Muscle-sparing rectus myocutaneous
IIA/B
Vertical rectus abdominis myocutaneous
Gracilis
Singapore
Pedicled jejunum
Sigmoid colon
Fig. 14.3  Algorithm for reconstruction of the vagina based on
defect type.
Type I
Partial
Type IA
Anterior or
lateral wall
Vaginal Defect
Singapore
Type IB
Posterior wall
Rectus
Type II
Circumferential
Type IIA
Upper two-thirds
Rolled rectus
or colon
Type IIB
Total
Bilateral
gracilis

326
SECTION II
CHAPTER 14 • Reconstruction of acquired vaginal defects
planning. If the right rectus is to be used for reconstruction, ask
the colorectal surgeon not to plan the abdominal incision
around the left side of the umbilicus, as this will lead to vas-
cular compromise of the umbilicus when harvesting the rectus
flap.
Either a vertical or transverse skin island design may be
used for the rectus myocutaneous flap, depending on the size
is required when planning the stoma. Usually the stoma is
placed on the patient’s left side, thus sparing the right rectus
for reconstruction. If there is only one available rectus for both
stoma placement and the reconstructive donor site, the colorec-
tal surgeon may be able to place the stoma through an empty
rectus sheath, or through the external oblique. Communication
with the colorectal surgeon is also required for incision
Fig. 14.4  Modified Singapore fasciocutaneous flap. See text for details.
A
B
C
D
Fig. 14.5  (A) Marking of the modified Singapore fasciocutaneous flap. (B) Flap elevation. (C) Flap inset.
A
B
C

327
Treatment/surgical technique
of the defect and the characteristics of the patient’s abdominal
wall. For posterior wall reconstruction, the vertical rectus
abdominis myocutaneous (VRAM) design is usually prefer-
able because it maximizes blood supply by centering the skin
island over the medial and lateral rows of perforators, and
does not interfere with the contralateral muscle and stoma
placement.
Both the vertical and transverse rectus abdominis myocu-
taneous flaps can be designed up to 10 × 20 cm in size with
easy donor site closure. When the flap is inset into a posterior
wall defect, care must be taken to avoid constriction or tension
on the vascular pedicle as this is the principal cause of flap
failure. Leaving the distal muscle insertion intact to decrease
tension on the pedicle is helpful in this regard (Fig. 14.7).
The rectus abdominis musculoperitoneal flap is a modifica-
tion rectus flap for type I vaginal defects. Here a patch of
posterior rectus sheath and peritoneum above the arcuate line
is harvested with the rectus to the exact dimensions of the
resected vaginal mucosa. The pedicled flap is then transposed
into the vaginal canal, and the peritoneal patch is sutured
to the edges of the vaginal mucosa. This technique avoids
the need for harvesting skin and anterior rectus sheath. The
peritoneum has previously been shown to re-epithelialize
to squamous epithelium, making it indistinguishable from
vaginal mucosa.17
Type IIA defects are circumferential defects involving the
upper two-thirds of the vagina and, like type IB defects, they
are well reconstructed with the pedicled rectus myocutaneous
flap due to its skin and soft-tissue bulk. The rectus is prefer-
able to bilateral gracilis flaps because the intervening vulvar
Fig. 14.7  Rotation and insetting of a pedicled vertical rectus abdominis myocutaneous flap for a posterior wall defect.
A
B
C
Fig. 14.6  Pedicled rectus myocutaneous flap.

328
SECTION II
CHAPTER 14 • Reconstruction of acquired vaginal defects
closed superiorly, and sutured inferiorly to the vaginal cuff.
Excessive secretions and unpleasant odor, especially for the
sigmoid colon, persist as common patient complaints and
limit the usefulness of these techniques.22
Type IIB defects are circumferential defects involving the
entire vagina and frequently the introitus. These are usually
total pelvic exenteration defects. Given the need for a large skin
island, bilateral gracilis flaps are an excellent reconstructive
choice for these defects. The subcutaneous tissue and muscle
of the two conjoined flaps will provide a large volume of soft
tissue that can obliterate the dead space within the pelvis.
The vascular supply of the gracilis flap is the medial femoral
circumflex artery, which enters the gracilis muscle 7–10 cm
below the pubic tubercle (Fig. 14.9A). An elliptical skin island
approximately 6 × 20 cm can be designed centered over the
proximal two-thirds of the muscle, with the anterior border of
and pelvic floor musculature prohibits transfer of the gracili
to the defect. When using the rectus myocutaneous flap for
these defects, the cutaneous portion of the flap is tubed. A
transverse skin island is easier to manipulate and leaves a
slightly longer pedicle than the VRAM. A flap width of
12–15 cm will provide a neovagina with a 4 cm diameter.20
Once tubed, the flap is then sutured to the remaining vaginal
cuff from above (Fig. 14.8).
The sigmoid colon or jejunum may also be used to recon-
struct type IIA defects for patients in whom the rectus flap
cannot be utilized. For the sigmoid colon flap, a segment of
colon is isolated and pedicled on a branch of the inferior
mesenteric artery.12 For the jejunum flap, a 15 cm segment of
jejunum is isolated and pedicled on the fourth branch of the
superior mesenteric artery, approximately 30 cm distal to the
ligament of Treitz.21 For both of these flaps the bowel is stapled
Fig. 14.8  Tubing and insetting a pedicled rectus flap for a circumferential defect.
A
B

329
Treatment/surgical technique
Fig. 14.9  Anatomy, design, elevation, and insetting of bilateral gracilis flaps for a type IIB defect. See text for details.
A
B
C
D
E
F

330
SECTION II
CHAPTER 14 • Reconstruction of acquired vaginal defects
pelvic exenteration, both of which result in a poorly vascular
dead space often requiring chemoradiotherapy. In these cases
local flaps can be used to obliterate the non-collapsible dead
space with vascularized tissue. Butler compared immediate
VRAM flap reconstruction of irradiated APR wounds that
could have been closed primarily vs. primary closure.11 The
flap group had significantly lower incidence of perineal abscess
(9% vs. 37%, p=0.002), major perineal wound dehiscence
(9 vs. 30%, p=0.014), and drainage procedures required for
perineal/pelvic fluid collection (3% vs. 25%, p=0.003) than the
control group. Although both groups could have been closed
primarily, bringing in healthy vascularized tissue reduced
major perineal wound complications by filling the dead space,
separating the bowel from the underlying perineum, and
closing the perineal skin defect with non-irradiated flap skin.
Finally, in patients with previous vaginal reconstruction
and recurrent disease, the choice of regional flap might be
extremely limited, perhaps warranting free flap reconstruc-
tion.23,24 Several pedicled perforator flaps recently described
are good alternative options in these cases. Examples include
the muscle-sparing vertical rectus,25 the deep inferior epigas-
tric perforator (DIEP) flap,26,27 superior and inferior gluteal
artery perforator (SGAP and IGAP) flaps,28 anterolateral thigh
(ALT) flaps,29 and even free-style perforator flaps.30
Postoperative care
Immediate perioperative period
At the end of the reconstructive case, it is imperative to leave a
pelvic drain in place in order to drain the fluid that will inevi-
tably collect in any remaining dead space. While these drains
typically drain a large amount, the goal should be to keep it
the incision lying on a line between the pubic tubercle and the
semitendinosus tendon. Once elevated, the flaps are tunneled
subcutaneously into the vaginal defect (Fig. 14.9B & C). The
flaps are then sutured in the midline, and a neovaginal pouch is
formed (Fig. 14.9D & E). The neovaginal pouch is then inserted
into the defect, and the proximal flap edges are sutured to the
introitus (Figs. 14.9F & 14.10). The flap can maintain some sen-
sation for pressure through branches of the obturator nerve.22
Additional surgical considerations
While the majority of patients can be reconstructed by using
an algorithm based on defect type, a few may require a modi-
fied approach. In addition to the type of vaginal defect, con-
sideration should be given to patient specific risk factors, the
surrounding surgical defect, and the need for postoperative
radiation and/or chemotherapy. Obesity, for example, has
been shown to be a significant risk factor for poor wound
healing after rectus flap reconstruction.6 Obese patients with
type IIB defects therefore may be better reconstructed with
thin, bilateral Singapore flaps. Alternatively, the rectus may
be used without its cutaneous portion and a skin graft applied
directly to the muscle over a vaginal stent. In elderly patients
or patients with significant comorbidities who are unlikely to
resume intercourse after reconstruction, a full vaginal recon-
struction may be omitted. Using a rectus muscle flap to
obliterate dead space within the pelvis may still be of wound-
healing benefit to these patients.
In addition to patient specific risk factors, and the vaginal
defect, consideration must be given to surrounding surgical
defects as well. When the ablative surgeon resects nearby
pelvic contents, the resulting non-collapsible dead space may
need to be addressed. Such is the case in low rectal tumors
requiring APR or more advanced rectal cancers requiring
Fig. 14.10  Postoperative results of a vaginal
reconstruction using bilateral gracilis flaps.
A
B

331
Complications, prognosis, and outcomes
flap loss; gracilis myocutaneous flaps are less reliable with a
10% to greater than 20% incidence of total or partial flap
loss.32–34 The success rate of both of these flaps depends on
careful attention to design and surgical technique. The modi-
fied Singapore flap is susceptible to apical necrosis, but
complete flap loss occurs in up to 15%.14,19 Partial flap loss may
be managed by debridement and local wound care. In the
setting of irradiated tissue, full debridement and reconstruc-
tion with an alternative flap may be required. In general, the
overall complication rate for the VRAM is lower than either
the gracilis or Singapore flaps in vaginal reconstruction (32%,
62%, and 47%, respectively).32
In addition to complications at the site of the vaginal
reconstruction, one must also consider potential donor site
complications. For all potential donor sites, hypertrophic scar-
ring, infection, and wound-healing problems must be consid-
ered. When harvesting the rectus myocutaneous flap for
vaginal reconstruction, an abdominal donor site complication
rate of 16–30% has been reported, including such complica-
tions as dehiscence, delayed healing, or hernia.11,35 However,
comparing abdominal complications in similar patients
without flap reconstruction shows similar abdominal compli-
cation rates, thus questioning whether harvesting the rectus
muscle adds significant morbidity to these patients.11 Thigh
abscess or hematoma, infection, sensory anomalies, or hyper-
trophic scarring are the most common complications in
patients who have had their gracilis muscles harvested, occur-
ring in up to 40% of patients.33,35
Prognosis and outcomes
After pelvic exenteration, there is a 40–60% chance of 5-year
survival among patients with gynecologic cancer. Among
APR patients, there is a 25–40% chance of 5-year survival.4 For
the patients who do well with their disease and ultimately
achieve wound healing, sexual function and body image are
fundamental quality-of-life issues. Vaginal reconstruction has
been associated with improved body image and sexual func-
tion.36,37 In a pooled analysis of patients undergoing vaginal
reconstruction by local flaps, 122 of 246 (50%) patients resumed
sexual activity postoperatively.38 Anatomic reconstruction of
the vagina does not equate with restoration of sexual function
for a variety of reasons. In a review of 44 patients who under-
went bilateral gracilis flap reconstruction, Ratliff et al. found
that 33% complained of vaginal dryness, whereas 28% com-
plained of excess vaginal secretions. Twenty percent thought
their neovagina was too small, whereas 5% found it to be too
large. Eighteen percent had flap prolapse, and a further 18%
had pain with intercourse.9 The most important determinant
of postoperative sexual activity, however, is prior sexual activ-
ity, and this is not affected by the type of reconstruction.32,38
Extensive preoperative counseling is essential to ensure real-
istic patient expectations regarding postoperative sexual
function.
in place until the patient is mobile and the drainage begins to
decrease, rather than reaching below a certain set point.
Postoperatively, careful attention must also be paid to the
patient’s hemodynamic and nutritional support. All patients
should receive deep-vein thrombosis prophylaxis and be
placed on a fluidized mattress and given instructions not to
sit for a minimum of 4 weeks. Positioning is difficult due to
these restrictions, and patients should be encouraged to lie on
either side, stand, or walk. Prophylactic perioperative antibi-
otics are often used.
Long-term care
The placement of a vaginal stent intraoperatively is not routine
for all flap reconstructions. However, once the flap is healed,
gradual dilatation with a lubricator may be important in order
to increase the size of the orifice. If the patient wishes to use
the neovagina for intercourse, she should be told that dilata-
tion must be continued on an ongoing and regular basis for
life. Dilatation can begin at approximately 2 months post-
reconstruction, as long as everything has healed well. Custom
dilators are usually constructed for each patient. Estrogen
creams applied to reconstructed type I defects can also be
helpful to maintain lubrication.
Complications, prognosis,
and outcomes
Complications
The principal early complications after vaginal reconstruction
include infection and pelvic abscess, delayed wound healing,
and flap loss. While the risk of infection and pelvic abscess is
decreased when flap reconstruction is performed after vaginal
resection, it still remains significant at approximately 10%.5,11,14
Perioperative antibiotics, adequate drainage, and patient
positioning, as mentioned in the previous section, are all
important preventive measures. Once a pelvic infection is
established, percutaneous or operative drainage is generally
necessary to prevent worsening sepsis. The incidence of
delayed wound healing or wound dehiscence varies widely
in the literature, ranging up to 46% of patients.31 Radiotherapy,
obesity, and smoking are all risk factors for poor wound
healing that should be considered preoperatively. The most
common location for wound separation is the posterior peri-
neal closure site, which usually responds to conservative
management.
Flap loss, both partial and complete, is a major postopera-
tive problem that will delay adjuvant therapy and increase
patient morbidity. The incidence of flap loss depends on the
type of flap used, surgical technique, and patient characteris-
tics. When used for vaginal reconstruction, the VRAM flap is
highly reliable with less than 5% incidence of total or partial
11. Butler CE, Gundeslioglu AO, Rodriguez-Bigas MA. Outcomes of
immediate vertical rectus abdominis myocutaneous flap
reconstruction for irradiated abdominoperineal resection defects. J
Am Coll Surg. 2008;206(4):694–703. In this retrospective case series, the
authors assess the impact of immediate closure of irradiated APR defects
with VRAM flaps as compared to primary closure. They conclude that
VRAM flaps reduce perineal wound complications without increasing
early abdominal wall complications.
Access the complete references list online at

332
SECTION II
CHAPTER 14 • Reconstruction of acquired vaginal defects
13. McCraw J, kemp G, Given F, et al. Correction of high pelvic defects
with the inferiorly based rectus abdominis myocutaneous flap. Clin
Plast Surg. 1988;15(3):449–454.
14. Shibata D, Hyland W, Busse P, et al. Immediate reconstruction of
the perineal wound with gracilis muscle flaps following
abdominoperineal resection and intraoperative radiation therapy
for recurrent carcinoma of the rectum. Ann Surg Oncol. 1999;6(1):33–
37. This is a retrospective case review evaluating the efficacy of gracilis
flaps for immediate perineal reconstructions. This modality was found to
decrease the rate of major wound infections significantly in this
population.
16. Woods JE, Alter G, Meland B, et al. Experience with vaginal
reconstruction utilizing the modified Singapore flap. Plast Reconstr
Surg. 1992;90(2):270–274. The authors describe a modification of the
Singapore flap in which the labia majora are released, yielding good
contour and no flap loss. The technique is illustrated and sample cases are
described.
17. Wu LC, Song DH. The rectus abdominis musculoperitoneal flap for
the immediate reconstruction of partial vaginal defects. Plast
Reconstr Surg. 2005;115(2):559–562.
18. Cordeiro PG, Pusic AL, Disa JJ. A classification system and
reconstructive algorithm for acquired vaginal defects. Plast Reconstr
Surg. 2002;110(4):1058–1065. A classification system for acquired vaginal
defects is presented based on a 7-year case review. From this experience, the
authors derive a reconstructive algorithm and conduct an outcomes assessment.
33. Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh
flaps for immediate reconstruction of pelvic and perineal cancer
resection defects. Plast Reconstr Surg. 2009;123(1):175–183. The
authors compare the efficacy of VRAM flaps to that of thigh flaps in
immediate pelvic and perineal reconstruction. VRAM flaps are found to
reduce major perineal wound complications without increasing early
abdominal wall morbidity.

332.e1
References
References
1. Rajput A, Bullard Dunn K. Surgical management of rectal cancer.
Semin Oncol. 2007;34(3):241–249.
2. Miles. A method of performing abdominoperineal resection for
adenocarcinoma of the low rectum. Lancet. 1908;1812–1813.
3. Brunschwig A. Complete excision of pelvic viscera for advanced
carcinoma; a one-stage abdominoperineal operation with end
colostomy and bilateral ureteral implantation into the colon above
the colostomy. Cancer. 1948;1(2):177–183.
4. Crowe PJ, Temple WJ, Lopez MJ, Ketcham AS. Pelvic exenteration
for advanced pelvic malignancy. Semin Surg Oncol.
1999;17(3):152–160.
5. Jakowatz JG, Porudominsky D, Riihimaki DU, et al. Complications
of pelvic exenteration. Arch Surg. 1985;120(11):1261–1265.
6. Small T, Friedman DJ, Sultan M. Reconstructive surgery of the
pelvis after surgery for rectal cancer. Semin Surg Oncol.
2000;18(3):259–264.
7. Gray H. Anatomy of the Human Body. In: Febiger L, ed. Philadelphia:
Lewis W; 2000.
8. Hendren SK, Swallow CJ, Smith A, et al. Complications and sexual
function after vaginectomy for anorectal tumors. Dis Colon Rectum.
2007;50(6):810–816.
9. Ratliff CR, Gershenson DM, Morris M, et al. Sexual adjustment of
patients undergoing gracilis myocutaneous flap vaginal
reconstruction in conjunction with pelvic exenteration. Cancer.
1996;78(10):2229–2235.
10. Capone MA, Westie KS, Good RS. Sexual rehabilitation of the
gynecologic cancer patient: an effective counseling model. Front
Radiat Ther Oncol. 1979;14:123–129.
11. Butler CE, Gundeslioglu AO, Rodriguez-Bigas MA. Outcomes of
immediate vertical rectus abdominis myocutaneous flap
reconstruction for irradiated abdominoperineal resection defects. J
Am Coll Surg. 2008;206(4):694–703. In this retrospective case series, the
authors assess the impact of immediate closure of irradiated APR defects
with VRAM flaps as compared to primary closure. They conclude that
VRAM flaps reduce perineal wound complications without increasing
early abdominal wall complications.
12. Hendren WH, Atala A. Use of bowel for vaginal reconstruction. J
Urol. 1994;152(2 Pt 2):752–755, discussion 6–7.
13. McCraw J, kemp G, Given F, et al. Correction of high pelvic defects
with the inferiorly based rectus abdominis myocutaneous flap. Clin
Plast Surg. 1988;15(3):449–454.
14. Shibata D, Hyland W, Busse P, et al. Immediate reconstruction of
the perineal wound with gracilis muscle flaps following
abdominoperineal resection and intraoperative radiation therapy
for recurrent carcinoma of the rectum. Ann Surg Oncol. 1999;6(1):33–
37. This is a retrospective case review evaluating the efficacy of gracilis
flaps for immediate perineal reconstructions. This modality was found to
decrease the rate of major wound infections significantly in this
population.
15. Wee JT, Joseph VT. A new technique of vaginal reconstruction using
neurovascular pudendal-thigh flaps: a preliminary report. Plast
Reconstr Surg. 1989;83(4):701–709.
16. Woods JE, Alter G, Meland B, et al. Experience with vaginal
reconstruction utilizing the modified Singapore flap. Plast Reconstr
Surg. 1992;90(2):270–274. The authors describe a modification of the
Singapore flap in which the labia majora are released, yielding good
contour and no flap loss. The technique is illustrated and sample cases are
described.
17. Wu LC, Song DH. The rectus abdominis musculoperitoneal flap for
the immediate reconstruction of partial vaginal defects. Plast
Reconstr Surg. 2005;115(2):559–562.
18. Cordeiro PG, Pusic AL, Disa JJ. A classification system and
reconstructive algorithm for acquired vaginal defects. Plast Reconstr
Surg. 2002;110(4):1058–1065. A classification system for acquired vaginal
defects is presented based on a 7-year case review. From this experience,
the authors derive a reconstructive algorithm and conduct an outcomes
assessment.
19. Gleeson NC, Baile W, Roberts WS, et al. Pudendal thigh
fasciocutaneous flaps for vaginal reconstruction in gynecologic
oncology. Gynecol Oncol. 1994;54(3):269–274.
20. Tobin GR, Pursell SH, Day TG Jr. Refinements in vaginal
reconstruction using rectus abdominis flaps. Clin Plast Surg.
1990;17(4):705–712.
21. Chen HC, Chana JS, Feng GM. A new method for vaginal
reconstruction using a pedicled jejunal flap. Ann Plast Surg.
2003;51(4):429–431.
22. Martello JY, Vasconez HC. Vulvar and vaginal reconstruction after
surgical treatment for gynecologic cancer. Clin Plast Surg.
1995;22(1):129–140.
23. John HE, Jessop ZM, Di Candia M, et al. An algorithmic approach
to perineal reconstruction after cancer resection–experience from
two international centers. Ann Plast Surg. 2013;71(1):96–102.
24. Stechl NM, Baumeister S, Grimm K, et al. Microsurgical
reconstruction of the pelvic floor after pelvic exenteration. Reduced
morbidity and improved quality of life by an interdisciplinary
concept. Chirurg. 2011;82(7):625–630.
25. Weiwei L, Zhifei L, Ang Z, et al. Vaginal reconstruction with the
muscle-sparing vertical rectus abdominis myocutaneous flap.
JPRAS. 2009;62(3):335–340.
26. Ang Z, Qun Q, Peirong Y, et al. Refined DIEP flap technique for
vaginal reconstruction. Urology. 2009;74(1):197–201.
27. Wang X, Qiao Q, Burd A, et al. A new technique of vaginal
reconstruction with the deep inferior epigastric perforator flap: a
preliminary report. Plast Reconstr Surg. 2007;119(6):1785–1790,
discussion 91.
28. Wagstaff MJ, Rozen WM, Whitaker IS, et al. Perineal and posterior
vaginal wall reconstruction with superior and inferior gluteal artery
perforator flaps. Microsurgery. 2009;29(8):626–629.
29. Zelken JA, Al Deek NF, Hsu CC, et al. Algorithmic approach to
lower abdominal, perineal, and groin reconstruction using
anterolateral thigh flaps. Microsurgery. 2014;36(2):104–114.
30. Hashimoto I, Abe Y, Nakanishi H. The internal pudendal artery
perforator flap: free-style pedicle perforator flaps for vulva, vagina,
and buttock reconstruction. Plast Reconstr Surg. 2014;133(4):924–933.
31. de Haas WG, Miller MJ, Temple WJ, et al. Perineal wound closure
with the rectus abdominis musculocutaneous flap after tumor
ablation. Ann Surg Oncol. 1995;2(5):400–406.
32. Casey WJ 3rd, Tran NV, Petty PM, et al. A comparison of 99
consecutive vaginal reconstructions: an outcome study. Ann Plast
Surg. 2004;52(1):27–30.
33. Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh
flaps for immediate reconstruction of pelvic and perineal cancer
resection defects. Plast Reconstr Surg. 2009;123(1):175–183. The
authors compare the efficacy of VRAM flaps to that of thigh flaps in
immediate pelvic and perineal reconstruction. VRAM flaps are found to
reduce major perineal wound complications without increasing early
abdominal wall morbidity.
34. Soper JT, Rodriguez G, Berchuck A, et al. Long and short gracilis
myocutaneous flaps for vulvovaginal reconstruction after radical
pelvic surgery: comparison of flap-specific complications. Gynecol
Oncol. 1995;56(2):271–275.
35. Soper JT, Secord AA, Havrilesky LJ, et al. Comparison of gracilis
and rectus abdominis myocutaneous flap neovaginal reconstruction
performed during radical pelvic surgery: flap-specific morbidity. Int
J Gynecol Cancer. 2007;17(1):298–303.
36. D’Souza DN, Pera M, Nelson H, et al. Vaginal reconstruction
following resection of primary locally advanced and recurrent
colorectal malignancies. Arch Surg. 2003;138(12):1340–1343.
37. Mirhashemi R, Averette HE, Lambrou N, et al. Vaginal
reconstruction at the time of pelvic exenteration: a surgical and
psychosexual analysis of techniques. Gynecol Oncol.
2002;87(1):39–45.
38. McArdle A, Bischof DA, Davidge K, et al. Vaginal reconstruction
following radical surgery for colorectal malignancies: a systematic
review of the literature. Ann Surg Oncol. 2012;19(12):3933–3942.

SECTION II • Trunk Surgery
15 
Surgery for gender dysphoria
Loren S. Schechter
SYNOPSIS
■ The goal of surgery is a successful functional and cosmetic result.
■ Surgery is only one factor in the overall therapeutic process.
■ Multidisciplinary care is essential for the transgender individual.
■ Surgical techniques for transwomen include penile inversion and
intestinal transposition.
■ Surgical techniques for transmen include metoidioplasty and pedicled/
free flap phalloplasty.
■ Secondary surgical procedures for the face and breast/chest are
available for transgender individuals.
Access the Historical Perspective section online at

Introduction
Gender dysphoria – definition
The term gender dysphoria describes a heterogeneous group
of individuals who express varying degrees of dissatisfaction
with their anatomic gender, and the desire to possess the
secondary sexual characteristics of the opposite sex.1 For these
individuals, surgical therapy plays a pivotal role in relieving
their psychological discomfort.2 As noted by Dr. Milton Edg-
erton in 1983, “transsexualism is a severe, and pathologic
condition that is undesirable for both the patient and society…
and non-surgical treatment continues to be expensive, time-
consuming, and enormously disappointing”.3
While the intent of Dr. Edgerton’s statement is accurate,
there have been significant advances not only in the under-
standing, management, and care of transgender individuals
but also in the social and political climate over the past 35
years. In fact, in 2010 the World Professional Association for
Transgender Health (WPATH) released a statement recom-
mending the de-psychopathologization of gender nonconfor-
mity stating that “the expression of gender characteristics,
including identities, that are not stereotypically associated
with one’s assigned sex at birth is a common and culturally
diverse human phenomenon [that] should not be judged as
inherently pathological or negative”.4
Goals of therapy
Congruent genitalia
WPATH developed the Standards of Care to help provide “the
highest standards” of care for individuals. The Standards of
Care state that the overarching treatment goal is “…lasting
personal comfort with the gendered self, in order to maximize
overall health, psychological well-being and self-fulfillment”.4
Toward this end, gender confirmation surgery provides the
appropriate physical morphology and alleviates the extreme
psychological discomfort of the patient. Furthermore, as dis-
cussed by Meyer et al. in 2001 and Cohen-Kettenis in 1984,
adjusting the mind to the body is not an effective treatment,
while adjusting the body to the mind is the best way to assist
severely gender dysphoric persons.
Congruent genitalia allows an individual to experience
harmony between one’s body and self-identity, appear nude
in social situations without violating taboos (i.e., health clubs,
physician offices, etc.), and have legal identification concor-
dant with one’s physical appearance.
Surgical goals
A successful surgical result involves:
Transwomen
The creation of a natural-appearing vagina and mons pubis
that is both sensate and functional. This includes a feminine-
appearing labia majora and minora, removal of the stigmatiz-
ing scrotum, a sensate neoclitoris, and adequate vaginal depth
  Access video lecture content for this chapter online at expertconsult.com

334
SECTION II
CHAPTER 15 • Surgery for gender dysphoria
at the donor site, and potential complications associated with
urethral reconstruction and implantable prostheses has led
some individuals to forego this procedure. The alternative, a
metoidioplasty, entails lengthening of the virilized clitoris and
may be performed with, or without, urethral lengthening.
Chest surgery, involving bilateral subcutaneous mastecto-
mies and contouring of the chest, is commonly performed
prior to genital surgery. Chest surgery also includes reposi-
tioning and re-sizing of the nipple–areola complex when
necessary. Several different techniques are employed, and the
choice of technique depends upon the volume of breast
parenchyma, degree of breast ptosis and position of the
nipple–areola complex, and degree of skin elasticity.
Definitions
Pyschosexual development and differentiation entails three
major components:
i.
gender identity, referring to one’s sense of belonging to
the male or female sex category, both or neither
ii. gender role, sexually dimorphic behaviors and
psychological characteristics within the population, such
as toy preferences and mannerisms
iii. sexual orientation, one’s pattern of erotic
responsiveness.
As noted by the Institute of Medicine’s 2011 report, The Health
of Lesbian, Gay, Bisexual, and Transgender People, “transgender
people are defined according to their gender identity and
presentation. This group encompasses individuals whose
gender identity differs from the sex originally assigned to
them at birth or whose gender expression varies significantly
from what is traditionally associated with or typical for that
sex (i.e., people identified as male at birth who subsequently
identify as female, and people identified as female at birth
who later identify as male), as well as other individuals who
vary from or reject traditional cultural conceptualizations of
gender in terms of the male–female dichotomy. The transgen-
der population is diverse in gender identity, expression, and
sexual orientation. Some transgender individuals have under-
gone medical interventions to alter their sexual anatomy and
physiology, others wish to have such procedures in the future,
and still others do not. Transgender people can be hetero-
sexual, homosexual, or bisexual in their sexual orientation.
Some lesbians, gay men, and bisexuals are transgender; most
are not. Male-to-female transgender people are known as MtF,
transgender females, or transwomen, while female-to-male
transgender people are known as FtM, transgender males, or
transmen. Some transgender people do not fit into either of
these binary categories”.5
While gender nonconformity describes a difference
between an individual’s gender identity, role, or expression
and that of cultural norms, gender dysphoria describes
the discomfort or distress experienced by an individual due
to a discrepancy between one’s gender identity and the sex
assigned at birth.4
Some
gender-nonconforming
individuals
experience
gender dysphoria, and treatment is available to assist these
people. As noted in the Standards of Care, “transsexual, trans-
gender, and gender-nonconforming individuals are not inher-
ently disordered…the distress of gender dysphoria…is the
concern that might be diagnosable and for which various
treatment options are available”.4
and introital width for intercourse. Additional desirable quali-
ties include a moist appearance to the labia minora, clitoral
hooding, and lubrication for intercourse (Figs. 15.1 & 15.2).
Aside from genital reconstruction, breast augmentation,
thyroid chondrolaryngoplasty (“tracheal shave”), and facial
feminization offer additional procedures designed to feminize
one’s appearance.
Transmen
While phalloplasty represents the most complete genito-
perineal transformation, the need for complex, staged proce-
dures, the use of tissue from remote sites resulting in scarring
Fig. 15.1  Postoperative appearance following single-stage vaginoplasty.
Fig. 15.2  Postoperative appearance following second-stage labiaplasty. Note the
neoclitoris and prepuce formed by the glans penis and urethra. Additionally, a moist
appearance of the labia minora is provided by the use of a urethral flap.

335
Introduction
sex is atypical.7 This terminology replaces terms such as
“intersex”, “pseudohermaphroditism”, “hermaphroditism”,
and “sex reversal”. DSDs include a group of conditions inter-
fering with normal sex determination and differentiation in
the embryo and fetus. Although data on the prevalence and
incidence of DSDs is limited, it is estimated that the incidence
is 1 in 550.8 Congenital adrenal hyperplasia is the most
common cause of ambiguous genitalia, followed in frequency
by mixed gonadal dysgenesis. Gender dissatisfaction occurs
more often in individuals with DSDs as compared with the
general population, but it is difficult to predict, based upon
karyotype, prenatal androgen exposure, degree of genital
virilization, or assigned gender. A summary of DSDs is
included in Table 15.1.8
The birth of a child with ambiguous genitalia is distressing
to families, and management of children with DSDs benefits
from a multidisciplinary approach. Clinical management
includes (1) avoidance of gender assignment prior to expert
evaluation; (2) evaluation and management by a multidisci-
plinary team; (3) receipt of a gender assignment in all indi-
viduals; (4) communication with patients and families, as well
as their participation and inclusion in decision-making; and
(5) respect for patient and family concerns with strict adher-
ence to patient confidentiality.7 In discussions involving the
Epidemiology
Gender dysphoria
While early estimates on the prevalence of gender identity
disorders were focused on identification of individuals for
gender confirmation surgery, it was later realized that some
individuals neither desired, nor were candidates, for reassign-
ment surgery.6 Early estimates of the prevalence of transsexu-
alism were 1 in 37 000 biologic males and 1 in 107 000 biologic
females.6 Interestingly, approximately three times as many
biologic males as compared to biologic females seek genital
surgery. This discrepancy may exist for multiple reasons,
including accessibility, cost, and surgical options available for
biologic females. However, with the increase in third party
coverage of gender confirmation surgery, there has been a
corresponding increase in the number of biologic males
seeking genital surgery.
Disorders of sex development
Distinct from gender identity disorders are disorders of sex
development (DSD). DSDs represent congenital conditions in
which development of chromosomal, gonadal, or anatomic
Table 15.1  Summary of the various types of disorders of sex development
Revised nomenclature
Types
Sex chromosome, DSD
45,X Turner syndrome (mosaic, isodicentric Xq, ring chromosome, etc.)
46,XY DSD
Defects in testicular development
  Complete gonadal dysgenesis (Swyer syndrome)
  Partial gonadal dysgenesis (WT1, SOX9, SF-1 mutations)
  Gonadal regression
  Ovotesticular DSD
Disorders in androgen synthesis or action
  Androgen biosynthesis defects (e.g., 17-HSD, 5α-RD, StAR, POR, 3β-HSD, 17,20 lyase, Leydig
cell hypoplasia or aplasia)
  Defects in androgen action (CAIS, PAIS)
Others
  Hypospadias, micropenis, cloacal exstrophy, congenital anomaly syndromes
  Persistent Müllerian duct syndrome
46,XX DSD
Defects in ovarian development
  Ovotesticular DSD
  Gonadal transformation (e.g., SRY translocation)
  Gonadal dysgenesis
Disorders of androgen excess
  Fetal: CAH (11 hydroxylase deficiency, 21 hydroxylase deficiency, 3β-HSD, POR)
  Fetoplacental: aromatase deficiency, POR
  Maternal: luteoma of pregnancy, exogenous androgen
Others
  Congenital anomaly syndromes, vaginal atresia, cloacal exstrophy, MURCS
Ovotesticular DSD
46,XX/ 46,XY (chimeric)
45,X/46,XY (mixed gonadal dysgenesis)
46,XX Testicular DSD
XX sex reversal (SRY translocation)
46,XY Complete gonadal
dysgenesis
XY sex reversal (SF1, WT1, SOX9)
Swyer syndrome
CAIS, Complete androgen insensitivity; DSD, disorder of sex development; 17-HSD, 17-hydroxysteroid dehydrogenase; 3β-HSD, 3β-hydroxysteroid dehydrogenase;
MURCS, Müllerian, renal, cervicothoracic somite abnormalities; PAIS, partial androgen insensitivity; POR, P450 oxidoreductase; 5α-RD, 5α-reductase deficiency; SF1,
splicing factor 1; SOX9, sex determining region box 9; StAR, steroidogenic acute regulatory protein; WT1, Wilms tumor gene.
(From Nabhan ZM, Lee PA. Disorders of sex development. Curr Opin Obstet Gynecol. 2007;19:440-445.)

336
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CHAPTER 15 • Surgery for gender dysphoria
aggressive features.21 As such, psychoanalysts viewed sex
reassignment surgery as “psychosurgery” and argued that
treatment of transsexualism could only be achieved through
psychoanalysis.21
Proponents of a biologic explanation have examined a
variety of theories including anatomic differences in the
brains of transsexuals as well as hormonal influences on brain
development at critical gestational stages. Paralleling advances
in radiographic brain imaging, early biologic theories, referred
to as gender transposition, examined hormone-induced
cephalic differentiation.21 This concept relied on the “default
theory”: in the absence of androgens, an embryo will feminize,
and in the presence of androgens, testicles develop. However,
many of these theories rested upon extrapolation from animal
studies. Subsequent research later demonstrated important
differences between hormone secretions in humans and
animals.
Some of the most recent theories have focused attention on
an attempt to identify a genetic link explaining transsexual-
ism. However, at this time, no genetic markers have been
identified that explain transsexualism. Therefore studies have
used differences in physical characteristics between transsexu-
als and nontranssexuals as indirect evidence of a genetic etiol-
ogy. These studies include such factors as the observation of
a high prevalence of left-handedness in transsexuals, height
differences between male-to-female transsexuals and non-
transgendered males, the presence of an anomalous inframa-
mmary ligament in female-to-male transsexuals, a higher rate
of polycystic ovaries in female-to-male transsexuals, and dif-
ferences in bone proportion and fat distribution.21 Still other
theories have examined differences in autopsied brains of
male-to-female transsexuals. These differences were noted in
the region of the hypothalamus, an area of the brain involved
in sexual behavior. The study noted that genetic females and
male-to-female transsexuals had similar and smaller volumes
of the central sulci of the stria terminalis compared to both
homosexual and heterosexual males.21
However, in spite of continued research in this area, it must
also be recognized that a spectrum of gender variance exists.
Additionally, both cultural and social constructs play a sig-
nificant factor in gender role. For example, while most of
the studies compare transsexuals to nontranssexuals, these
studies do not account for biologic explanations as to cross-
dressing heterosexual males or children with a history of
gender identity disorder who become gender typical as adults.
As Dr. Randi Ettner concludes, “…the etiology of transgen-
derism remains unknown. The goal of treatment, however, is
known and is indisputable: to assist gender-variant patients
who request medical interventions by providing state-of-the-
art treatment”.21
Diagnosis
Transgender is not a formal diagnosis.4 When individuals
possess concerns, uncertainties, and questions about gender
identity, which persist during their development, become the
most important aspect of their life, or prevent the establish-
ment of an unconflicted gender identity, they have passed a
clinical threshold. When such an individual meets the speci-
fied criteria in one of the two official nomenclatures, the
International Classification of Diseases – 10th edition (ICD-10) or
parents of newborns with DSDs, the description of the child’s
genitalia should include both the bipotential of the initial
genital organs in addition to a discussion that the usual
genetic and hormonal controls many not be fully functional.
Children with DSDs may have conditions that result in exces-
sive stimulation of female genitalia, leading to masculiniza-
tion, or inadequate androgen stimulation of male genitalia
resulting in incomplete formation or underdevelopment. Fol-
lowing appropriate testing and assessment of completeness
of development of female and male structures, information
should be provided to the parents so as to assist the family
and physicians with the most appropriate sex assignment.
Subsequent clinical discussions with the family include the
need for, and benefits of, surgery, predicting future hormone
production, and the projection of potential fertility.8
The surgical management of the genitalia of children with
DSDs is made by the parents and, when appropriate, the
patient. The goal of surgery is to achieve genitalia compatible
with sex; prevent urinary obstruction, urinary incontinence,
and infection; and provide good adult sexual and reproduc-
tive function.9 Although controversy exists on the timing of
genital surgery in girls with congenital adrenal hyperplasia
(CAH), surgery is typically considered in cases of severe vir-
ilization and, when necessary, in association with repair of a
common urogenital sinus. Surgery should be anatomically
based so as to preserve erectile function and innervation of
the clitoris. While the American Academy of Pediatric guide-
lines recommend genitoplasty between 2 and 6 months of
age,10 it is recognized that revision vaginoplasty will be per-
formed at the time of puberty. For male newborns with
hypospadias, standard techniques for chordee repair and
urethral reconstruction apply. In patients requiring phallo-
plasty, the magnitude and complexity of the procedure must
be discussed, especially if sex assignment depends upon it.7
In individuals with 46, XY gonadal dysgenesis raised as
females, testes or fragments of Y-chromosome material should
be removed to prevent testicular malignancy. Gonadectomy
is generally advised soon after diagnosis so as to initiate
estrogen replacement when desired. In individuals with
gonadal dysgenesis and scrotal testes, the current recommen-
dation is to perform testicular biopsy at puberty to assess for
malignancy. In females with ovotesticular DSD and functional
ovarian tissue, early separation and removal of the testicular
component is advised in an attempt to preserve fertility.8
DSDs can be managed such that children can mature into
well-adjusted individuals with a potential for sexual expres-
sion and, in select cases, reproductive potential.8
Etiology
The etiology of transsexualism remains unknown21 and has
included genetic links, the hormonal milieu, family dynamics,
and psychoanalytic observations.1 Early theories were based
largely in psychoanalytic contexts, followed by attempts to
define transsexualism in a biologic context. There are essen-
tially three theories relating to the etiology of transsexualism:
a psychological or sociological etiology, a biologic etiology, or
some combination thereof.
Psychoanalytic explanations have ranged from an inability
to separate on the part of the mother and child, psychotic
disorders, and an unconscious motivation to discard bad and

336.e1
Historical perspective
Historical perspective
Transsexualism, gender dysphoria, and gender variance have
been recorded throughout history and across cultures. These
feelings have manifested as a spectrum of findings ranging
from a conflict or feelings of inappropriateness of the assigned
sex to a desire to surgically change one’s external appearance.
References to these conditions are included in the ancient
Greek literature of Herodotus, the life of the Roman emperors
Caligula and Elagabalus, the literature of Shakespeare, and
the accounts of the French diplomat Chevalier d’Eon.11
Perhaps one of the most widely known crossdressers in
history is Joan of Arc, a French heroine and Roman Catholic
saint. Executed by the English for heresy in 1431, Joan rou-
tinely wore traditional male clothing and soldier’s dress.
It is also important to realize that the surgical alteration of
one’s genitalia has existed for millennia. Eunuchs, or castrated
men, have existed since Biblical times. Additionally, self-
inflicted operations were described in 17th century diaries, as
providing “great and lasting subjective relief of gender dys-
phoria”.12 Additionally, in South Asia, the Hijra, or “third
sex”, are boys who undergo voluntary demasculinization
surgery, often consisting of removal of the penis, testes, and
scrotum. This surgery prevents the development of secondary
sexual characteristics and maintains a childlike appearance.8
Likewise, in Thailand, the Kathoey, sometimes referred to as
ladyboys, may range from men who dress as women to what
may more commonly be referred to as transgender.
In the modern medical sense, accounts of transsexualism
were first mentioned in the German medical literature by
Friederich in 1830, followed by a description of a case of
“transvestism” by Westphal in 1870.11 However, it is Magnus
Hirschfeld, a German physician and pioneer in the field of
sexology, who is credited with the term “transsexualism”,
when he used the term seelischer transsexualismus or “psychic
transsexualism” in 1923.13 Hirschfeld founded the Institut für
Sexualwissenschaft (Institute for Sexual Science) in Berlin in
1919 and was credited with referring the first male-to-female
patient for surgery. Additionally, Hirschfeld oversaw the
initial surgical management of the Danish transgender
woman, Lili Elbe, who travelled to Berlin for removal of her
testicles in 1931. Elbe eventually succumbed following five
surgical procedures, including failed ovarian and uterus
transplants by the surgeon Kurt Warnekros at the Dresden
Municipal Women’s clinic. It is Dr. Felix Abraham, a German
surgeon, who was the first to report and publish his experi-
ence with staged vaginoplasty on two patients, in 1931.14
Abraham described the surgery as “…a kind of emergency
surgery necessary to save patients from worse self-inflicted
procedures”.14
In 1949, David O. Cauldwell, an American physician,
described the term psychopathia transsexualis in describing an
individual who desired to be a member of the opposite sex.15
This was significant in delineating the difference between
“transsexualism” and “transvestism”. However, the contem-
porary study of transsexualism is credited to a public lecture
and paper by Dr. Harry Benjamin, in 1953.16,17 Benjamin
(1885–1986), a German born physician who had met Magnus
Hirschfeld while in Berlin, received his doctorate for a dis-
sertation regarding tuberculosis. Dr. Benjamin had an interest
in hormonal research and visited Eugen Steinach, a renowned
Austrian physiologist and pioneer in endocrinology during
the summers between the 1920s and 1930s. Following a pro-
fessional visit to the United States in 1913, Dr. Benjamin’s
return to Germany was disrupted when the ship on which he
was travelling was caught mid-Atlantic by the Royal Navy
during the outbreak of World War I. Preferring to return to
the United States rather than be treated as an enemy alien in
a British internment camp, Dr. Benjamin began his career
practicing general medicine in New York in 1915. With his
interest in sexual medicine, Dr. Benjamin began treating
individuals often referred by other physicians and sexolo-
gists. He believed in a physiologic basis of transsexualism,
drawing the distinction between transsexualism and trans-
vestism, the term, until that time, used to describe individuals.
Benjamin often worked with other specialists, including
psychiatrists such as John Alden and C.L. Ihlenfeld, electrolo-
gist Martha Foss in San Francisco, plastic surgeon Jose Jesus
Barbosa in Tijuana, Mexico, and gynecologist, Georges Borou
in Casablanca. The medical, legal, political, and social climate
at this time often considered wearing clothing of the opposite
sex in public as illegal, male castration illegal, homosexuality
was persecuted, if not illegal, and medical treatments often
consisted of electroconvulsive therapy, lobotomy, and forced
drugging. In 1966, Benjamin’s book, The Transsexual Phenom-
enon, raised awareness as to the potential benefits of sex
reassignment surgery,18 and, in 1979, the Harry Benjamin
International Gender Dysphoria Association was formed
(now known as the World Professional Association for Trans-
gender Health).
Perhaps most widely noted, the well publicized case of
Christine Jorgensen, an American who underwent surgery in
Denmark in the 1950s, drew international attention to the field
of transsexualism. Published in the Journal of the American
Medical Association in 1953, Dr. Christian Hamburger, a Danish
physician, detailed the hormonal and surgical therapy pro-
vided to Ms. Jorgensen. Following permission by the Danish
Ministry of Justice, Ms. Jorgensen underwent surgical castra-
tion and penile amputation by E. Dahl-Iversen and P. Fogh-
Anderson. Approximately one year later, Ms. Jorgensen
requested removal of the “last visible remains of the detested
masculinity” and underwent additional surgery to feminize
her genitalia.19 However, no vaginoplasty was performed, as
this was not requested by the patient. Dr. Hamburger con-
cluded by stating that “the goal was attained; by hormonal
feminization and operative demasculinization the patient’s
soma harmonized with the pronounced feminine psyche”.19
Other notable individuals include Dr. Renée Richards, an
American ophthalmologist and professional tennis player
who underwent sex reassignment surgery in 1975. Following
denial of entry into the 1976 US Open by the United States
Tennis Association, she disputed the ban. In 1977, the New
York Supreme Court ruled in her favor.
In the 1950s, Dr. Georges Burou, a French gynecologist
practicing in Casablanca at the Clinique du Parc, described
the anteriorly pedicled penile skin flap inversion technique.
Dr. Burou is reported to have performed over 3000 male-to-
female sex reassignment procedures, some on famous female
impersonators.12
In America, Dr. Milton Edgerton is credited with establish-
ing the first multidisciplinary center for care of the transgen-
dered patient. The Johns Hopkins University Gender Identity
Clinic was formed in 1965 and was composed of

336.e2
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CHAPTER 15 • Surgery for gender dysphoria
representatives from psychiatry, psychology, plastic surgery,
gynecology, urology, and endocrinology. This multidisci-
plinary clinic was important in establishing a method of
preoperative follow-up.11 Moreover, Edgerton noted the
importance of a multidisciplinary approach as well as post-
operative follow-up, so as to continue to evaluate lessons
learned from the operative experience. However, in 1979, Dr.
Jon Meyer, a psychiatrist at Johns Hopkins University, pub-
lished a follow-up study of 100 patients treated at the Hopkins
Gender Identity Clinic. Of these 100 patients, 34 individuals
underwent surgery, and 66 individuals were unoperated
upon. In this study, the authors describe two groups of
patients: those who will self-select either for or against surgery.
Interestingly, Meyer noted that in both groups, improvement
was demonstrated over time. Furthermore, while sex reas-
signment surgery “confers no objective advantage in terms of
social rehabilitation…it remains subjectively satisfying to
those who have…undergone it”.20

337
Multidisciplinary treatment
so, a collaborative effort between the surgeon, mental health
professional, and medical physician responsible for hormonal
therapy is recommended. Understanding the limitations in
access to formal multidisciplinary gender teams, the WPATH
Standards of Care provides recommendations designed to
standardize the process of surgical evaluation, treatment, and
postoperative care of transgender individuals.4 This standard-
ized process of surgical management will, hopefully, lead to
uniform and consistent surgical results worldwide.
Embryology
Genetic sex is determined at fertilization, either XX or XY. For
the first six weeks of development, gender is not distinguish-
able, and this is known as the indifferent period. Characteristic
external genitalia begin to form beginning about the ninth
week of gestation.
Sexual differentiation of the internal and external female
genitalia requires no active intervention. However, for devel-
opment of the male external genitalia, androgen production
by the Leydig cells and Müllerian inhibiting hormone (MIH)
production by the Sertoli cells is required. Ovarian activity is
not required for development of female internal genitalia.
The internal genitalia can only develop into one gender and
are therefore termed unipotent. In the male, the Wolffian duct
develops from the mesonephric duct, and in the female, the
Müllerian ducts develop from the paramesonephric duct. In
the male, MIH and androgens prevent development of female
internal genitalia. Additionally, androgens actively maintain
the Wolffian ducts, while MIH induces the regression of the
Müllerian ducts. In the female, Wolffian ducts regress in the
absence of androgens, while the Müllerian ducts persist.
External genitalia have the potential to be either male or
female and are therefore termed bipotential. In order to
develop male external genitalia, testosterone is required. In
about the fourth week of development in both sexes, the
genital tubercle develops and elongates to form the phallus.
In a developing male, androgens induce the urethral folds to
fuse to form the urethra. Additionally, the genital tubercle
enlarges to form the glans penis. Midline fusion of the genital
swellings results in formation of the scrotum. Alternatively,
female development occurs in the absence of testosterone,
independent of ovarian activity. The urethral folds and genital
swellings remain separate to form the labia minora and
majora, while the genital tubercle forms the clitoris.
In constructing the appropriate physical morphology,
the relevant homologous structures are used to create
“like-with-like”.
Preoperative evaluation
Prior to performing gender confirmation surgery, the surgeon
must be satisfied that the diagnosis of gender dysphoria has
been established. Although the diagnosis is typically made by
the behavioral scientist, the surgeon must be convinced that
the diagnosis is accurate. As noted by Dr. J.J. Hage, “the
surgeon remains responsible for any diagnosis on the basis of
which he performs surgical interventions”.24 Direct commu-
nication between the surgeon and mental health professional(s)
is both encouraged and recommended. This serves to educate
the surgeon and to aid with his or her understanding of each
patient’s unique needs. It also helps to prevent possible falsi-
fication of letters of recommendation. The surgeon must be
the Diagnostic Statistical Manual of Mental Disorders – 5th edition
(DSM-5), they are diagnosed as having a Gender Identity
Disorder (GID) or Gender Dysphoria.
The ICD-1022 provides five diagnoses for gender identity
disorders (F64):
■ Transsexualism (F64.0), which has three criteria:

i.
The desire to live and be accepted as a member of the
opposite sex, usually accompanied by the wish to
make his or her body as congruent as possible with
the preferred sex through surgery and hormone
treatment.

ii. The transsexual identity has been present persistently
for at least 2 years.

iii. The disorder is not a symptom of another mental
disorder or a chromosomal abnormality
■ Dual-role transvestism (F64.1)
■ Gender identity disorder of childhood (F64.2)
■ Other gender identity disorders (F64.8)
■ Gender identity disorder, unspecified (F64.9)
In 1994, the DSM-IV committee replaced the diagnosis of
“transsexualism” with “gender identity disorder”. Incorpo-
rate to DSM-IV, individuals must demonstrate a strong and
persistent cross-gender identification and a persistent discom-
fort with their sex or a sense of inappropriateness in the
gender role of that sex. It is important to realize that the
DSM-IV and ICD-10 are designed to guide research and treat-
ment. The designation of gender identity disorders as mental
disorders is not a license for stigmatization, or for the depriva-
tion of gender patients’ civil rights.4 In DSM-V, published in
2013, the term “gender identity disorder was replaced with
the term “gender dysphoria”.
After the diagnosis of gender dysphoria is made, the thera-
peutic approach commonly included three phases (triadic
therapy): a real-life experience in the desired role, hormones
of the desired gender, and surgery to change the genitalia and
other sex characteristics.
Multidisciplinary treatment
While the goals of surgery include a successful cosmetic and
functional result with minimal complications, surgery is only
one determinant in the overall therapeutic process.23 As such,
the surgeon performing gender confirmation procedures
must assume an active and integral role in the overall care of
the patient. It is the responsibility of the operating surgeon to
understand the diagnosis that has led to the recommendation
for genital surgery, medical comorbidities that may impact the
surgical outcome, the effects of hormonal therapy on the
patient’s health, and the patient’s ultimate satisfaction with
the surgical result.24 Furthermore, the surgeon should assist
with the coordination of the patient’s postoperative care in
order to assure appropriate continuity.
Recognizing that, in appropriately selected individuals,
gender reassignment surgery is the best way to normalize the
lives of transgender individuals,2 the question of how best to
integrate the surgeon in the multidisciplinary team continues
to undergo investigation. Although typically introduced to the
patient only after diagnosis and hormonal therapy, the surgeon
must actively participate in understanding the patient’s diag-
nosis and hormonal and medical therapies. In order to do

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CHAPTER 15 • Surgery for gender dysphoria
surgery. In patients with chronic medical conditions, the
surgeon should work closely with medical colleagues to
optimize and manage these conditions prior to surgery.
The goal of endocrine therapy is to change secondary sex
characteristics in order to reduce gender dysphoria and/or
facilitate a physical presentation consistent with the individ-
ual’s sense of self.33 Hormonal therapy is typically individual-
ized to the needs and desires of the patient based upon their
goals, associated medical conditions, and consideration of
social and economic issues. The Standards of Care indicate the
physician prescribing the hormones should:
1. Perform an initial evaluation that includes health
history, physical examination, and relevant laboratory
tests
2. Explain what feminizing/masculinizing medications do
and the possible side effects/health risks
3. Confirm that the patient has the capacity to understand
the risks and benefits of treatment and to make an
informed decision about medical care
4. Inform the patient of the Standards of Care and
eligibility/readiness requirements
5. Provide ongoing medical monitoring, including regular
physical and laboratory examination to monitor
hormone effects and side effects.
Feminization through hormonal therapy is achieved by two
mechanisms: suppression of androgen effects and induction
of female physical characteristics. Androgen suppression is
achieved by using medications that either suppress gonado-
tropin releasing hormone (GnRH) or are GnRH antagonists
(progestational agents), suppress the production of luteinizing
hormone (progestational agents, cyproterone acetate), interfere
with testosterone production or metabolism of testosterone to
dihydrotestosterone (spironolactone, finasteride, cyproterone
acetate), or interfere with the binding of androgen to its recep-
tors in target tissues (spironolactone, cyproterone acetate,
flutamide). Additionally, estrogen is used to induce female
secondary sex characteristics, and its mechanism of action is
through direct stimulation of receptors in target tissues
(Table 15.2).33
Within the first 6 months of therapy, there is a redistribu-
tion of body fat, decreased muscle mass, softening of skin, and
decreased libido. Breast growth may be expected after 3–6
months of therapy and continue for ≥2 years. Over a period
of several years, body fat and facial hair become finer, although
they are not completely eliminated by hormonal therapy
alone. Progression of male pattern baldness may slow;
however, hair does not typically regrow in bald areas. Many
of the changes, perhaps with the exception of breast growth,
are reversible with cessation of therapy.33
Masculinization through hormonal therapy for transmen
follows general principles of hormone replacement for treat-
ment of male hypogonadism. Both parenteral and transdermal
testosterone preparations are available and may be used to
achieve testosterone values in the normal male range.34 Tes-
tosterone therapy results in increased muscle mass and
decreased fat mass, increased facial hair and acne, male
pattern baldness, and increased libido. In reference to male-
to-female individuals, testosterone results in clitoromegaly,
temporary or permanent decreased fertility, deepened voice,
vaginal atrophy, and cessation of menses. If uterine bleeding
continues, a progestational agent may be added. GnRH
willing to personally communicate with other healthcare
providers when questions or concerns regarding a patient’s
appropriateness for surgery exist. However, this communica-
tion should not be limited to the evaluation phase. It is the
responsibility of the surgeon to communicate pertinent opera-
tive findings as well as postoperative instructions with the
relevant members of the healthcare team.25
Although multiple studies conducted at a variety of inter-
national centers confirm the efficacy of surgery and low
complication rates,2,26–31 the surgeon must be familiar with
preoperative psychosocial risk factors that may increase the
risk of postoperative complications. It is incumbent upon the
surgeon to actively investigate these potential risk factors
prior to proceeding with surgery. In a study investigating the
standards and policies of 19 gender clinics in Europe and
North America, a high degree of consistency regarding poli-
cies and criteria for approval of reassignment surgery was
identified.32 Based upon questionnaire data, conditions that
could result in delay or denial of surgery included psychoso-
cial instability, married status, substance abuse, chronic or
psychotic illness, and antisocial behavior. In addition, in a
retrospective review of 136 patients who underwent sex reas-
signment in Sweden, several preoperative factors were identi-
fied and reported to be associated with higher rates of
unsatisfactory surgical outcomes. These included personal
and social instability, unsuitable body build, and age over 30
at operation. Additionally, in this study, adequate family and
social support were noted to be important for adequate post-
operative functioning.23
Though understanding potential preoperative risk factors
is important, their presence is not necessarily a contraindica-
tion to surgery. In a retrospective review of 232 male-to-female
transsexuals, Lawrence28 noted that no participants regretted
sexual reassignment surgery outright and only 6% were
occasionally regretful. In this study, dissatisfaction was associ-
ated with unsatisfactory surgical results, not other indicators
of transsexual typology, such as age at surgery, previous mar-
riage or parenthood, or sexual orientation. This serves to
reinforce the concept that the Standards of Care are intended to
provide flexible direction for the treatment of transgender
individuals. It is generally recognized that individual centers
may vary with regard to specific hormonal regimens and time
requirements for the real life test. It must be emphasized that
the Standards of Care are not intended as barriers to surgery,
but rather as a means of identifying patients who would
benefit from surgical reassignment.
Hormone regimen
Upon completion of the first or diagnostic phase, the patient
is referred to a medical physician for hormonal therapy.
Though specific hormonal regimens may vary between
centers, the surgeon should be familiar with the possible side
effects of hormonal therapy and how they relate to the surgi-
cal care of the transgender patient. These include issues
related to liver function, risk of venous thromboembolism,
electrolyte imbalance, drug–drug interactions, and possible
malignancy (i.e., breast cancer). It is helpful if the medical
physician is a member of the multidisciplinary team. If not,
the medical physician should have substantial experience in
the field of transgender medicine.24 Medical comorbidities
should be investigated and, if possible, treated prior to

339
Multidisciplinary treatment
followed, and the patient has successfully completed the
second stage or real-life test, surgical therapy is considered. A
preoperative surgical consultation is obtained. During this
consultation, the procedure and postoperative course are
described, the potential risks and benefits of surgery are
reviewed, and the patient’s questions are answered. Equally
important is a discussion of the patient’s expectations as well
as an understanding of the limitations of surgery. In a follow
study of 55 transsexual patients treated in Belgium, De
Cuypere et al.27 noted that the transsexual person’s expecta-
tions were met at an emotional and social level, but less so at
the physical and sexual level. This occurred despite an indi-
cated improvement in sex life and sexual excitement after
reassignment surgery.27 Based upon these findings, it was
recommended that discussion regarding sexual expectations
be entertained prior to surgery. After deciding to proceed with
surgery, written documentation of informed consent should
be included in the patient’s chart.
Surgical conversion of the genitalia in transwomen has
evolved since the use of skin grafts for creation of a neovagina
in cases of vaginal agenesis.35 The use of pedicled penile and
scrotal flaps was described over 40 years ago, and despite
technical refinements, remains the mainstay for neovaginal
construction.36–38 The vascular basis of these flaps is derived
from one of two sources: 1) the femoral artery (deep and
superficial external pudendal arteries) and 2) the internal
pudendal artery (perineal branches).
A successful surgical result involves the creation of a nat-
ural-appearing vagina and mons pubis. This includes a fem-
inine-appearing labia majora and minora with removal of the
stigmatizing scrotum, a sensate neoclitoris, and adequate
vaginal depth and introital width for intercourse (Figs. 15.3–
15.5). Although a functional vaginoplasty is performed in a
single stage, further feminization of the mons pubis can be
performed at a second surgical stage. The labiaplasty, which
can be performed under local anesthesia as an outpatient
procedure three months after vaginoplasty, creates a conver-
gent anterior commissure and provides additional clitoral
hooding. However, with recent trends towards hair removal
analogs or depot medroxyprogesterone may be used to stop
menses and to reduce estrogen levels to those found in bio-
logic males.34 Individuals should be routinely monitored so as
to maintain testosterone levels in the physiologic normal male
range and avoid adverse events such as erythrocytosis, liver
dysfunction, hypertension, excessive weight gain, salt reten-
tion, lipid changes, cystic acne, and adverse psychological
changes.34
Adolescent therapy
Over the past decade, an emerging area of clinical interest
involves the treatment of transgender adolescents. Adoles-
cents with gender dysphoria may consider the physical
changes of puberty unbearable. In an effort to prevent psy-
chological harm, some centers have initiated treatment of
adolescents with puberty-suppressing medications, such as a
GnRH analog, before development of irreversible secondary
sex characteristics. Potential benefits of this approach to
pubertal suppression may include a relief of gender dysphoria
and better psychological and physical outcome.34
The physical changes of puberty result from maturation of
the hypothalamo-pituitary-gonadal axis and development of
secondary sex characteristics. In girls, the first physical sign
of puberty is breast budding, while in boys, an increase in
testicular volume heralds the onset of puberty. Pubertal sup-
pression may aid with management of gender dysphoria, and
the hormonal changes are fully reversible.34 Hormone-treated
adolescents may be referred for surgery when the real-life
experience has resulted in a satisfactory social role change, the
individual is satisfied about the hormonal effects, and the
individual desires definitive surgical changes.34 Surgery is
typically considered at 18 years of age, although individual
exceptions may be appropriate.
Feminizing surgical therapy
Once the surgeon is satisfied that the diagnosis has been
established, a hormonal regimen has been instituted and
Table 15.2  Hormone regimen
Agent
Estrogen
Androgen antagonist
17β-estradiol
Spironolactone
and/or
Finasteride
Transdermala
or
Oral
Oral
Oral
Pre-orchiectomy
Start at 0.1 mg/24 h
applied twice a
week; gradually
increase up to
maximum of
0.2 mg/24 h applied
twice per week
Start with
1–2 mg
daily;
gradually
increase up
to maximum
4 mg daily
Start with 50–100 mg daily;
increase by 50–100 mg each
month up to average
200–300 mg daily (maximum
500 mg daily). Modify if there
are risks of adverse effectsb
Use 2.5–5.0 mg
daily for systemic
anti-androgen
effect; use 2.5 mg
every other day if
solely for alopecia
androgenetica
Post-orchiectomy
0.375–0.1 mg/24 h
applied twice per
week
1–2 mg daily
25–50 mg daily
2.5 mg daily
aUse transdermal estradiol if the patient is >40 years of age or is at risk for DVT. Oral estradiol is an option if the patient is <40 years of age and is low risk for DVT.
bIf taking ACE-inhibitors or other potassium-sparing medication, spironolactone should not go above 25 mg daily and serum potassium should be closely monitored. If
the patient has low blood pressure or renal insufficiency start at 50 mg and increase by up to 50 mg per week to a maximum of 300 mg daily, with a renal function test
1–2 weeks after each increase.
(From Dahl M, Feldman JL, Goldberg JM, Jaberi A. Physical aspects of transgender endocrine therapy. Int J Transgenderism. 2006;9:111–134.)

340
SECTION II
CHAPTER 15 • Surgery for gender dysphoria
the drawbacks of intestinal transposition include the need for
an intra-abdominal operation with a bowel anastomosis and
the potential for excess neovaginal secretions with a malodor-
ous discharge. Nongenital flaps are typically considered for
reconstruction following oncologic resections, traumatic
repair, or reconstruction following infection. Regardless of
which technique is utilized, a preoperative bowel preparation
is administered. Additionally, hair removal, whether by elec-
trolysis or laser, is completed as thoroughly as possible from
the penile shaft and central perineum and scrotum (Fig. 15.6)
prior to surgery. Preoperative depilation helps to prevent
of the mons, fewer individuals opt to proceed with the
vaginoplasty.
The surgical options for feminizing genital surgery consist
of one of three options: penile inversion vaginoplasty, intesti-
nal transplantation, or nongenital flaps. Most centers perform
primary vaginoplasty with the penile inversion vaginoplasty
using an anteriorly pedicled penile skin flap combined with
a posteriorly based scrotal–perineal flap and/or skin graft.
However, intestinal transposition, typically reserved for revi-
sion cases, is a first-line surgical therapy at some centers. The
advantage of intestinal transposition is the creation of a vas-
cularized 12–15 cm vagina with a moist lining. This may
lessen the requirements for postoperative vaginal dilation as
well as the need for lubrication during intercourse. However,
Fig. 15.3  Postoperative appearance following single-stage vaginoplasty, prior to
labiaplasty. Note the width of the introitus provided by the perineal–scrotal flap and
resection of the superficial muscles. Adequate introital width is essential for vaginal
intercourse.
Fig. 15.4  Rigid dilator used for intraoperative blunt dissection of the neovaginal
cavity.
Fig. 15.5  Demonstration of introital width and depth of the neovaginal cavity.
Markings on the mons pubis delineate the local tissue rearrangement for the
labiaplasty. The labiaplasty will provide convergence to the labia majora as well as
additional definition of the prepuce of the neoclitoris.
Fig. 15.6  Preoperative depilation of the penile shaft and scrotum.

341
Multidisciplinary treatment
for additional vaginal depth. Full-thickness skin grafts may
be harvested from discarded portions of the scrotum. If this
is insufficient, additional full-thickness skin grafts may be
harvested with a Pfannenstiel incision.40 Alternatively, split-
thickness skin grafts may also be harvested from the lower
abdomen or mons region. However, the donor site of the
split-thickness skin grafts may be left with areas of hypopig-
mentation depending upon depth of harvest and patient’s
skin tone.
Prior to surgery, sequential compression devices are placed
and intravenous antibiotics are administered. Following
induction of general anesthesia, chemoprophylaxis for VTE is
administered subcutaneously (either fractionated or unfrac-
tionated heparin depending upon institutional policies), the
patient is positioned in lithotomy, and an indwelling urinary
catheter is placed under sterile conditions after the patient is
prepped and draped.
The procedure is begun with the creation of a posteriorly
based scrotal–perineal flap. This flap, which measures
approximately 15 cm in length and 8 cm in transverse dimen-
sion, requires sufficient width so as not to limit the vaginal
introitus. Additionally, the lateral aspect of the flap is designed
in a “V”-shaped fashion so as not to create a circular introitus,
thereby minimizing the chance of introital contracture (Fig.
15.8A). The flap is centered cephalad to the anus and dissected
to the level of the anal sphincter, with care taken not to injure
the external anal sphincter (Fig. 15.8B).
An incision is made on the ventral penis along the midline
raphe (Fig. 15.8C). This allows access to the testicles for the
performance of bilateral orchiectomies. The orchiectomy,
including resection of the spermatic cords, is performed at the
level of the inguinal ring. This allows the spermatic cord to
retract within the inguinal canal and prevents a palpable
bulge in the groin area. The skin of the penile shaft is then
circumferentially incised at the junction of the glans and
penile shaft. This facilitates separation of the penile skin from
the underlying corpora cavernosa and corpora spongiosum,
as well as the overlying muscles, the ischiocavernosus, and
bulbospongiosus muscles, respectively (Fig. 15.8D).
Fig. 15.7  Postoperative appearance: the labia majora are formed from the scrotum,
the neoclitoris is formed from the dorsal glans penis, the labia minora are formed
with a urethral flap, and the native penile urethra is shortened and spatulated to
form the neo-urethra.
Fig. 15.8  (A) Design of the perineal–scrotal flap. Note the “V”-shape of the lateral aspect of this flap. This design assists with widening of the introitus and lessening the
risks of introital scar contracture. (B) Elevation of the posteriorly based perineal–scrotal flap. (C) Incision of the ventral penile skin along the midline raphe. (D) Exposure of
the corpora spongiosum and ischiocavernosus muscles with underlying corpora cavernosa. A sponge is placed in the neovaginal cavity.
A
B
C
CD
intravaginal hair growth. Finally, hormones are discontinued
approximately two weeks prior to surgery to reduce the risk
of venous thromboembolism.
Penile inversion
Primary vaginoplasty surgery most commonly involves
penile disassembly and inversion with an anteriorly based
pedicled penile flap. Although a variety of technical modifica-
tions are described in the literature, the penile disassembly
and inversion technique utilizes the penile skin and a second,
posteriorly based, scrotal–perineal flap to construct the
vaginal cavity.39 The author’s preferred technique is described
herein: the labia majora are formed from the lateral aspects of
the scrotum, the neoclitoris is formed from the dorsal glans
penis, and the labia minora are formed with the creation of
a urethral flap. The penile urethra is shortened, spatulated,
and everted to create the neo-urethral meatus (Fig. 15.7).
Depending upon the length of the penis and previous surgi-
cal history (i.e., circumcision), skin grafts may be required

342
SECTION II
CHAPTER 15 • Surgery for gender dysphoria
The neoclitoris is then fashioned from the dorsal glans
penis and dissected on the dorsal neurovascular bundle (Figs.
15.10 & 15.11A). The dissection of the dorsal vein and paired
dorsal arteries and nerves is performed deep to Buck’s fascia
along the corpora cavernosa.42 Dissection of the neurovascular
pedicle is performed to the pubic symphysis, exposing the
divergence of the underlying corpora cavernosa. The corpora
cavernosa are resected at the pubis, leaving a short remnant
of corpora on either sided. The retained corpora will be
sutured together to form a base, upon which the neoclitoris
will be attached (S. Monstrey, pers. comm).
In order to aid with the advancement of the penile flap, the
skin of the mons and lower abdomen may be elevated to the
umbilicus (Fig. 15.11B). In some individuals, this facilitates
intravaginal positioning of the penile flap.43 Depending upon
the length of the penile flap, skin grafts may be required to
increase vaginal depth. These may be harvested as full-
thickness grafts from the non-used scrotum, groin crease, or
lower abdomen. Additionally, split-thickness grafts may be
At this point, the vaginal cavity is developed by dissection
between the prostate and rectum. Care must be taken to avoid
inadvertent entry into the rectum. Dissection follows Denon-
villiers’ fascia until the peritoneal reflection is reached. Most
of the dissection is performed bluntly; however, release of the
attachments between the prostate and rectum may require
sharp division. The levator ani are then scored with electro-
cautery to further expand the neovaginal cavity (Fig. 15.9).
Adequate dissection of the neovaginal space is essential in
creating and maintaining adequate vaginal depth. Once the
vaginal cavity is created, the superficial perineal muscles are
resected. Resection of the ischiocavernosus muscles aids with
creation of the introitus and exposure of the corpora caver-
nosa. At this point, the corpora spongiosum is separated from
the corpora cavernosa. The corpora spongiosum is resected
from the bulb of the penis in order to further open the vaginal
cavity. If excess erectile tissue is not removed, this tissue may
become engorged during sexual arousal and restrict entry to
the vaginal cavity.41
Fig. 15.9  The release of levator ani to aid with
maintenance of neovaginal cavity.
Crus of penis
Perineal membrane
Pubococcygeus (part of levator ani)
Iliococcygeus
(part of levator ani)
Puborectalis
(part of levator ani)
External anal
sphincter
Deep
Superficial
Subcutaneous
Prostate
Bulb of penis
Sacro-tuberous ligament
Areolar sheet
Gluteus maximus
Fig. 15.10  Dissection of dorsal glans penis on
dorsal neurovascular bundle.
Spermatic cord
Pampiniform plexus
Testicular artery
Genital branch of
genitofemoral nerve
Ductus deferens
Superficial dorsal
vein of penis
Tunica vaginalis
Buck’s fascia
Glans of penis
External pudendal vessels
Suspensory ligament
Deep dorsal vein and
arteries of penis
Dorsal nerve of penis
External spermatic fascia
Cremaster muscle
Dartos fascia
Scrotal skin

343
Multidisciplinary treatment
Fig. 15.11  (A) Intraoperative: demonstrating design of neoclitoris. (B) Undermining of the lower abdominal skin to the level of the umbilicus. Undermining facilitates
advancement of the penile flap into the intravaginal position. (C) Design of the urethral flap to form the labia minora and prepuce of the neoclitoris. (D) Postoperative: after
single-stage vaginoplasty. (E) Postoperative: following second-stage labiaplasty. Note the convergence of the labia majora in the mons pubis. (F) Postoperative: following
second-stage labiaplasty. Note the prepuce of the neoclitoris. (G) Postoperative: demonstrating moist appearance of labia minora and neoclitoris with associated prepuce.
CA
B
C
CD
E
CF
CG
harvested from the mons or lower abdominal region.44 The
scrotal–perineal flap is sutured to the penile flap over a silastic
stent and advanced into the intravaginal position. A “Y”-
shaped incision is made in the penile flap in order to create
the urethral meatus. The penile urethra is shortened and
incised ventrally. This creates a urethral flap through which
the glans penis will be placed, thereby creating the labia
minora and providing a prepuce to the neoclitoris (Fig.
15.11C). The scrotal skin is then tailored to form the labia
majora, and the incisions are closed in a layered fashion with
absorbable sutures. Drains are placed on either side of the
vaginal cavity (Fig. 15.11D).
Although most surgeons perform a single-stage vagino-
plasty, an optional second stage, referred to as a labiaplasty,
may be performed for further feminization of the mons pubis.
This procedure is performed approximately 3 months after
the vaginoplasty. The labiaplasty involves a local tissue rear-
rangement, frequently in the form of multiple “Z”-plasties, so
as to create convergence of the labia majora and provide for
additional clitoral hooding (Fig. 15.11E–G).
Technical variations include the use of a urethral flap inset
within the penile skin designed to either lengthen or provide
lubrication to the vaginal cavity.45 Additionally, intravaginal
placement of the glans penis to act as a neocervix has been
described.46
The postoperative care consists of a variable period of
bedrest, typically 4–5 days, during which a silastic stent is
used to maintain the vaginal cavity. Additionally, a urinary
catheter remains in place until the vaginal packing is removed
and ambulation is initiated, typically 5–6 days after surgery.
Once the vaginal stent is removed, a regimen of vaginal dila-
tion with a rigid prosthesis is begun. Initially, dilation of the

344
SECTION II
CHAPTER 15 • Surgery for gender dysphoria
Fig. 15.15B appears online only.
The neovagina is packed for 3–4 days with a soft stent, and
the patient remains on bedrest with a urinary catheter. Upon
return of bowel function and oral intake, the patient is dis-
charged from the hospital.
The potential drawbacks of intestinal-based flaps include
copious secretions, most notably with the small intestine,
and possible malodorous discharge with the large intestine.
Additional concerns include the possibility of diversion
colitis in the defunctionalized sigmoid colon, as well as the
risk of GI malignancies. Finally, the colonic mucosa may be
somewhat friable, and small amounts of postcoital bleeding
may occur.
Complications
Early postoperative complications include bleeding, infection,
and delayed wound healing. Additional early or late compli-
cations include rectovaginal fistula, urinary stream abnor-
malities, inadequate vaginal depth or constricted introitus,
partial flap loss, loss of neoclitoral sensation, and unsatisfac-
tory cosmetic appearance.
neovaginal cavity is performed 3–4 times daily for 6 weeks.
The frequency of dilation is reduced over a period of 2–3
months, ultimately requiring dilation two to three times per
week. This schedule may be varied depending upon the fre-
quency of vaginal intercourse.
Additionally, intermittent vaginal douching with a dilute
povidone-iodine solution is performed to remove intravaginal
debris. This is initially performed two to three times per week
beginning three to four weeks after surgery. Vaginal inter-
course may begin 6–8 weeks after surgery. An annual specu-
lum and prostate exam are also recommended.
Intestinal vaginoplasty
In the event that vaginal depth is inadequate, revision vagi-
noplasty typically requires either skin grafting, local and
regional nongenital flaps, or intestinal transposition. While a
skin graft may alleviate the need for an intra-abdominal
procedure, the dissection of the previously operated upon
vaginal cavity may be difficult. Visualization and protection
of the urethra and bladder anteriorly and rectum posteriorly
may be limited. Additionally, donor sites for full-thickness
skin grafts may be limited, and hypopigmentation from split-
thickness skin graft donor sites may be undesirable. Further-
more, skin grafts require regular postoperative dilation so as
to prevent contraction of the neovagina. Local and regional
nongenital flaps include the use of various thigh or perineal-
based flaps. The advantages of these nongenital flaps include
less risk of postoperative contraction. However, many of these
flaps are bulky, limit the size of the neovagina, and provide
no intrinsic lubrication. The advantage of intestinal transposi-
tion, especially in revision cases, is the provision of a reliable
length of vascularized tissue with mucus secretion providing
lubrication for vaginal intercourse. Intestinal transposition
may utilize either the small or large intestine; however, the
sigmoid colon is the most commonly used. The advantage of
the sigmoid colon is the larger luminal diameter and less
copious secretions as compared to that of jejunum or ileum.
Prior to performing the sigmoid vaginoplasty, a preopera-
tive colonoscopy is performed so as to evaluate for colorectal
malignancies. As with a primary procedure, a bowel prepara-
tion is prescribed preoperatively. The sigmoid vaginoplasty is
also performed in the lithotomy position in conjunction with
general surgery. A combined abdominal and perineal approach
is utilized and allows visualization and protection of the
bladder and urethra anteriorly and the rectum posteriorly.
The sigmoid colon is harvested by the general surgery team,
and the perineal dissection is performed concurrently by the
plastic surgery team. A 12–15 cm segment of sigmoid colon is
transferred in an isoperistaltic fashion (Figs. 15.12–15.14). The
defunctionalized sigmoid colon is sutured to the introitus of
the neovagina with a single layer of absorbable sutures. In
order to prevent contraction of the introitus, several Z-plasties
are used when insetting the distal bowel segment with the
perineal skin (Fig. 15.15
). Additionally, the mesentery of the
defunctionalized sigmoid colon is gently sewn to the pelvis
to prevent torsion of the vascular pedicle. An end-to-end
colonic anastomosis is performed to restore intestinal continu-
ity, and the distal stump of the neovagina is separated from
the colorectal anastomosis so as to reduce the risk of fistuliza-
tion. Intravenous antibiotics are maintained for 24 hours
postoperatively.
Fig. 15.12  Incision along mesentery of colon and development of the vascular
pedicle.

345
Multidisciplinary treatment
imperative that the individual continue routine dilation so as
to prevent the risk of vaginal stenosis. Although the frequency
of dilation may be reduced with sexual intercourse, pedicled
penile flaps and skin grafts still require compliance with
vaginal dilation.
Routine medical care of the transgender individual is
recommended and includes clinical and laboratory moni-
toring. This allows assessment of the beneficial, as well as
possible adverse, effects associated with cross-sex hormonal
therapy. Monitoring of weight and blood pressure, directed
physical examinations, complete blood counts, renal and liver
function tests, and lipid and glucose metabolism should be
considered.
Additional monitoring considerations for transwomen on
estrogen therapy include measurement of prolactin levels,
evaluation for cardiac risk factors, screening guidelines for
prostate disease as recommended for biologic males, and
screening guidelines for breast cancer as recommended for
biologic females.34 For transmen, additional monitoring
considerations include evaluation of bone mineral density
if risk factors for osteoporotic fracture are present, and, if
mastectomy/hysterectomy/oophorectomy are not performed,
mammograms and annual Pap smear, as recommended by
the American Cancer Society and American College of Obste-
tricians and Gynecologists, respectively.47
Additional feminizing procedures
Additional procedures include both facial feminization as
well as breast augmentation. The goal of these procedures is
to remove the secondary sexual characteristics and stigmata
associated with the male appearance. The timing of these
surgeries in relation to genital surgery may vary between
centers as well as within individual centers. It is not
In the event that a rectovaginal fistula is recognized intra-
operatively, the rectum is closed in a layered fashion and may
be left to heal. Because the patient has undergone a preopera-
tive bowel preparation, the rectum may heal without further
intervention. However, there is the potential need for diver-
sion with a colostomy, as well as the risk of neovaginal stenosis.
Although minor urinary stream abnormalities are not uncom-
mon, the risk of stenosis of the neo-urethral meatus may be
reduced by spatulation and eversion of the urethra. It is also
Fig. 15.13  Harvest of sigmoid colon.
Fig. 15.14  This figure demonstrates placement of defunctionalized sigmoid colon
to position of neovagina. The colorectal anastomosis is isolated from the sutured
stump of the defunctionalized sigmoid colon.
Fig. 15.15  (A) This figure demonstrates insetting of sigmoid colon. The use of
laparoscopic instruments facilitates insetting several centimeters cephalad to the
introitus.

345.e1
Multidisciplinary treatment
(B) Postoperative: intestinal vaginoplasty.
B
Fig. 15.15

346
SECTION II
CHAPTER 15 • Surgery for gender dysphoria
endoscope, reduction of the frontal bone and lateral brow is
facilitated with the open approach. In addition, the open
approach, performed through an anterior hairline incision,
allows advancement of the frontal hairline, if desired (Fig.
15.17). Prior to proceeding with reduction of the frontal bone,
lateral skull films are obtained in order to assess the thickness
of the anterior table of the frontal sinus. Depending upon the
thickness of the anterior table in relation to the degree of
frontal bossing, craniofacial techniques may be employed for
the desired correction.
A feminizing rhinoplasty typically involves dorsal hump
reduction, cephalic trim, elevation of the nasal tip, and oste-
otomies to narrow the nasal pyramid. The chin and mandible
represent additional anatomic sites that may require
uncommon for these procedures to be performed prior to
genital surgery so as to improve the individual’s sense of
well-being and facilitate the real life test.2
Following hormonal therapy, there is frequently some
breast growth in the transwomen. However, the degree of
breast growth is oftentimes inadequate, and individuals
continue to wear external prostheses or padded bras. As such,
augmentation mammaplasty is a frequently requested proce-
dure. Anatomic differences between the male and female
chest are relevant as to implant selection, incision choice, and
pocket location.48
The male chest is not only wider than the female chest, but
the pectoral muscle is usually more developed. Furthermore,
the male areola is smaller than the female areola, the distance
between the nipple and inframammary crease is less, and
there is less ptosis in the natal male breast, even after hormonal
therapy.49 Based upon these characteristics, a larger implant is
commonly chosen. In addition, silicone implants are usually
requested. Pocket location and incision choice depend upon
the individual and the degree of breast growth in response to
hormonal therapy. Either a subglandular, subfascial, or sub-
pectoral pocket may be used. The potential issues associated
with a subpectoral pocket are implant displacement due to
the activity of the overlying pectoralis muscle. However,
potential concerns with the subglandular pocket include
capsular contracture and palpability of the implant due to less
soft-tissue coverage. In terms of incisions, transaxillary, peri-
areolar, or inframammary crease approaches may be used and
are tailored to the requests and anatomy of the individual
(Fig. 15.16).
Facial features may also be typically male or female. As
such, surgery to “feminize” the face of transwomen is fre-
quently requested. A variety of characteristics have been
identified as male and are often associated with the forehead,
nose, malar region, mandible, and thyroid cartilage. These
differences include more pronounced supraorbital bossing in
the male and a more continuous forehead curvature in the
female.50 The malar region is also more prominent in the
female, and the female nose tends to be smaller, with a less
acute glabellar angle than the male.50,51 In addition, qualitative
and quantitative differences in the skin, subcutaneous tissue,
and hair also exist.52
Because the female eyebrow is located above the supraor-
bital rim and has a more arched appearance than the male,
typical procedures for facial feminization include a brow lift
with advancement of the frontal hairline and frontal bone
reduction. Although the brow lift may be performed with an
Fig. 15.16  Pre- and postoperative: following subpectoral silicone gel
augmentation mammaplasty performed through an inframammary crease incision.
Fig. 15.17  (A) Preoperative: prior to brow lift and frontal bone reduction.
(B) Postoperative: following brow lift and frontal bone reduction performed through
an open, anterior hairline approach.
CA
CB

347
Multidisciplinary treatment
with sedation. The procedure is performed through a
transverse incision in a naturally occurring skin crease. Fol-
lowing vertical division of the middle cervical fascia, the
sternothyroid and thyrohyoid muscles are retracted laterally.
The perichondrium is incised and a subperichondrial dissec-
tion is performed with care so as to enter the thyrohyoid
membrane. On the posterior surface of the cartilage, subperi-
chondrial dissection is performed inferiorly to the thyroepi-
glottic ligament. Dissection stops at this point so as not to
injure the insertion of the vocal cords or destabilize the epi-
glottis. Identification of the insertion of the vocal cords may
be facilitated with fiberoptic laryngoscopy by the anesthesi-
ologist. Resection of the thyroid cartilage is performed
between the superior thyroid notch in the midline and the
superior thyroid tubercle superolaterally. The perichondrium
is reapproximated, and the incision is closed in a layered
fashion.53
Voice surgery, designed to raise vocal pitch, may be
requested by individuals following voice therapy. Hormonal
intervention does not commonly affect vocal pitch, and this
may represent a residual stigma of masculinity. As such,
various techniques to shorten the vocal cords, increase vocal
cord tension, or reduce vibrating vocal cord mass may be
performed.21
Masculinizing surgical therapy
Chest surgery
Chest-wall contouring is an important early surgical step in
the process of gender confirmation for transmen. The goals of
chest surgery include the aesthetic contouring of the chest by
removal of breast tissue and skin excess, reduction and repo-
sitioning of the nipple–areola complex, release of the inframa-
mmary crease, and minimization of chest scars.54
Chest surgery in transmen presents an aesthetic challenge
due to breast volume, breast ptosis, nipple–areola size and
position, degree of skin excess, and potential loss of skin
elasticity. Breast binding, commonly performed by female-to-
male transsexuals, may lead to loss of skin elasticity, thereby
necessitating additional skin removal. Both skin quality
and elasticity are important determinants in the choice of
surgical technique.54 Technical considerations related to the
subcutaneous mastectomy include preservation of subcuta-
neous fat on the skin flaps, preservation of the pectoralis
fascia, and release of the inframammary crease and sternal
attachments.
Choice of incision is largely determined by degree of breast
ptosis and skin quality/elasticity as well as position of the
nipple–areola complex. Incisions may range from a periareolar
incision in small breasts with a small areola and good skin
elasticity, to circumareolar incisions, to transverse inframam-
mary crease incisions with free nipple grafts. Liposuction may
be used as an adjunct to excisional techniques. The decision as
to maintenance of the nipple–areola complex on a dermoglan-
dular pedicle versus a free nipple–areola graft must
also be considered. In positioning the nipple–areolar complex,
the patient is sat upright and clinical judgment is used. In
general, the nipple–areola is positioned just medial to the
lateral border of the pectoralis major muscle, approximately
2–3 cm above the inferior insertion of the pectoralis major
muscle (Fig. 15.19
). Postoperative management includes
treatment. Based upon the individual’s anatomy, either chin
implants or osteoplastic genioplasty may be required. In addi-
tion, reduction of the masseter muscle or contouring of the
mandibular angle may be performed through intraoral
incisions. Other procedures, such as upper lip shortening,
facelift (Fig. 15.18), blepharoplasty, malar implants, hair
transplantation, injectable fillers, and skin resurfacing may
also be requested.
Reduction thyroid chondroplasty is frequently requested to
reduce the appearance of the “Adam’s apple” or prominent
thyroid cartilage (pomus Adamus). The procedure is typically
performed as an outpatient under general or local anesthesia
CA
Fig. 15.18  (A) Preoperative: prior to facelift, upper eyelid blepharoplasty, and TCA
chemical peel. (B) Postoperative: following facelift, upper eyelid blepharoplasty,
and TCA chemical peel.
CB

348
SECTION II
CHAPTER 15 • Surgery for gender dysphoria
clitoris.58 Additional lengthening of the urethra is performed
with flaps developed from the labia minora. The vaginal
mucosa and labial flaps are sutured to each other in a beveled
fashion over a urinary catheter (Fig. 15.20
).
Fig. 15.20 appears online only.
Scrotoplasty, constructed with bilateral labia majora flaps,
may be performed at the time of metoidioplasty. Testicular
implants are placed at a secondary surgical procedure so as
to reduce the risk of infection and urethral complications (see
Fig. 15.20C).
Conclusion
A letter addressed to the relevant governmental agencies
petitioning for a change of legal “sex” status may be requested
by the individual following surgery. This letter may be impor-
tant for the individual’s legal documents (i.e., driver’s license,
passport, social security, etc.) and should include the nature
of the treatment rendered. Individual state laws may vary in
regard to the requirements for change of legal documents.
Continued collaboration between the surgeon, mental
health professional, and medical physician is important in
providing comprehensive care to the transgender individual.
In addition, continued research focused on objective param-
eters and reporting of outcomes data will foster innovation
and continued improvements in surgical techniques.
drains and elastic compression. Secondary revisions related to
the scar and/or nipple–areolar complex are not uncommon.
Fig. 15.19C & E appear online only.
Genital surgery
The goal of genital surgery in transmen may range from cli-
toral release with or without urethral lengthening and capable
of allowing voiding while standing, to a complete penis,
capable of sexual penetration.55
Metoidioplasty
Metoidioplasty, described in 1196 by Hage, has been offered
as an alternative to microsurgical or pedicled flap phalloplasty
in transmen. The term, coined by Laub, is based upon the
Greek prefix meta-, relating to change, and aidoio, relating to
the genitals.56 The procedure entails lengthening the hormon-
ally hypertrophied clitoris by release of the suspensory liga-
ment and resection of the ventral chordee and lengthening of
the female urethra with the aid of labia minora and/or vaginal
musculomucosal flaps.57 Additionally, buccal mucosa grafts
have been utilized to aid with urethral extension. Urethral
reconstruction is the major challenge associated with metoid-
ioplasty, and most complications involve either urethral fistu-
lae and/or strictures.
The operative technique may involve concomitant removal
of the female genitalia (vaginectomy) in addition to metoid-
ioplasty.58 Most often, a hysterectomy and oophorectomy are
performed prior to the metoidioplasty. A caudally based
anterior vaginal wall flap incorporating the muscularis of the
ventral vaginal wall may be used. This flap can be used to
reconstruct the fixed portion of the neo-urethra.56 If a vaginec-
tomy is not performed, the vaginal donor site is closed,
thereby narrowing the retained vagina. The clitoral shaft is
degloved and released by detaching the suspensory ligament
from the pubic bone. On the ventral aspect of the clitoris, the
urethral plate is dissected from the clitoral bodies. The
urethral plate is divided so as to release the ventral clitoral
curvature allowing straightening and lengthening of the
Bonus images for this chapter can be found online at

Fig. 15.15 (B) Postoperative: intestinal vaginoplasty
Fig. 15.19 (C) Preoperative: limited incision chest surgery. (E) Postoperative:
limited incision chest surgery.
Fig. 15.20 Metoidioplasty preoperative and postoperative photos.
(A) Preoperative: metoidioplasty. (B) Intraoperative: metoidioplasty.
(C) Postoperative: metoidioplasty.
A
B
D
Fig. 15.19  (A) Preoperative: prior to chest surgery (right side). (B) Preoperative: prior to chest surgery (left side). (D) Postoperative: subcutaneous mastectomy with free
nipple graft.

348.e1
Multidisciplinary treatment
C
E
(E) Postoperative:
Fig. 15.19  (C) Preoperative: limited incision chest surgery.
limited incision chest surgery.

349
Conclusion
2. Monstrey S, Hoebeke P, Dhont M, et al. Surgical therapy in
transsexual patients: a multi-disciplinary approach. Acta Chir Belg.
2001;101:200–209. Excellent review article on the care of transgender
individuals.
7. Lee PA, Houk CP, Ahmed SF, et al. in collaboration with the
participants in the International Consensus Conference on Intersex.
Consensus statement on management of intersex disorders.
Pediatrics. 2006;118:e488–e500. Review article on disorders of sexual
development.
21. Ettner R. The etiology of transsexualism. In: Ettner R, Monstrey S,
Eyler E, eds. Principles of Transgender Medicine and Surgery. New
York: Haworth Press; 2007:1–14.
25. Schechter L. The surgeon’s relationship with the physician
prescribing hormones and the mental health professional: review
for version 7 of the World Professional Association for Transgender
Health’s Standards of care. Int J Transgend. 2009;11:222–225.
26. Bowman C, Goldberg J. Care of the patient undergoing sex
reassignment surgery. Int J Transgend. 2006;9:135–165.
33. Dahl M, Feldman JL, Goldberg JM, et al. Physical aspects of
transgender endocrine therapy. Int J Transgend. 2006;9:111–134.
Guidelines for endocrine therapy for transgender individuals.
34. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al.
Endocrine treatment of transsexual persons: an endocrine society
clinical practice guideline. J Clin Endocrinol Metab. 2009;94:3132–
3153.
37. Edgerton MT, Bull J. Surgical construction of the vagina and labia
in male transsexuals. Plast Reconstr Surg. 1970;46:529–539.
41. Karim RB, Hage JJ, Bouman FG, et al. The importance of near total
resection of the corpora cavernosa in the surgery of male to female
transsexuals. Ann Plast Surg. 1991;26:554–557.
45. Perovic SV, Stanojevic DS, Djordjevic MI. Vaginoplasty in male
transsexuals using penile skin and a urethral flap. BJU Int.
2000;86:843–850.
51. Hage JJ, Vossen M, Becking AG. Rhinoplasty as part of gender-
confirming surgery in male transsexuals: basic considerations and
clinical experience. Ann Plast Surg. 1997;39:266–271.
52. Hage JJ, Becking AG, de Graf FH, et al. Gender-confirming facial
surgery: consideration on the masculinity and femininity of faces.
Plast Reconstr Surg. 1997;97:1799–1807.
Access the complete reference list online at

349.e1
Conclusion
Fig. 15.20  Metoidioplasty pre- and postoperative photos. (A) Preoperative:
metoidioplasty. (B) Intraoperative: metoidioplasty. (C) Postoperative: metoidioplasty.
A
B
C

349.e2
SECTION II
CHAPTER 15 • Surgery for gender dysphoria
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