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Try out PMC Labs and tell us what you think. Learn More. In female-to-male transsexuals, the operative procedures are usually performed in different stages: first the subcutaneous mastectomy which is often combined with a hysterectomy-ovarectomy endoscopically assisted. The next operative procedure consists of the genital transformation and includes a vaginectomy, a reconstruction of the horizontal part of the urethra, a scrotoplasty and a penile reconstruction usually with a radial forearm flap or an alternative.
After about one year, penile erection prosthesis and testicular prostheses can be implanted when sensation has returned to the tip of the penis. The authors provide a state-of-the-art overview of the different gender reasment surgery procedures that can be performed in a female-to-male transsexual. Transsexual patients have the absolute conviction of being born in the wrong body and this severe identity problem in a lot of suffering from early childhood on.
Although the exact etiology of transsexualism is still not fully understood, it is most probably a result of a combination of various biological and psychological factors. Gender reasment usually consists of a diagnostic phase mostly supported by a mental health professionalfollowed by hormonal therapy through an endocrinologista real-life experience, and at the end the gender reasment surgery itself.
It is usually advised to stop all hormonal therapy 2 to 3 weeks preoperatively. Because hormonal treatment has little influence on breast size, the first and, arguably, most important surgery performed in the female-to-male FTM transsexual is the creation of a male chest by means of a SCM. The goal of the SCM in a FTM transsexual patient is to create an aesthetically pleasing male chest, which includes Post op transsexual photos of breast tissue and excess skin, reduction and proper positioning of the nipple and areola, obliteration of the inframammary fold, and minimization of chest-wall scars.
In the largest series to date, Monstrey et al 6 described an Post op transsexual photos of five different techniques to perform an aesthetically satisfactory SCM Fig. Preoperative parameters to be evaluated include breast volume, degree of excess skin, nipple-areola complex NAC size and position, and skin elasticity. Regardless of the technique, it is extremely important to preserve all subcutaneous fat when dissecting the glandular tissue Post op transsexual photos the flaps. This ensures thick flaps that produce a pleasing contour. Liposuction is only occasionally indicated laterally, or to attain complete symmetry at the end of the procedure.
Postoperatively, a circumferential elastic bandage is placed around the chest wall and maintained for a total of 4 to 6 weeks. The semicircular technique Fig. It is useful for individuals with smaller breasts and elastic skin. A sufficient amount of glandular tissue should be left in situ beneath the NAC to avoid a depression.
The particular advantage of this technique is the small and well-concealed scar which is confined to the lower half of the nipple-areola complex. The major drawback is the small window through which to work, making excision of breast tissue and hemostasis more challenging. Semicircular technique. A Incisions and scar; B preoperative; C postoperative. In cases of smaller breasts with large prominent nipples, the transareolar technique Fig. This is similar to the procedure described by Pitanguy in 8 and allows for subtotal resection and immediate reduction of the nipple.
The resulting scar traverses the areola horizontally and passes around the upper aspect of the nipple. Transareolar technique. A,B Incisions and scar; C preoperative; D postoperative. The concentric circular technique Fig. The resulting scar will be confined to the circumference of the areola. The concentric incision can be drawn as a circle or ellipse, enabling deepithelialization of a calculated amount of skin in the vertical or horizontal direction. A purse-string suture is placed and set to the desired areolar diameter usually 25—30 mm. Concentric circular technique.
A incisions; B preoperative; C postoperative. The extended concentric circular technique Fig. This technique is useful for correcting skin excess and wrinkling produced by large differences between the inner and outer circles. The resulting scars will be around the areola, with horizontal extensions onto the breast skin, depending on the degree of excess skin. Extended concentric circular technique. A Incisions and scar; B preoperative preoperative; C postoperative. The free nipple graft technique Fig. Our preference is to place the incision horizontally 1 to 2 cm above the inframammary fold, and then to move upwards laterally below the lateral border of the pectoralis major muscle.
The placement of the NAC usually corresponds to the 4th or 5th intercostal space. Clinical judgment is most important, however, and we always sit the patient up intraoperatively to check final nipple position. The advantages of the free nipple graft technique are easy chest contouring, excellent exposure and more rapid resection of tissue, as well as nipple reduction, areola resizing, and repositioning.
The disadvantages are the long residual scars, NAC pigmentary and sensory changes, and the possibility of incomplete graft take. Free nipple graft technique. Postoperative Post op transsexual photos include hematoma most frequent, despite drains and compression bandagespartial nipple necrosis, and abscess formation. This underscores the importance of achieving good hemostasis intraoperatively.
Smaller hematomas and seromas can be evacuated through puncture, but for larger collections surgical evacuation is required. Another not infrequent complication consists of skin slough of the NAC, which can be left to heal Post op transsexual photos conservative means.
The exceptional cases of partial or total Post op transsexual photos necrosis may require a secondary nipple reconstruction.
The likelihood of an additional aesthetic correction should be discussed with the patient in advance. The recommendations of the authors are summarized in their algorithm Fig. The FTM transsexual patients are rightfully becoming a patient population that is better informed and more demanding Post op transsexual photos to the aesthetic outcomes.
Finally, it is important to note that there have been reports of breast cancer after bilateral SCM in this population 141516 because in most patients the preserved NAC and the always incomplete glandular resection leave behind tissue at risk of malignant transformation. In performing a phalloplasty for a FTM transsexual, the surgeon should reconstruct an aesthetically appealing neophallus, with erogenous and tactile sensation, which enables the patient to void while standing and have sexual intercourse like a natural male, in a one-stage procedure.
Despite the multitude of flaps that have been employed and described often as Case Reportsthe radial forearm is universally Post op transsexual photos the gold standard in penile reconstruction. In the largest series to date almost patientsMonstrey et al 29 recently described the technical aspects of radial forearm phalloplasty and the extent to which this technique, in their hands approximates the criteria for ideal penile reconstruction. For the genitoperineal transformation vaginectomy, urethral reconstruction, scrotoplasty, phalloplastytwo surgical teams operate at the same time with the patient first placed in a gynecological lithotomy position.
In the perineal area, a urologist may perform a vaginectomy, and lengthen the urethra with mucosa between the minor labiae. The vaginectomy is a mucosal colpectomy in which the mucosal lining of the vaginal cavity is removed.
After excision, a pelvic floor reconstruction is always performed to prevent possible diseases such as cystocele and rectocele. This reconstruction of the fixed part of the urethra is combined with a scrotal reconstruction by means of two transposition flaps of the greater labia resulting in a very natural looking bifid scrotum. Simultaneously, the plastic surgeon dissects the free vascularized flap of the forearm. The creation of a phallus with a tube-in-a-tube technique is performed with the flap still attached to the forearm by its vascular pedicle Fig.
This is commonly performed on the ulnar aspect of the skin island. A small skin flap and a skin graft are used to create a corona and simulate the glans of the penis Fig. A—D Phallic reconstruction with the radial forearm flap: creation of a tube urethra within a tube penis. Once the urethra is lengthened and the acceptor recipient vessels are dissected in the groin area, the patient is put into Post op transsexual photos supine position.
The free flap can be transferred to the pubic area after the urethral anastomosis: the radial artery is microsurgically connected to the common femoral artery in an end-to-side fashion and the venous anastomosis is performed between the cephalic vein and the greater saphenous vein Fig.
One forearm nerve is connected to the ilioinguinal nerve for protective sensation and the other nerve of the arm is anastomosed to one of the dorsal clitoral nerves for erogenous sensation. The clitoris is usually denuded and buried underneath the penis, thus keeping the possibility to be stimulated during sexual intercourse with the neophallus.
In the first 50 patients of this series, the defect on the forearm was covered with full-thickness skin grafts taken from the groin area. In subsequent patients, the defect was covered with split-thickness skin grafts harvested from the medial and anterior thigh Fig. The patients remain in bed during a one-week postoperative period, after which the transurethral catheter is removed. At that time, the suprapubic catheter was clamped, and voiding was begun. Effective voiding might not be observed for several days.
Before removal of the suprapubic catheter, a cystography with voiding urethrography was performed. Tattooing of the glans should be performed after a 2- to 3-month period, before sensation returns to the penis. Implantation of the testicular prostheses should be performed after 6 months, but it is typically done in combination with the implantation of a penile erection prosthesis. Before these procedures are undertaken, Post op transsexual photos must be returned to the tip of the penis. This usually does not occur for at least a year.
What can be achieved with this radial forearm flap technique as to the ideal requisites for penile reconstruction? InHage 20 stated that a complete penile reconstruction with erection prosthesis never can be performed in one single operation. Monstrey et al, 29 early in their series and to reduce the of surgeries, performed a sort of all-in-one procedure that included a SCM and a complete genitoperineal transformation. However, later in their series they performed the SCM first most often in combination with a total hysterectomy and ovariectomy.
Phallic construction has become predictable enough to refine its aesthetic goals, which includes the use of a technique that can be replicated with minimal complications. In this respect, the radial forearm flap has several advantages: the flap is thin and pliable allowing the construction of Post op transsexual photos normal sized, tube-within-a-tube penis; the flap is easy to dissect and is predictably well vascularized making it safe to perform an aesthetic glansplasty at the distal end of the flap. The final cosmetic outcome of a radial forearm phalloplasty is a subjective determination, but the ability of most patients to shower with other men or to go to the sauna is the usual cosmetic barometer Fig.
A—C Late postoperative of radial forearm phalloplasties. The potential aesthetic drawbacks of the radial forearm flap are the need for a rigidity prosthesis and possibly some volume loss over time. Of the various flaps used for penile reconstruction, the radial forearm flap has the greatest sensitivity. The denuded clitoris was always placed directly below the phallic shaft. Later manipulation of the neophallus allows for stimulation of the still-innervated clitoris. After one year, all patients had regained tactile sensitivity in their penis, which is an absolute requirement for safe insertion of an erection prosthesis.
For biological males as well as for FTM transsexuals undergoing a phalloplasty, the ability to void while standing is a high priority. Complications following phalloplasty include the general complications attendant to any surgical intervention such as minor wound healing problems in the groin area or a few patients with a minor pulmonary embolism despite adequate prevention interrupting hormonal therapy, fractioned heparin subcutaneously, elastic stockings.
A vaginectomy is usually considered a particularly difficult operation with a high risk of postoperative Post op transsexual photos, but in their series no major bleedings were seen. 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 ificant risk factor, under our current policy, we no longer operate on patients who fail to quit smoking one year prior to their surgery.
The major drawback of the radial forearm flap has always been the unattractive donor site scar on the forearm Fig. Selvaggi et al conducted a long-term follow-up study 38 of radial forearm phalloplasties to assess the degree of functional loss Post op transsexual photos aesthetic impairment after harvesting such a large forearm flap.Post op transsexual photos
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Before & After Photos