In female-to-male transsexuals, the operative procedures are usually performed in different stages: 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 reassignment 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 results 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 reassignment usually consists of a "Transsexual operation female to male before and after" phase mostly supported by a mental health professionalfollowed by hormonal therapy through an endocrinologista real-life experience, and at the end the Transsexual operation female to male before and after reassignment 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 removal 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 algorithm 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 from 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
Transsexual operation female to male before and after 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. 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. 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. A incisions; B preoperative; C postoperative.
The extended concentric circular technique Fig. This technique is useful for correcting Transsexual operation female to male before and after 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 complications 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 by conservative means. The exceptional cases of partial or total nipple 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 as 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
Transsexual operation female to male before and after. Despite the multitude of flaps that have been employed and described often as Case Reportsthe radial forearm is universally considered 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: Once the urethra is lengthened the acceptor recipient vessels are dissected in the groin area, the patient is put into a supine position.
The free flap can be transferred to the pubic area after the urethral anastomosis: 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 "Transsexual operation female to male before and after" 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.